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Chan KW, Kwong ASK, Tsui PN, Chan GCW, Choi WF, Yiu WH, Cheung SCY, Wong MMY, Zhang ZJ, Tan KCB, Lao L, Lai KN, Tang SCW. Add-on astragalus in type 2 diabetes and chronic kidney disease: A multi-center, assessor-blind, randomized controlled trial. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2024; 130:155457. [PMID: 38810556 DOI: 10.1016/j.phymed.2024.155457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 02/03/2024] [Accepted: 02/14/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Diabetes leads to chronic kidney disease (CKD) and kidney failure, requiring dialysis or transplantation. Astragalus, a common herbal medicine and US pharmacopeia-registered food ingredient, is shown kidney protective by retrospective and preclinical data but with limited long-term prospective clinical evidence. This trial aimed to assess the effectiveness of astragalus on kidney function decline in macroalbuminuric diabetic CKD patients. METHODS This randomized, assessor-blind, standard care-controlled, multi-center clinical trial randomly assigned 118 patients with estimated glomerular filtration rate (eGFR) of 30-90 ml/min/1.73m2 and urinary albumin-to-creatinine ratio (UACR) of 300-5000 mg/g from 7 public outpatient clinics and the community in Hong Kong between July 2018 and April 2022 to add-on oral astragalus granules (15 gs of raw herbs daily equivalent) or to continue standard care alone as control for 48 weeks. Primary outcomes were the slope of change of eGFR (used for sample size calculation) and UACR of the intention-to-treat population. Secondary outcomes included endpoint blood pressures, biochemistry, biomarkers, concomitant drug change and adverse events. (ClinicalTrials.gov: NCT03535935) RESULTS: During the 48-week period, the estimated difference in the slope of eGFR decline was 4.6 ml/min/1.73m2 per year (95 %CI: 1.5 to 7.6, p = 0.003) slower with astragalus. For UACR, the estimated inter-group proportional difference in the slope of change was insignificant (1.14, 95 %CI: 0.85 to 1.52, p = 0.392). 117 adverse events from 31 astragalus-treated patients and 41 standard care-controlled patients were documented. The 48-week endpoint systolic blood pressure was 7.9 mmHg lower (95 %CI: -12.9 to -2.8, p = 0.003) in the astragalus-treated patients. 113 (96 %) and 107 (91 %) patients had post-randomization and endpoint primary outcome measures, respectively. CONCLUSION In patients with type 2 diabetes, stage 2 to 3 CKD and macroalbuminuria, add-on astragalus for 48 weeks further stabilized kidney function on top of standard care.
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Affiliation(s)
- Kam Wa Chan
- Division of Nephrology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Alfred Siu Kei Kwong
- Department of Family Medicine and Primary Healthcare, Hospital Authority Hong Kong West Cluster, Hong Kong Special Administrative Region, China
| | - Pun Nang Tsui
- Department of Family Medicine and Primary Healthcare, Hospital Authority Hong Kong East Cluster, Hong Kong Special Administrative Region, China
| | - Gary Chi Wang Chan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Wing Fai Choi
- School of Chinese Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Wai Han Yiu
- Division of Nephrology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Simon Chi Yuen Cheung
- Division of Nephrology, Department of Medicine, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China
| | - Michelle Man Ying Wong
- Department of Family Medicine and Primary Healthcare, Hospital Authority Hong Kong East Cluster, Hong Kong Special Administrative Region, China
| | - Zhang-Jin Zhang
- School of Chinese Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kathryn Choon Beng Tan
- Division of Endocrinology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Lixing Lao
- School of Chinese Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Virginia University of Integrative Medicine, VA, USA
| | - Kar Neng Lai
- Division of Nephrology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Sydney Chi Wai Tang
- Division of Nephrology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.
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Sriraman S, Sreejith D, Andrew E, Okello I, Willcox M. Use of herbal medicines for the management of type 2 diabetes: A systematic review of qualitative studies. Complement Ther Clin Pract 2023; 53:101808. [PMID: 37977099 DOI: 10.1016/j.ctcp.2023.101808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/21/2023] [Accepted: 10/25/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Many people with Type 2 Diabetes Mellitus (T2DM) use herbal medicines, some of which can improve glycaemic control. Providing evidence-based advice on herbal medicines could be an effective intervention to improve control of diabetes, if it is designed to address key needs and concerns of T2DM patients. AIM To understand the views and experiences of patients and health professionals on herbal treatments for self-management of T2DM. METHOD MEDLINE, EMBASE, CINAHL, SOCIOFILE and Google Scholar were searched for qualitative studies in T2DM patients about their views on herbal medicines. Included papers were analysed using thematic synthesis. RESULTS Thirty-one papers (about 30 studies) were included: 20 from low-and-middle income countries, 10 from high income countries, and 1 internet-based study. Almost all studies from high income countries focussed on ethnic minorities. Many people with T2DM wanted a "cure", and often took advice from friends and family, but also traditional healers and mass media. However, they were reluctant to discuss herbal medicines with health professionals, whom they perceived as "closed-minded". They based their treatment decisions on personal experience (from "trial-and-error"), availability, cost and convenience of both herbal and conventional medicines. Most health professionals were reluctant to discuss herbal medicines, or recommended against their use, because of lack of knowledge and concerns about their quality, efficacy and potential interactions. CONCLUSION Evidence-based information could help to overcome the current lack of communication about herbal medicines between people with T2DM and health professionals.
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Affiliation(s)
- Shraddha Sriraman
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, UK
| | - Devika Sreejith
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, UK
| | - Evie Andrew
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, UK
| | - Immaculate Okello
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, UK
| | - Merlin Willcox
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, UK.
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Ashrafizadeh H, Gheibizadeh M, Rassouli M, Hajibabaee F, Rostami S. Needs Assessment and the Identification of Palliative Care Dimensions of the Essential Service Package for the Elderly with Alzheimer's Disease: A Mixed Exploratory Study. FLORENCE NIGHTINGALE JOURNAL OF NURSING 2023; 31:160-172. [PMID: 37823829 PMCID: PMC10724800 DOI: 10.5152/fnjn.2023.23032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/13/2023] [Indexed: 10/13/2023]
Abstract
AIM This study was conducted with the aim of assessing the needs and determining the care dimensions of the essential palliative care service package for the elderly with Alzheimer's disease. METHOD The mixed exploratory study was conducted in three phases. The first phase of the study was conducted in the form of a qualitative study and a literature review. This qualitative research was done through in-depth and semi-structured interviews with 19 qualified caregivers (11 informal caregivers and 8 formal caregivers) The samples were selected using the purposive sampling method by referring to hospitals, nursing homes, and active branches of the Alzheimer's Association in some provinces. In the second phase, the dimensions of palliative care were codified, and in the third phase, the prioritization and the validation of the dimensions of palliative care were performed in the form of two Delphi rounds. RESULTS Based on the results of the first phase of the study, the care dimensions of the service package were placed in eight categories based on National Consensus Project. In the second phase, the needs of Alzheimer's patients were arranged in the form of a questionnaire consisting of 8 parts, with 180 indicators. Then, in the third phase, the dimensions of the palliative care essential package were designed with 74 items in the form of 4 dimensions. CONCLUSION The dimensions of the essential service package of palliative care included a series of interventions as well as physical, psychological, cognitive, and spiritual support.
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Affiliation(s)
- Hadis Ashrafizadeh
- Department of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mahin Gheibizadeh
- Nursing Care Research Center in Chronic Diseases, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Maryam Rassouli
- Nursing Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Hajibabaee
- Department of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahnaz Rostami
- Nursing Care Research Center in Chronic Diseases, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Shirinabadi Farahani A, Ashrafizadeh H, Khoubbin Khoshnazar TAS, Mehrnoush N, Karami M, Khademi F, Eshaghian Dorcheh A, Ebrahimloee S, Koohi Rostamkalaee Z, Rassouli M. Barriers to Applying Integrative Oncology from the Perspective of the Care Providers in Iran: A Mixed-Methods Study. Semin Oncol Nurs 2023; 39:151444. [PMID: 37271659 DOI: 10.1016/j.soncn.2023.151444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVE The present study aims to explain and determine the use of integrative oncology from the perspective of the care providers in Iran. DATA SOURCES This mixed-methods study is a convergent type of study with quantitative and qualitative phases that have been performed simultaneously. The quantitative phase was a descriptive study that was conducted through convenience sampling. With the use of a psychometrically evaluated questionnaire with 10 items, 202 nurses and physicians were included in the study to assess their views on the integration of traditional and complementary medicine (TCM) within supportive cancer care. The qualitative part of the study was conducted through semistructured interviews with 11 care providers. The interviews were analyzed through conventional content analysis and the method proposed by Graneheim and Lundman with the use of MaxQDA software. CONCLUSION After the quantitative and the qualitative data were combined, we identified four main categories as the important dimensions of using TCM: patients' main expectations of TCM services, reasons for using these services, existing challenges and barriers, and recommendations and strategies to improve the interaction between physicians and patients to facilitate the use of integrative oncology . IMPLICATION FOR NURSING PRACTICE Although cancer patients use TCM due to a wide range of expectations, there are many barriers to integrative oncology in Iran. Therefore, it is necessary to pay attention to the benefits of conventional medical and TCM treatments, conceptualize integrative oncology, and try to meet the existing challenges.
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Affiliation(s)
- Azam Shirinabadi Farahani
- Assistant Professor, Department of Pediatric & Neonatal Intensive Care Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hadis Ashrafizadeh
- Assistant Professor, School of Nursing, Student Research Committee, Dezful University of Medical Sciences, Dezful, Iran
| | | | - Nasrin Mehrnoush
- Assistant Professor, School of Nursing & Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Maryam Karami
- PhD Candidate, Department of Medical Surgical Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Khademi
- MSc in Nursing, Candidate, Department of Nursing, Faculty of Nursing, Arak University of Medical Sciences, Arak, Iran
| | - Azam Eshaghian Dorcheh
- PhD in Nursing Candidate, Kashani Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saba Ebrahimloee
- MSc in Nursing, Department of Nursing, Nursing & Midwifery School, Tabriz University of Medical Sciences, Tabriz; School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Maryam Rassouli
- Professor, Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Chan KW, Yu KY, Yiu WH, Xue R, Lok SWY, Li H, Zou Y, Ma J, Lai KN, Tang SCW. Potential Therapeutic Targets of Rehmannia Formulations on Diabetic Nephropathy: A Comparative Network Pharmacology Analysis. Front Pharmacol 2022; 13:794139. [PMID: 35387335 PMCID: PMC8977554 DOI: 10.3389/fphar.2022.794139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/10/2022] [Indexed: 11/14/2022] Open
Abstract
Background: Previous retrospective cohorts showed that Rehmannia-6 (R-6, Liu-wei-di-huang-wan) formulations were associated with significant kidney function preservation and mortality reduction among chronic kidney disease patients with diabetes. This study aimed to investigate the potential mechanism of action of common R-6 variations in a clinical protocol for diabetic nephropathy (DN) from a system pharmacology approach. Study Design and Methods: Disease-related genes were retrieved from GeneCards and OMIM by searching “Diabetic Nephropathy” and “Macroalbuminuria”. Variations of R-6 were identified from a published existing clinical practice guideline developed from expert consensus and pilot clinical service program. The chemical compound IDs of each herb were retrieved from TCM-Mesh and PubChem. Drug targets were subsequently revealed via PharmaMapper and UniProtKB. The disease gene interactions were assessed through STRING, and disease–drug protein–protein interaction network was integrated and visualized by Cytoscape. Clusters of disease–drug protein–protein interaction were constructed by Molecular Complex Detection (MCODE) extension. Functional annotation of clusters was analyzed by DAVID and KEGG pathway enrichment. Differences among variations of R-6 were compared. Binding was verified by molecular docking with AutoDock. Results: Three hundred fifty-eight genes related to DN were identified, forming 11 clusters which corresponded to complement and coagulation cascades and signaling pathways of adipocytokine, TNF, HIF-1, and AMPK. Five variations of R-6 were analyzed. Common putative targets of the R-6 variations on DN included ACE, APOE, CCL2, CRP, EDN1, FN1, HGF, ICAM1, IL10, IL1B, IL6, INS, LEP, MMP9, PTGS2, SERPINE1, and TNF, which are related to regulation of nitric oxide biosynthesis, lipid storage, cellular response to lipopolysaccharide, inflammatory response, NF-kappa B transcription factor activity, smooth muscle cell proliferation, blood pressure, cellular response to interleukin-1, angiogenesis, cell proliferation, peptidyl-tyrosine phosphorylation, and protein kinase B signaling. TNF was identified as the seed for the most significant cluster of all R-6 variations. Targets specific to each formulation were identified. The key chemical compounds of R-6 have good binding ability to the putative protein targets. Conclusion: The mechanism of action of R-6 on DN is mostly related to the TNF signaling pathway as a core mechanism, involving amelioration of angiogenesis, fibrosis, inflammation, disease susceptibility, and oxidative stress. The putative targets identified could be validated through clinical trials.
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Affiliation(s)
- Kam Wa Chan
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Kam Yan Yu
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Wai Han Yiu
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Rui Xue
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Sarah Wing-Yan Lok
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Hongyu Li
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yixin Zou
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Jinyuan Ma
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Kar Neng Lai
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
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Chan KW, Chow TY, Yu KY, Feng Y, Lao L, Bian Z, Wong VT, Tang SCW. Effectiveness of Integrative Chinese-Western Medicine for Chronic Kidney Disease and Diabetes: A Retrospective Cohort Study. THE AMERICAN JOURNAL OF CHINESE MEDICINE 2022; 50:371-388. [PMID: 35168474 DOI: 10.1142/s0192415x2250015x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Diabetes and chronic kidney disease (CKD) are pandemic, requiring more therapeutic options. This retrospective cohort evaluated the effectiveness, safety profile and prescription pattern of a pilot integrative medicine service program in Hong Kong. Data from 38 patients with diabetes and CKD enrolled to receive 48-week individualized add-on Chinese medicine (CM) were retrieved from the electronically linked hospital database. A 1:1 cohort was generated with patients from the same source and matched by propensity score. The primary outcomes are the change of estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) analyzed by analysis of covariance and mixed regression model adjusted for baseline eGFR, age, gender, duration of diabetes history, history of hypertension, diabetic retinopathy, and the use of insulin and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. The rate of adverse events and the change of key biochemical parameters were analyzed. After a median of 51 weeks, patients who received add-on CM had stabilized eGFR (difference in treatment period: 0.74 ml/min/1.73m2, 95% CI: -1.01 to 2.50) and UACR (proportional difference in treatment period: 0.95, 95% CI: 0.67 to 1.34). Add-on CM was associated with significantly preserved eGFR (Inter-group difference: 3.19 ml/min/1.73m2, 95%CI: 0.32 to 6.06, [Formula: see text] 0.030) compared to standard care. The intergroup ratio of UACR was comparable (0.70, 95% CI: 0.45 to 1.08, [Formula: see text] 0.104). The result is robust in sensitivity analysis with different statistical methods, and there was no interaction with CKD stage and UACR. The rate of serious adverse events (8.1% vs. 18.9%, [Formula: see text] 0.174), moderate to severe hyperkalemia (8.1% vs. 2.7%, [Formula: see text] 0.304) and hypoglycemia (13.5% vs. 5.4%, [Formula: see text] 0.223), and the levels of key biochemical parameters were comparable between groups. The top seven most used CMs contained two classical formulations, namely Liu-wei-di-huang-wan and Si-jun-zi-tang. Individualized add-on CM was associated with significant kidney function preservation and was well tolerated. Further randomized controlled trials using CM prescriptions based on Liu-wei-di-huang-wan and Si-jun-zi-tang are warranted.
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Affiliation(s)
- Kam Wa Chan
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, P. R. China
| | - Tak Yee Chow
- Hong Kong Association for Integration of Chinese-Western Medicine, Hong Kong SAR, P. R. China
| | - Kam Yan Yu
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, P. R. China
| | - Yibin Feng
- School of Chinese Medicine, The University of Hong Kong, Hong Kong SAR, P. R. China
| | - Lixing Lao
- School of Chinese Medicine, The University of Hong Kong, Hong Kong SAR, P. R. China.,Virginia University of Integrative Medicine, Fairfax, Virginia, USA
| | - Zhaoxiang Bian
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, P. R. China
| | - Vivian Taam Wong
- School of Chinese Medicine, The University of Hong Kong, Hong Kong SAR, P. R. China.,Hong Kong Association for Integration of Chinese-Western Medicine, Hong Kong SAR, P. R. China
| | - Sydney Chi-Wai Tang
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, P. R. China
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Yuen SCS, Chua KK, Zhong LLD, Chan KW, Chan CKH, Chan KL, Lin Z, Mok V, Lau AY, Li M. Chinese herbal medicine treatment based on subgroup differentiation as adjunct therapy for Parkinson’s disease: study protocol of a pilot add-on, randomised, controlled, pragmatic clinical trial. Chin Med 2022; 17:16. [PMID: 35073963 PMCID: PMC8785505 DOI: 10.1186/s13020-022-00572-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/08/2022] [Indexed: 11/22/2022] Open
Abstract
Background Parkinson’s disease (PD) is a prevalent and debilitating condition. Conventional medications cannot control all symptoms and may inflict adverse effects. A survey reported that Chinese herbal medicine (CHM) is frequently sought. Existing CHM trials were contradictory and often of poor quality due to lack of methodological rigor. A national clinical guideline was drafted in China with diagnostic criteria and treatment strategy of Chinese medicine (CM) patterns subgroups of PD. The suggested CHM were found to exhibit neuroprotective effect in in vitro and in vivo studies. This trial aims to preliminarily assess the effect of CHM prescribed based on pattern differentiation on PD symptoms and patients’ quality of life, and evaluate the feasibility of the trial design for a future large-scale trial. Methods This trial will be a pilot assessor- and data analyst blind, add-on, randomised, controlled, pragmatic clinical trial. 160 PD patients will be recruited and randomised into treatment or control groups in a 1:1 ratio. The trial will be conducted over 32 weeks. PD patients in the treatment group will be stratified into subgroups based on CM pattern and receive CHM accordingly in addition to conventional medication (ConM). The control group will receive ConM only. The primary outcome will be part II of the Movement Disorder Society Sponsored Revision of Unified Parkinson’s Disease Rating Scale (MDS-UPDRS). Secondary outcomes will include part and total scores of MDS-UPDRS, domain and total scores of Non-motor symptom scale (NMSS). Adverse events will be monitored by monthly follow-ups and questionnaires. Mixed models will be used to analyse data by Jamovi and R. Expected outcomes The success of our trial will show that the pragmatic design with subgroup differentiation is feasible and can produce reliable results. It will also provide preliminary data of the effect of CHM on improving clinical outcomes and quality of PD patients. Data collected will be used to optimize study design of the future large-scale clinical study. Ethical clearance Ethical clearance of this study was given by the Research Ethics Committee of Hong Kong Baptist University (REC/20-21/0206). Trial registration This trial is registered on ClinicalTrials.gov (NCT05001217, Date: 8/10/2021, https://clinicaltrials.gov/ct2/show/NCT05001217). Type of manuscript: clinical trial protocol (date: 3rd November, 2021, version 1) Supplementary Information The online version contains supplementary material available at 10.1186/s13020-022-00572-0.
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Chan KW, Lee PW, Leung CPS, Law YK, Gao L, Chan GCW, Yiu WH, Lam TP, Tang SCW. PRAgmatic Clinical Trial Design of Integrative MediCinE (PRACTICE): A Focus Group Series and Systematic Review on Trials of Diabetes and Kidney Disease. Front Med (Lausanne) 2021; 8:668913. [PMID: 34513860 PMCID: PMC8429603 DOI: 10.3389/fmed.2021.668913] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 07/23/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Pragmatic trials inform clinical decision with better generalizability and can bridge different streams of medicine. This study collated the expectations regarding pragmatic trial design of integrative medicine (IM) for diabetes and kidney diseases among patients and physicians. Dissonance between users' perspective and existing pragmatic trial design was identified. The association between risk of bias and pragmatism of study design was assessed. Method: A 10-group semi-structured focus group interview series [21 patients, 14 conventional medicine (ConM) and 15 Chinese medicine (CM) physicians] were purposively sampled from private and public clinics in Hong Kong. Perspectives were qualitatively analyzed by constant comparative method. A systematic search of four databases was performed to identify existing IM pragmatic clinical trials in diabetes or kidney disease. Primary outcomes were the pragmatism, risk of bias, and rationale of the study design. Risk of bias and pragmatism were assessed based on Cochrane risk-of-bias tool and PRECIS-2, respectively. The correlation between risk of bias and pragmatism was assessed by regression models with sensitivity analyses. Results: The subtheme on the motivation to seek IM service was analyzed, covering the perceived limitation of ConM effect, perceived benefits of IM service, and assessment of IM effectiveness. Patients expected IM service to retard disease progression, stabilize concomitant drug dosage, and reduce potential side effects associated with ConM. In the systematic review, 25 studies from six countries were included covering CM, Korean medicine, Ayurvedic medicine, and western herbal medicine. Existing study designs did not include a detailed assessment of concomitant drug change and adverse events. Majority of studies either recruited a non-representative proportion of patients as traditional, complementary, and integrative medicine (TCIM) diagnosis was used as inclusion criteria, or not reflecting the real-world practice of TCIM by completely dropping TCIM diagnosis in the trial design. Consultation follow-up frequency is the least pragmatic domain. Increase in pragmatism did not associate with a higher risk of bias. Conclusion: Existing IM pragmatic trial design does not match the patients' expectation in the analysis of incident concomitant drug change and adverse events. A two-layer design incorporating TCIM diagnosis as a stratification factor maximizes the generalizability of evidence and real-world translation of both ConM and TCIM.
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Affiliation(s)
- Kam Wa Chan
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Pak Wing Lee
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Crystal Pui-sha Leung
- Department of Family Medicine and Primary Healthcare, Hong Kong East Cluster, Hospital Authority, Hong Kong, China
| | - Yee Kwan Law
- Department of Biochemistry, University of Oxford, Oxford, United Kingdom
| | - Lucy Gao
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | | | - Wai Han Yiu
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Tai Pong Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
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Chan KW, Chow TY, Yu KY, Xu Y, Zhang NL, Wong VT, Li S, Tang SCW. SYmptom-Based STratification of DiabEtes Mellitus by Renal Function Decline (SYSTEM): A Retrospective Cohort Study and Modeling Assessment. Front Med (Lausanne) 2021; 8:682090. [PMID: 34195211 PMCID: PMC8236588 DOI: 10.3389/fmed.2021.682090] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/17/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Previous UK Biobank studies showed that symptoms and physical measurements had excellent prediction on long-term clinical outcomes in general population. Symptoms and signs could intuitively and non-invasively predict and monitor disease progression, especially for telemedicine, but related research is limited in diabetes and renal medicine. Methods: This retrospective cohort study aimed to evaluate the predictive power of a symptom-based stratification framework and individual symptoms for diabetes. Three hundred two adult diabetic patients were consecutively sampled from outpatient clinics in Hong Kong for prospective symptom assessment. Demographics and longitudinal measures of biochemical parameters were retrospectively extracted from linked medical records. The association between estimated glomerular filtration rate (GFR) (independent variable) and biochemistry, epidemiological factors, and individual symptoms was assessed by mixed regression analyses. A symptom-based stratification framework of diabetes using symptom clusters was formulated by Delphi consensus method. Akaike information criterion (AIC) and Bayesian information criterion (BIC) were compared between statistical models with different combinations of biochemical, epidemiological, and symptom variables. Results: In the 4.2-year follow-up period, baseline presentation of edema (-1.8 ml/min/1.73m2, 95%CI: -2.5 to -1.2, p < 0.001), epigastric bloating (-0.8 ml/min/1.73m2, 95%CI: -1.4 to -0.2, p = 0.014) and alternating dry and loose stool (-1.1 ml/min/1.73m2, 95%CI: -1.9 to -0.4, p = 0.004) were independently associated with faster annual GFR decline. Eleven symptom clusters were identified from literature, stratifying diabetes predominantly by gastrointestinal phenotypes. Using symptom clusters synchronized by Delphi consensus as the independent variable in statistical models reduced complexity and improved explanatory power when compared to using individual symptoms. Symptom-biologic-epidemiologic combined model had the lowest AIC (4,478 vs. 5,824 vs. 4,966 vs. 7,926) and BIC (4,597 vs. 5,870 vs. 5,065 vs. 8,026) compared to the symptom, symptom-epidemiologic and biologic-epidemiologic models, respectively. Patients co-presenting with a constellation of fatigue, malaise, dry mouth, and dry throat were independently associated with faster annual GFR decline (-1.1 ml/min/1.73m2, 95%CI: -1.9 to -0.2, p = 0.011). Conclusions: Add-on symptom-based diagnosis improves the predictive power on renal function decline among diabetic patients based on key biochemical and epidemiological factors. Dynamic change of symptoms should be considered in clinical practice and research design.
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Affiliation(s)
- Kam Wa Chan
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Tak Yee Chow
- Hong Kong Association for Integration of Chinese-Western Medicine, Hong Kong, China
| | - Kam Yan Yu
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Yulong Xu
- School of Information Technology, Henan University of Traditional Chinese Medicine, Zhengzhou, China
| | - Nevin Lianwen Zhang
- Department of Computer Science and Engineering, The Hong Kong University of Science and Technology, Hong Kong, China
| | - Vivian Taam Wong
- School of Chinese Medicine, The University of Hong Kong, Hong Kong, China
| | - Saimei Li
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
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Chan KW, Kwong ASK, Tsui PN, Cheung SCY, Chan GCW, Choi WF, Yiu WH, Zhang Y, Wong MMY, Zhang ZJ, Tan KCB, Lao L, Tang SCW. Efficacy, safety and response predictors of adjuvant astragalus for diabetic kidney disease (READY): study protocol of an add-on, assessor-blind, parallel, pragmatic randomised controlled trial. BMJ Open 2021; 11:e042686. [PMID: 33436470 PMCID: PMC7805381 DOI: 10.1136/bmjopen-2020-042686] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Diabetic kidney disease (DKD) is a prevalent and costly complication of diabetes with limited therapeutic options, being the leading cause of end-stage kidney disease in most developed regions. Recent big data studies showed that add-on Chinese medicine (CM) led to a reduced risk of end-stage kidney disease and mortality among patients with chronic kidney disease (CKD) and diabetes. Astragalus, commonly known as huang-qi, is the most prescribed CM or used dietary herb in China for diabetes and DKD. In vivo and in vitro studies showed that astragalus ameliorated podocyte apoptosis, foot process effacement, mesangial expansion, glomerulosclerosis and interstitial fibrosis. Nevertheless, the clinical effect of astragalus remains uncharacterised. This pragmatic clinical trial aims to evaluate the effectiveness of add-on astragalus in patients with type 2 diabetes, stage 2-3 CKD and macroalbuminuria, and to identify related response predictors. METHODS AND ANALYSIS This is an add-on, assessor-blind, parallel, pragmatic randomised controlled clinical trial. 118 patients diagnosed with DKD will be recruited and randomised 1:1 to receive 48 weeks of add-on astragalus or standard medical care. Primary endpoints are the changes in estimated glomerular filtration rate and urine albumin-to-creatinine ratio between baseline and treatment endpoint. Secondary endpoints include adverse events, fasting blood glucose, glycated haemoglobin, lipids and other biomarkers. Adverse events are monitored through self-complete questionnaire and clinical visits. Outcomes will be analysed by regression models. Subgroup and sensitivity analyses will be conducted for different epidemiological subgroups and statistical analyses. Enrolment started in July 2018. ETHICS AND DISSEMINATION This study was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West/East/Kowloon Central clusters (UW 16-553/HKEC-2019-026/REC (KC/KE)-19-0049/ER-4). We will report the findings in medical journals and conferences. The dataset will be available on reasonable request. TRIAL REGISTRATION NUMBER NCT03535935.
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Affiliation(s)
- Kam Wa Chan
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Alfred Siu Kei Kwong
- Department of Family Medicine and Primary Healthcare, Hospital Authority Hong Kong West Cluster, Hong Kong, China
| | - Pun Nang Tsui
- Department of Family Medicine and Primary Healthcare, Hospital Authority Hong Kong East Cluster, Hong Kong, China
| | | | | | - Wing Fai Choi
- School of Chinese Medicine, The University of Hong Kong, Hong Kong, China
| | - Wai Han Yiu
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Yanbo Zhang
- School of Chinese Medicine, The University of Hong Kong, Hong Kong, China
| | - Michelle Man-Ying Wong
- Department of Family Medicine and Primary Healthcare, Hospital Authority Hong Kong East Cluster, Hong Kong, China
| | - Zhang-Jin Zhang
- School of Chinese Medicine, The University of Hong Kong, Hong Kong, China
| | | | - Lixing Lao
- School of Chinese Medicine, The University of Hong Kong, Hong Kong, China
- Virginia University of Integrative Medicine, Fairfax, Virginia, USA
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