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Del Campo VL, Morán JFO, Cagigal VM, Martín JM, Pagador JB, Hornero R. The use of the eye-fixation-related potential to investigate visual perception in professional domains with high attentional demand: a literature review. Neurol Sci 2024; 45:1849-1860. [PMID: 38157102 DOI: 10.1007/s10072-023-07275-w] [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: 06/18/2023] [Accepted: 12/17/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Visual attention is a cognitive skill related to visual perception and neural activity, and also moderated by expertise, in time-constrained professional domains (e.g., aviation, driving, sport, surgery). However, the contribution of both perceptual and neural processes on performance has been studied separately in the literature. DEVELOPMENT We defend an integration of visual and neural signals to offer a more complete picture of the visual attention displayed by professionals of different skill levels when performing free-viewing tasks. Specifically, we propose to zoom the analysis in data related to the quiet eye and P300 component jointly, as a novel signal processing approach to evaluate professionals' visual attention. CONCLUSION This review highlights the advantages of using portable eye trackers and electroencephalogram systems altogether, as a promising technique for a better understanding of early cognitive components related to attentional processes. Altogether, the eye-fixation-related potentials method may provide a better understanding of the cognitive mechanisms employed by the participants in natural settings, revealing what visual information is of interest for participants and distinguishing the neural bases of visual attention between targets and non-targets whenever they perceive a stimulus during free viewing experiments.
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Affiliation(s)
- Vicente Luis Del Campo
- Laboratorio de Aprendizaje y Control Motor, Facultad de Ciencias del Deporte, Universidad de Extremadura, Avda. de La Universidad, S/N, 10003, Cáceres, Spain.
| | | | - Víctor Martínez Cagigal
- Grupo de Ingeniería Biomédica, Universidad de Valladolid, E.T.S.I. Telecomunicación, Paseo Belén 15, 47011, Valladolid, Spain
- Centro de Investigación Biomédica en Red - Bioingeniería, Biomateriales y Biomedicina (CIBER-BBN), E.T.S.I. Telecomunicación, Paseo Belén 15, 47011, Valladolid, Spain
| | - Jesús Morenas Martín
- Laboratorio de Aprendizaje y Control Motor, Facultad de Ciencias del Deporte, Universidad de Extremadura, Avda. de La Universidad, S/N, 10003, Cáceres, Spain
| | - J Blas Pagador
- Centro de Cirugía de Mínima Invasión Jesús Usón, Ctra. N-521, Km. 41,8, 10071, Cáceres, Spain
| | - Roberto Hornero
- Grupo de Ingeniería Biomédica, Universidad de Valladolid, E.T.S.I. Telecomunicación, Paseo Belén 15, 47011, Valladolid, Spain
- Centro de Investigación Biomédica en Red - Bioingeniería, Biomateriales y Biomedicina (CIBER-BBN), E.T.S.I. Telecomunicación, Paseo Belén 15, 47011, Valladolid, Spain
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Thomson S, Ainsworth G, Selvanathan S, Kelly R, Collier H, Mujica-Mota R, Talbot R, Brown ST, Croft J, Rousseau N, Higham R, Al-Tamimi Y, Buxton N, Carleton-Bland N, Gledhill M, Halstead V, Hutchinson P, Meacock J, Mukerji N, Pal D, Vargas-Palacios A, Prasad A, Wilby M, Stocken D. Posterior cervical foraminotomy versus anterior cervical discectomy for Cervical Brachialgia: the FORVAD RCT. Health Technol Assess 2023; 27:1-228. [PMID: 37929307 PMCID: PMC10641711 DOI: 10.3310/otoh7720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Posterior cervical foraminotomy and anterior cervical discectomy are routinely used operations to treat cervical brachialgia, although definitive evidence supporting superiority of either is lacking. Objective The primary objective was to investigate whether or not posterior cervical foraminotomy is superior to anterior cervical discectomy in improving clinical outcome. Design This was a Phase III, unblinded, prospective, United Kingdom multicentre, parallel-group, individually randomised controlled superiority trial comparing posterior cervical foraminotomy with anterior cervical discectomy. A rapid qualitative study was conducted during the close-down phase, involving remote semistructured interviews with trial participants and health-care professionals. Setting National Health Service trusts. Participants Patients with symptomatic unilateral cervical brachialgia for at least 6 weeks. Interventions Participants were randomised to receive posterior cervical foraminotomy or anterior cervical discectomy. Allocation was not blinded to participants, medical staff or trial staff. Health-care use from providing the initial surgical intervention to hospital discharge was measured and valued using national cost data. Main outcome measures The primary outcome measure was clinical outcome, as measured by patient-reported Neck Disability Index score 52 weeks post operation. Secondary outcome measures included complications, reoperations and restricted American Spinal Injury Association score over 6 weeks post operation, and patient-reported Eating Assessment Tool-10 items, Glasgow-Edinburgh Throat Scale, Voice Handicap Index-10 items, PainDETECT and Numerical Rating Scales for neck and upper-limb pain over 52 weeks post operation. Results The target recruitment was 252 participants. Owing to slow accrual, the trial closed after randomising 23 participants from 11 hospitals. The qualitative substudy found that there was support and enthusiasm for the posterior cervical FORaminotomy Versus Anterior cervical Discectomy in the treatment of cervical brachialgia trial and randomised clinical trials in this area. However, clinical equipoise appears to have been an issue for sites and individual surgeons. Randomisation on the day of surgery and processes for screening and approaching participants were also crucial factors in some centres. The median Neck Disability Index scores at baseline (pre surgery) and at 52 weeks was 44.0 (interquartile range 36.0-62.0 weeks) and 25.3 weeks (interquartile range 20.0-42.0 weeks), respectively, in the posterior cervical foraminotomy group (n = 14), and 35.6 weeks (interquartile range 34.0-44.0 weeks) and 45.0 weeks (interquartile range 20.0-57.0 weeks), respectively, in the anterior cervical discectomy group (n = 9). Scores appeared to reduce (i.e. improve) in the posterior cervical foraminotomy group, but not in the anterior cervical discectomy group. The median Eating Assessment Tool-10 items score for swallowing was higher (worse) after anterior cervical discectomy (13.5) than after posterior cervical foraminotomy (0) on day 1, but not at other time points, whereas the median Glasgow-Edinburgh Throat Scale score for globus was higher (worse) after anterior cervical discectomy (15, 7, 6, 6, 2, 2.5) than after posterior cervical foraminotomy (3, 0, 0, 0.5, 0, 0) at all postoperative time points. Five postoperative complications occurred within 6 weeks of surgery, all after anterior cervical discectomy. Neck pain was more severe on day 1 following posterior cervical foraminotomy (Numerical Rating Scale - Neck Pain score 8.5) than at the same time point after anterior cervical discectomy (Numerical Rating Scale - Neck Pain score 7.0). The median health-care costs of providing initial surgical intervention were £2610 for posterior cervical foraminotomy and £4411 for anterior cervical discectomy. Conclusions The data suggest that posterior cervical foraminotomy is associated with better outcomes, fewer complications and lower costs, but the trial recruited slowly and closed early. Consequently, the trial is underpowered and definitive conclusions cannot be drawn. Recruitment was impaired by lack of individual equipoise and by concern about randomising on the day of surgery. A large prospective multicentre trial comparing anterior cervical discectomy and posterior cervical foraminotomy in the treatment of cervical brachialgia is still required. Trial registration This trial is registered as ISRCTN10133661. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 21. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon Thomson
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gemma Ainsworth
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rachel Kelly
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Howard Collier
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rebecca Talbot
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sarah Tess Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Julie Croft
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Nikki Rousseau
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ruchi Higham
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Yahia Al-Tamimi
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Buxton
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Martin Gledhill
- Department of Speech and Language Therapy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Peter Hutchinson
- Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James Meacock
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nitin Mukerji
- Department of Neurosurgery, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Debasish Pal
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Anantharaju Prasad
- Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Martin Wilby
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Antoun L, Middleton L, Smith P, Saridogan E, Cooper K, Brocklehurst P, McKinnon W, Bevan S, Woolley R, Jones L, Fullard J, Morgan M, Roberts T, Clark TJ. LAparoscopic Versus Abdominal hysterectomy (LAVA): protocol of a randomised controlled trial. BMJ Open 2023; 13:e070218. [PMID: 37669836 PMCID: PMC10481847 DOI: 10.1136/bmjopen-2022-070218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 06/27/2023] [Indexed: 09/07/2023] Open
Abstract
INTRODUCTION There is uncertainty about the advantages and disadvantages of laparoscopic hysterectomy compared with abdominal hysterectomy, particularly the relative rate of complications of the two procedures. While uptake of laparoscopic hysterectomy has been slow, the situation is changing with greater familiarity, better training, better equipment and increased proficiency in the technique. Thus, a large, robust, multicentre randomised controlled trial (RCT) is needed to compare contemporary laparoscopic hysterectomy with abdominal hysterectomy to determine the safest and most cost-effective technique. METHODS AND ANALYSIS A parallel, open, non-inferiority, multicentre, randomised controlled, expertise-based surgery trial with integrated health economic evaluation and an internal pilot with an embedded qualitative process evaluation. A within trial-based economic evaluation will explore the cost-effectiveness of laparoscopic hysterectomy compared with open abdominal hysterectomy. We will aim to recruit 3250 women requiring a hysterectomy for a benign gynaecological condition and who were suitable for either laparoscopic or open techniques. The primary outcome is major complications up to six completed weeks postsurgery and the key secondary outcome is time from surgery to resumption of usual activities using the personalised Patient-Reported Outcomes Measurement Information System Physical Function questionnaire. The principal outcome for the economic evaluation is to be cost per QALY at 12 months' postsurgery. A secondary analysis is to be undertaken to generate costs per major surgical complication avoided and costs per return to normal activities. ETHICS AND DISSEMINATION The study was approved by the West Midlands-Edgbaston Research Ethics Committee, 18 February 2021 (Ethics ref: 21/WM/0019). REC approval for the protocol version 2.0 dated 2 February 2021 was issued on 18 February 2021.We will present the findings in national and international conferences. We will also aim to publish the findings in high impact peer-reviewed journals. We will disseminate the completed paper to the Department of Health, the Scientific Advisory Committees of the RCOG, the Royal College of Nurses (RCN) and the BSGE. TRIAL REGISTRATION NUMBER ISRCTN14566195.
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Affiliation(s)
- Lina Antoun
- Department of Gynaecology, Birmingham Women's NHS Foundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Lee Middleton
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Paul Smith
- Department of Gynaecology, Birmingham Women's NHS Foundation Trust, Birmingham, UK
| | - Ertan Saridogan
- Department of Gynaecology, University College London Hospitals, London, UK
| | - Kevin Cooper
- Aberdeen Royal Infirmary, Aberdeen, UK
- University of Aberdeen, Aberdeen, UK
| | | | | | | | - Rebecca Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Laura Jones
- Public Health, Epidemiology & Biostatistics, University of Birmingham, Birmingham, UK
| | | | | | - Tracy Roberts
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - T Justin Clark
- Department of Gynaecology, Birmingham Women's NHS Foundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
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Gonzato O, Schuster K. The role of patient advocates and sarcoma community initiatives in musculoskeletal oncology. Moving towards Evidence-Based Advocacy to empower Evidence-Based Medicine. J Cancer Policy 2023; 36:100413. [PMID: 36806641 DOI: 10.1016/j.jcpo.2023.100413] [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: 07/20/2022] [Revised: 01/29/2023] [Accepted: 02/16/2023] [Indexed: 02/19/2023]
Abstract
Musculoskeletal sarcomas are rare cancers that as the whole family of sarcomas pose several challenges at different levels, ranging from medical knowledge to clinical research and policymaking. Addressing these challenges, necessarily calls for the inclusion of patient perspective inside the decision-making processes of every area that contributes to treatment improvement, from the provision of high-quality services by healthcare organisations to research issues. Without patient-provided inputs to inform decisions, the current paradigm of patient-centred care makes no sense and sounds at the least irrational if not unethical. Putting PROMs on "centre stage" in cancer research and care, could allow to build a truly Evidence Based Advocacy (EBA) and therefore to empower Evidence Based Medicine (EBM).
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Affiliation(s)
- Ornella Gonzato
- Fondazione Paola Gonzato-Rete Sarcoma ETS, Italy; Sarcoma Patient Advocacy Global Network (SPAGN), Germany.
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Fusegi A, Kanao H, Tsumura S, Murakami A, Abe A, Aoki Y, Nomura H. Minimally invasive radical hysterectomy and the importance of avoiding cancer cell spillage for early-stage cervical cancer: a narrative review. J Gynecol Oncol 2023; 34:e5. [PMID: 36424702 DOI: 10.3802/jgo.2023.34.e5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/25/2022] [Accepted: 09/06/2022] [Indexed: 11/15/2022] Open
Abstract
Radical hysterectomy is a standard surgery to treat early-stage uterine cervical cancer. The Laparoscopic Approach to Cervical Cancer (LACC) trial has shown that patients receiving minimally invasive radical hysterectomy have a poorer prognosis than those receiving open radical hysterectomy; however, the reason for this remains unclear. The LACC trial had 2 concerns: the learning curve and the procedural effects. Appropriate management of the learning curve effect, including surgeons' skills, is required to correctly interpret the result of surgical randomized controlled trials. Whether the LACC trial managed the learning curve effect remains controversial, based on the surgeons' inclusion criteria and the distribution of institutions with recurrent cases. An appropriate surgical procedure is also needed, and avoiding intraoperative cancer cell spillage plays an important role during cancer surgery. Cancer cell spillage during minimally invasive surgery to treat cervical cancer is caused by several factors, including 1) exposure of tumor, 2) the use of a uterine manipulator, and 3) direct handling of the uterine cervix. Unfortunately, these issues were not addressed by the LACC trial. We evaluated the results of minimally invasive radical hysterectomy while avoiding cancer cell spillage for early-stage cervical cancer. Our findings show that avoiding cancer cell spillage during minimally invasive radical hysterectomy may ensure an equivalent oncologic outcome, comparable to that of open radical hysterectomy. Therefore, evaluating the importance of avoiding cancer cell spillage during minimally invasive surgery with a better control of the learning curve and procedural effects is needed.
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Affiliation(s)
- Atsushi Fusegi
- Department of Gynecologic Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiroyuki Kanao
- Department of Gynecologic Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Shiho Tsumura
- Department of Gynecologic Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Atsushi Murakami
- Department of Gynecologic Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akiko Abe
- Department of Gynecologic Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoichi Aoki
- Department of Gynecologic Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hidetaka Nomura
- Department of Gynecologic Oncology, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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Kim LT, Kaji AH, Salminen P. Practical Guide to Quality Control in Surgical Trials. JAMA Surg 2023; 158:91-92. [PMID: 36287542 DOI: 10.1001/jamasurg.2022.4898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This Guide to Statistics and Methods outlines the elements of clinical trial quality control that are important to safeguarding data integrity and addressing the unique challenges of procedural trials.
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Affiliation(s)
- Lawrence T Kim
- Department of Surgery, Division of Surgical Oncology and Endocrine Surgery, University of North Carolina at Chapel Hill
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine at University of California, Los Angeles, Torrance.,Statistical Editor, JAMA Surgery
| | - Paulina Salminen
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
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Gazendam A, Ekhtiari S, Rubinger L, Bhandari M. Common errors in the design of orthopaedic trials: Has anything changed? Injury 2021:S0020-1383(21)00997-9. [PMID: 34920878 DOI: 10.1016/j.injury.2021.12.010] [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] [Received: 11/03/2021] [Accepted: 12/04/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The adoption of evidence-based orthopaedics has shifted the focus from expert base opinions and anecdotal evidence to a focus on integrating the best available clinical research. This shift has led to an increased focus on randomized controlled trials (RCTs) within the field. Although RCTs are considered the highest level of evidence, methodologic errors can introduce bias and limit the validity of the results. Early trials were hampered by lack of blinding, inadequate sample sizes and other design flaws. The objective of this review was to examine the current literature to determine if the design and execution of RCTs has improved. DESIGN ERRORS The awareness of the importance of sample size increased over time with substantially more trials reporting sample size calculations. However, many contemporary RCTs are still underpowered and fail to reach their calculated sample size. Given the challenges of surgically based RCTs, the majority of historical trials lacked blinding, increasing the risk of bias. There is evidence that there has been a concerted effort to increase the blinding in RCTs, particularly in outcome assessors. A more recent development in the design of surgical trials is the introduction of expertise-based trial designs in which patients are randomized to a surgeon with expertise in a particular intervention. These trials minimize the bias that can arise from differential expertise bias and have the potential to improve the validity and feasibility of RCTs. Finally, there has been an increased focus on the reporting of patient reported outcomes (PROs) in orthopaedic RCTs. Alongside this movement has been the development of minimal important differences (MIDs) to define the changes that are relevant and meaningful to patients. Both PROs and MIDs should be taken into consideration when calculating the sample size and study power in clinical trials. CONCLUSIONS Although marked improvements have been made in the design and implementation of trials, there is still considerable room for improvement. Adequately blinded and powered studies evaluating clinically important outcomes and differences should be key considerations in trial design moving forward.
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Affiliation(s)
- Aaron Gazendam
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON Canada; Centre for Evidence-Based Orthopaedics, 293 Wellington St. N, Suite 110, Hamilton, ON L8L 8E7, Canada.
| | - Seper Ekhtiari
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON Canada; Centre for Evidence-Based Orthopaedics, 293 Wellington St. N, Suite 110, Hamilton, ON L8L 8E7, Canada
| | - Luc Rubinger
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON Canada.
| | - Mohit Bhandari
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, ON Canada; Centre for Evidence-Based Orthopaedics, 293 Wellington St. N, Suite 110, Hamilton, ON L8L 8E7, Canada
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Alsagheir A, Koziarz A, Belley-Côté EP, Whitlock RP. Expertise-based design in surgical trials: a narrative review. Can J Surg 2021; 64:E594-E602. [PMID: 34759044 PMCID: PMC8592777 DOI: 10.1503/cjs.008520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 12/29/2022] Open
Abstract
Randomized controlled trials (RCTs) are the most robust study design for evaluating the safety and efficacy of a therapeutic intervention. However, their internal validity are at risk when evaluating surgical interventions. This review summarizes existing expertise- based trials in surgery and related methodological concepts to guide surgeons performing this work. We provide caseloads required to reach the learning curve for various surgical interventions and report criteria for expertise from published and unpublished expertise-based trials. In addition, we review design and implementation concepts of expertise-based trials, including recruitment of surgeons, crossover, ethics, generalizability, sample size and definitions for learning curve. Several RCTs have used an expertise-based design. We found that the majority of definitions used for expertise were vague, heterogeneous, and inconsistent across trials evaluating the same surgical intervention. Statistical methods exist to adjust for the learning curve; however, there is limited guidance. We developed the following criteria for surgical expertise for future trials: 1) decide on the proxy to be used for the learning curve, and 2) assess eligible surgeons by comparing their performance to the previously defined expertise criteria.
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Affiliation(s)
- Ali Alsagheir
- From the Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ont. (Alsagheir, Whitlock); the Faculty of Medicine, University of Toronto, Toronto, Ont. (Kozirarz); the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ont. (Belley-Côté, Whitlock); and the Department of Medicine, McMaster University, Hamilton, Ont. (Belley-Côté)
| | - Alex Koziarz
- From the Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ont. (Alsagheir, Whitlock); the Faculty of Medicine, University of Toronto, Toronto, Ont. (Kozirarz); the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ont. (Belley-Côté, Whitlock); and the Department of Medicine, McMaster University, Hamilton, Ont. (Belley-Côté)
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Beard DJ, Davies LJ, Cook JA, MacLennan G, Price A, Kent S, Hudson J, Carr A, Leal J, Campbell H, Fitzpatrick R, Arden N, Murray D, Campbell MK. Total versus partial knee replacement in patients with medial compartment knee osteoarthritis: the TOPKAT RCT. Health Technol Assess 2021; 24:1-98. [PMID: 32369436 DOI: 10.3310/hta24200] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Late-stage medial compartment knee osteoarthritis can be treated using total knee replacement or partial (unicompartmental) knee replacement. There is high variation in treatment choice and insufficient evidence to guide selection. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of partial knee replacement compared with total knee replacement in patients with medial compartment knee osteoarthritis. The findings are intended to guide surgical decision-making for patients, surgeons and health-care providers. DESIGN This was a randomised, multicentre, pragmatic comparative effectiveness trial that included an expertise component. The target sample size was 500 patients. A web-based randomisation system was used to allocate treatments. SETTING Twenty-seven NHS hospitals (68 surgeons). PARTICIPANTS Patients with medial compartment knee osteoarthritis. INTERVENTIONS The trial compared the overall management strategy of partial knee replacement treatment with total knee replacement treatment. No specified brand or subtype of implant was investigated. MAIN OUTCOME MEASURES The Oxford Knee Score at 5 years was the primary end point. Secondary outcomes included activity scores, global health measures, transition items, patient satisfaction (Lund Score) and complications (including reoperation, revision and composite 'failure' - defined by minimal Oxford Knee Score improvement and/or reoperation). Cost-effectiveness was also assessed. RESULTS A total of 528 patients were randomised (partial knee replacement, n = 264; total knee replacement, n = 264). The follow-up primary outcome response rate at 5 years was 88% and both operations had good outcomes. There was no significant difference between groups in mean Oxford Knee Score at 5 years (difference 1.04, 95% confidence interval -0.42 to 2.50). An area under the curve analysis of the Oxford Knee Score at 5 years showed benefit in favour of partial knee replacement over total knee replacement, but the difference was within the minimal clinically important difference [mean 36.6 (standard deviation 8.3) (n = 233), mean 35.1 (standard deviation 9.1) (n = 231), respectively]. Secondary outcome measures showed consistent patterns of benefit in the direction of partial knee replacement compared with total knee replacement although most differences were small and non-significant. Patient-reported improvement (transition) and reflection (would you have the operation again?) showed statistically significant superiority for partial knee replacement only, but both of these variables could be influenced by the lack of blinding. The frequency of reoperation (including revision) by treatment received was similar for both groups: 22 out of 245 for partial knee replacement and 28 out of 269 for total knee replacement patients. Revision rates at 5 years were 10 out of 245 for partial knee replacement and 8 out of 269 for total knee replacement. There were 28 'failures' of partial knee replacement and 38 'failures' of total knee replacement (as defined by composite outcome). Beyond 1 year, partial knee replacement was cost-effective compared with total knee replacement, being associated with greater health benefits (measured using quality-adjusted life-years) and lower health-care costs, reflecting lower costs of the index surgery and subsequent health-care use. LIMITATIONS It was not possible to blind patients in this study and there was some non-compliance with the allocated treatment interventions. Surgeons providing partial knee replacement were relatively experienced with the procedure. CONCLUSIONS Both total knee replacement and partial knee replacement are effective, offer similar clinical outcomes and have similar reoperation and complication rates. Some patient-reported measures of treatment approval were significantly higher for partial knee replacement than for total knee replacement. Partial knee replacement was more cost-effective (more effective and cost saving) than total knee replacement at 5 years. FUTURE WORK Further (10-year) follow-up is in progress to assess the longer-term stability of these findings. TRIAL REGISTRATION Current Controlled Trials ISRCTN03013488 and ClinicalTrials.gov NCT01352247. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 20. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Loretta J Davies
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Jonathan A Cook
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Seamus Kent
- Department of Public Health, University of Oxford, Oxford, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Carr
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - Jose Leal
- Department of Public Health, University of Oxford, Oxford, UK
| | - Helen Campbell
- Department of Public Health, University of Oxford, Oxford, UK
| | - Ray Fitzpatrick
- Department of Public Health, University of Oxford, Oxford, UK
| | - Nigel Arden
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
| | - David Murray
- Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK
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Rosenberg JE, Jung JH, Lee H, Lee S, Bakker CJ, Dahm P. Posterior musculofascial reconstruction in robotic-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer. Cochrane Database Syst Rev 2021; 8:CD013677. [PMID: 34365635 PMCID: PMC9746600 DOI: 10.1002/14651858.cd013677.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Delayed recovery of urinary continence is a major adverse effect of robotic-assisted laparoscopic prostatectomy (RALP) in men undergoing prostate cancer treatment. To address this issue, a number of surgical techniques have been designed to reconstruct the posterior aspect of the rhabdosphincter, which is responsible for urinary continence after removal of the prostate; however, it is unclear how well they work. OBJECTIVES: To assess the effects of posterior musculofascial reconstruction RALP compared to no posterior reconstruction during RALP for the treatment of clinically localized prostate cancer. SEARCH METHODS We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, three other databases, trials registries, other sources of the grey literature, and conference proceedings, up to 12 March 2021. We applied no restrictions on publication language or status. SELECTION CRITERIA We included randomized controlled trials (RCTs) in which participants were randomized to undergo variations of posterior musculofascial reconstruction RALP versus no posterior reconstruction during RALP for clinically localized prostate cancer. DATA COLLECTION AND ANALYSIS Two review authors independently classified studies and abstracted data from the included studies. Primary outcomes were: urinary continence recovery within one week after catheter removal, at three months after surgery, and serious adverse events. Secondary outcomes were: urinary continence recovery at six and twelve months after surgery, potency recovery twelve months after surgery, positive surgical margins (PSM), and biochemical recurrence-free survival (BCRFS). We performed statistical analyses using a random-effects model. We rated the certainty of evidence (CoE) according to the GRADE approach. MAIN RESULTS Our search identified 13 records of eight unique RCTs, of which six were published studies and two were abstract proceedings. We included 1085 randomized participants, of whom 963 completed the trials (88.8%). All participants had either cT1c or cT2 or cT3a disease, with a mean prostate-specific antigen level of 8.15 ng/mL. Primary outcomes Posterior reconstruction RALP (PR-RALP) may improve urinary continence one week after catheter removal compared to no posterior reconstruction during RALP (risk ratio (RR) 1.25, 95% confidence interval (CI) 0.90 to 1.73; I2 = 42%; studies = 5, participants = 498; low CoE) although the CI also includes the possibility of no effect. Assuming 335 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 84 more men per 1000 (33 fewer to 244 more) reporting urinary continence recovery. Posterior reconstruction may have little to no effect on urinary continence three months after surgery compared to no posterior reconstruction during RALP (RR 0.98, 95% CI 0.84 to 1.14; I2 = 67%; studies = 6, participants = 842; low CoE). Assuming 701 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 14 fewer men per 1000 (112 fewer to 98 more) reporting urinary continence after three months. PR-RALP probably results in little to no difference in serious adverse events compared to no posterior reconstruction during RALP (RR 0.75, 95% CI 0.29 to 1.92; I2 = 0%; studies = 6, participants = 835; moderate CoE). Assuming 25 per 1000 men undergoing standard RALP experience a serious adverse event at this time point, this corresponds to six fewer men per 1000 (17 fewer to 23 more) reporting serious adverse events. Secondary outcomes PR-RALP may result in little to no difference in recovery of continence 12 months after surgery compared to no posterior reconstruction during RALP (RR 1.02, 95% CI 0.98 to 1.07; I2 = 25%; studies = 3, participants = 602; low CoE). Assuming 918 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 18 more men per 1000 (18 fewer to 64 more) reporting urinary continence recovery. We are very uncertain about the effects of PR-RALP on recovery of potency 12 months after surgery compared to no posterior reconstruction during RALP (RR 1.02, 95% CI 0.82 to 1.26; I2 = 3%; studies = 2, participants = 308; very low CoE). Assuming 433 per 1000 men undergoing standard RALP are potent at this time point, this corresponds to nine more men per 1000 (78 fewer to 113 more) reporting potency recovery. PR-RALP may result in little to no difference in positive surgical margins compared to no posterior reconstruction during RALP (RR 1.24, 95% CI 0.65 to 2.33; I2 = 50%; studies = 3, participants = 517; low CoE). Assuming 130 per 1000 men undergoing standard RALP have a positive surgical margin, this corresponds to 31 more men per 1000 (46 fewer to 173 more) reporting positive surgical margins. PR-RALP may result in little to no difference in biochemical recurrence compared to no posterior reconstruction during RALP (RR 1.36, 95% CI 0.74 to 2.52; I2 = 0%; studies = 2, participants = 468; low CoE). Assuming 70 per 1000 men undergoing standard RALP have experienced biochemical recurrence at this time point, this corresponds to 25 more men per 1000 (18 fewer to 107 more) reporting biochemical recurrence. AUTHORS' CONCLUSIONS: This review found evidence that PR-RALP may improve early continence one week after catheter removal but not thereafter. Meanwhile, adverse event rates are probably not impacted and surgical margins rates are likely similar. This review was unable to determine if or how these findings may be impacted by the person's age, nerve-sparing status, or clinical stage. Study limitations, imprecision, and inconsistency lowered the certainty of evidence for the outcomes assessed.
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Affiliation(s)
- Joel E Rosenberg
- University of Minnesota Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jae Hung Jung
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
- Center of Evidence-Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea, South
| | - Hunju Lee
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Solam Lee
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Caitlin J Bakker
- Health Sciences Libraries, University of Minnesota, Minneapolis, Minnesota, USA
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
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Clark TJ, Saridogan E. Is there still need for a further randomised controlled trial on the route of hysterectomy for benign disease? Facts Views Vis Obgyn 2021; 13:103-105. [PMID: 34184841 PMCID: PMC8291981 DOI: 10.52054/fvvo.13.2.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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12
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Spanos K, Behrendt CA, Kouvelos G, Giannoukas AD, Kölbel T. Reply. J Vasc Surg 2021; 73:2209-2210. [PMID: 34024465 DOI: 10.1016/j.jvs.2020.12.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/17/2020] [Indexed: 10/21/2022]
Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
| | | | - George Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany
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Serrano PE, Bhandari M, Simunovic M. Surgical Culture Shifts and Randomized Clinical Trials. JAMA Netw Open 2021; 4:e2115456. [PMID: 34191001 DOI: 10.1001/jamanetworkopen.2021.15456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Pablo E Serrano
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Marko Simunovic
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Nana P, Kouvelos G, Brotis A, Spanos K, Dardiotis E, Matsagkas M, Giannoukas A. Early Outcomes of Carotid Revascularization in Retrospective Case Series. J Clin Med 2021; 10:jcm10050935. [PMID: 33804315 PMCID: PMC7957582 DOI: 10.3390/jcm10050935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/06/2021] [Accepted: 02/10/2021] [Indexed: 11/28/2022] Open
Abstract
Background: Most data in carotid stenosis treatment arise from randomized control trials (RCTs) and cohort studies. The aim of this meta-analysis was to compare 30-day outcomes in real-world practice from centers providing both modalities. Methods: A data search of the English literature was conducted, using PubMed, EMBASE and CENTRAL databases, until December 2019, using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement (PRISMA) guidelines. Only studies reporting on 30-day outcomes from centers, where both techniques were performed, were eligible for this analysis. Results: In total, 15 articles were included (16,043 patients). Of the patients, 68.1% were asymptomatic. Carotid artery stenting (CAS) did not differ from carotid endarterectomy (CEA) in terms of stroke (odds ratio (OR) 0.98; 0.77–1.25; I2 = 0%), myocardial ischemic events (OR 1.03; 0.72–1.48; I2 = 0%) and all events (OR 1.0; 0.82–1.21; I2 = 0%). Pooled stroke incidence in asymptomatic patients was 1% (95% CI: 0–2%) for CEA and 1% for CAS (95% CI: 0–2%). Pooled stroke rate in symptomatic patients was 3% (95% CI: 1–4%) for CEA and 3% (95% CI: 1–4%) for CAS. The two techniques did not differ in either outcome both in asymptomatic and symptomatic patients. Conclusion: Carotid revascularization, performed in centers providing both CAS and CEA, is safe and effective. Both techniques did not differ in terms of post-procedural neurological and cardiac events, both in asymptomatic and symptomatic patients. These findings reiterate the importance of a tailored therapeutic strategy and that “real-world” outcomes may only be valid from centers providing both treatments.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (P.N.); (K.S.); (M.M.); (A.G.)
| | - George Kouvelos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (P.N.); (K.S.); (M.M.); (A.G.)
- Correspondence: ; Tel.: +30-694-558-5876
| | - Alexandros Brotis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 38221 Volos, Greece;
| | - Konstantinos Spanos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (P.N.); (K.S.); (M.M.); (A.G.)
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital of Larissa, School of Medicine, University of Thessaly, 38221 Volos, Greece;
| | - Miltiadis Matsagkas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (P.N.); (K.S.); (M.M.); (A.G.)
| | - Athanasios Giannoukas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41334 Larissa, Greece; (P.N.); (K.S.); (M.M.); (A.G.)
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Rosenberg JE, Jung JH, Edgerton Z, Lee H, Lee S, Bakker CJ, Dahm P. Retzius-sparing versus standard robotic-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer. Cochrane Database Syst Rev 2020; 8:CD013641. [PMID: 32813279 PMCID: PMC7437391 DOI: 10.1002/14651858.cd013641.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Robotic-assisted laparoscopic prostatectomy (RALP) is widely used to surgically treat clinically localized prostate cancer. It is typically performed using an approach (standard RALP) that mimics open retropubic prostatectomy by dissecting the so-called space of Retzius anterior to the bladder. An alternative, Retzius-sparing (or posterior approach) RALP (RS-RALP) has been described, which is reported to have better continence outcomes but may be associated with a higher risk of incomplete resection and positive surgical margins (PSM). OBJECTIVES To assess the effects of RS-RALP compared to standard RALP for the treatment of clinically localized prostate cancer. SEARCH METHODS We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, three other databases, trials registries, other sources of the grey literature, and conference proceedings, up to June 2020. We applied no restrictions on publication language or status. SELECTION CRITERIA We included trials where participants were randomized to RS-RALP or standard RALP for clinically localized prostate cancer. DATA COLLECTION AND ANALYSIS Two review authors independently classified and abstracted data from the included studies. Primary outcomes were: urinary continence recovery within one week after catheter removal, at three months after surgery, and serious adverse events. Secondary outcomes were: urinary continence recovery six and 12 months after surgery, potency recovery 12 months after surgery, positive surgical margins (PSM), biochemical recurrence-free survival (BCRFS), and urinary and sexual function quality of life. We performed statistical analyses using a random-effects model. We rated the certainty of evidence using the GRADE approach. MAIN RESULTS Our search identified six records of five unique randomized controlled trials, of which two were published studies, one was in press, and two were abstract proceedings. There were 571 randomized participants, of whom 502 completed the trials. Mean age of participants was 64.6 years and mean prostate-specific antigen was 6.9 ng/mL. About 54.2% of participants had cT1c disease, 38.6% had cT2a-b disease, and 7.1 % had cT2c disease. Primary outcomes RS-RALP probably improves continence within one week after catheter removal (risk ratio (RR) 1.74, 95% confidence interval (CI) 1.41 to 2.14; I2 = 0%; studies = 4; participants = 410; moderate-certainty evidence). Assuming 335 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 248 more men per 1000 (137 more to 382 more) reporting continence recovery. RS-RALP may increase continence at three months after surgery compared to standard RALP (RR 1.33, 95% CI 1.06 to 1.68; I2 = 86%; studies = 5; participants = 526; low-certainty evidence). Assuming 750 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 224 more men per 1000 (41 more to 462 more) reporting continence recovery. We are very uncertain about the effects of RS-RALP on serious adverse events compared to standard RALP (RR 1.40, 95% CI 0.47 to 4.17; studies = 2; participants = 230; very low-certainty evidence). Secondary outcomes There is probably little to no difference in continence recovery at 12 months after surgery (RR 1.01, 95% CI 0.97 to 1.04; I2 = 0%; studies = 2; participants = 222; moderate-certainty evidence). Assuming 982 per 1000 men undergoing standard RALP are continent at this time point, this corresponds to 10 more men per 1000 (29 fewer to 39 more) reporting continence recovery. We are very uncertain about the effect of RS-RALP on potency recovery 12 months after surgery (RR 0.98, 95% CI 0.54 to 1.80; studies = 1; participants = 55; very low-certainty evidence). RS-RALP may increase PSMs (RR 1.95, 95% CI 1.19 to 3.20; I2 = 0%; studies = 3; participants = 308; low-certainty evidence) indicating a higher risk for prostate cancer recurrence. Assuming 129 per 1000 men undergoing standard RALP have positive margins, this corresponds to 123 more men per 1000 (25 more to 284 more) with PSMs. We are very uncertain about the effect of RS-RALP on BCRFS compared to standard RALP (hazard ratio (HR) 0.45, 95% CI 0.13 to 1.60; I2 = 32%; studies = 2; participants = 218; very low-certainty evidence). AUTHORS' CONCLUSIONS Findings of this review indicate that RS-RALP may result in better continence outcomes than standard RALP up to six months after surgery. Continence outcomes at 12 months may be similar. Downsides of RS-RALP may be higher positive margin rates. We are very uncertain about the effect on BCRFS and potency outcomes. Longer-term oncologic and functional outcomes are lacking, and no preplanned subgroup analyses could be performed to explore the observed heterogeneity. Surgeons should discuss these trade-offs and the limitations of the evidence with their patients when considering this approach.
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Affiliation(s)
- Joel E Rosenberg
- University of Minnesota Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jae Hung Jung
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Zach Edgerton
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Hunju Lee
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Solam Lee
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea, South
| | - Caitlin J Bakker
- Health Sciences Libraries, University of Minnesota, Minneapolis, Minnesota, USA
| | - Philipp Dahm
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
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16
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Martin J, Bainbridge D. Randomized Trials in Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2020; 34:2884-2888. [PMID: 32653271 DOI: 10.1053/j.jvca.2020.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 06/04/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Janet Martin
- Department of Anesthesia and Perioperative Medicine and Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Daniel Bainbridge
- Department of Anesthesiology and Perioperative Medicine, Western University, London, ON, Canada
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17
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Conroy EJ, Rosala-Hallas A, Blazeby JM, Burnside G, Cook JA, Gamble C. Randomized trials involving surgery did not routinely report considerations of learning and clustering effects. J Clin Epidemiol 2019; 107:27-35. [DOI: 10.1016/j.jclinepi.2018.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/11/2018] [Accepted: 11/05/2018] [Indexed: 10/27/2022]
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19
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Cook JA, Campbell MK, Gillies K, Skea Z. Surgeons' and methodologists' perceptions of utilising an expertise-based randomised controlled trial design: a qualitative study. Trials 2018; 19:478. [PMID: 30189868 PMCID: PMC6127897 DOI: 10.1186/s13063-018-2832-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 08/01/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) are widely recognised to be the most rigorous way to test new and emerging clinical interventions. When the interventions under study are two different surgical procedures, however, surgeons are required to be trained and sufficiently proficient in the different surgical approaches to take part in such a trial. It is often the case that even where surgeons can perform both trial surgical procedures, they have a preference and/or have more expertise in one of the procedures. The expertise-based trial design, where participating surgeons only provide the procedure in which they have appropriate expertise, has been proposed to overcome this problem. When expertise-based designs should be best used remains unclear; such approaches may be more suited to addressing specific questions. The aim of this qualitative study was to improve understanding about the range of views that surgeons and methodologists have regarding the use of the expertise-based RCT design. METHODS Twelve individual interviews with surgeons and methodologists with experience of surgical trials were conducted. Interviews were semi-structured and conducted face-to-face or by telephone. Interviews were audio-recorded, transcribed and analysed systematically using an interpretive approach. RESULTS Both surgeons and methodologists saw potential advantages in the expertise-based design particularly in terms of surgeons' participation and in trials where the procedures being evaluated were significantly different. The main disadvantages identified were methodological (e.g. the potential for surgeons carrying out one of the trial procedure being systematically different) and operational (e.g. the need to 'transfer' patients between surgeons with potential consequences for the surgeon/patient relationship). CONCLUSION This study suggests that the expertise-based trial design has significant potential to increase surgeon participation in trials in some settings. In other settings the standard design was generally seen as the preferable design. Particularly suitable conditions for an expertise-based design include those where the surgical procedures under evaluation are substantially different, where they are routinely delivered by different health professionals/surgeons with clear proficiencies in each; and contexts in which a multiple-surgeon model is in use and trust between the patient and surgeons can be suitably protected. The standard design was seen by most participants as the default design. Several logistical and methodological concerns remain to be addressed before the expertise-based design is likely to be more widely adopted.
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Affiliation(s)
- Jonathan A Cook
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Rd, Oxford, OX3 7LD, UK. .,Surgical Intervention Trials Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Rd, Oxford, OX3 7LD, UK.
| | - Marion K Campbell
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Zoë Skea
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
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20
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Carson‐Chahhoud KV, Wakai A, van Agteren JEM, Smith BJ, McCabe G, Brinn MP, O'Sullivan R. Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults. Cochrane Database Syst Rev 2017; 9:CD004479. [PMID: 28881006 PMCID: PMC6483783 DOI: 10.1002/14651858.cd004479.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND For management of pneumothorax that occurs without underlying lung disease, also referred to as primary spontaneous pneumothorax, simple aspiration is technically easier to perform than intercostal tube drainage. In this systematic review, we seek to compare the clinical efficacy and safety of simple aspiration versus intercostal tube drainage for management of primary spontaneous pneumothorax. This review was first published in 2007 and was updated in 2017. OBJECTIVES To compare the clinical efficacy and safety of simple aspiration versus intercostal tube drainage for management of primary spontaneous pneumothorax. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1) in the Cochrane Library; MEDLINE (1966 to January 2017); and Embase (1980 to January 2017). We searched the World Health Organization (WHO) International Clinical Trials Registry for ongoing trials (January 2017). We checked the reference lists of included trials and contacted trial authors. We imposed no language restrictions. SELECTION CRITERIA We included randomized controlled trials (RCTs) of adults 18 years of age and older with primary spontaneous pneumothorax that compared simple aspiration versus intercostal tube drainage. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, assessed trial quality, and extracted data. We combined studies using the random-effects model. MAIN RESULTS Of 2332 publications obtained through the search strategy, seven studies met the inclusion criteria; one study was ongoing and six studies of 435 participants were eligible for inclusion in the updated review. Data show a significant difference in immediate success rates of procedures favouring tube drainage over simple aspiration for management of primary spontaneous pneumothorax (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.69 to 0.89; 435 participants, 6 studies; moderate-quality evidence). Duration of hospitalization however was significantly less for patients treated by simple aspiration (mean difference (MD) -1.66, 95% CI -2.28 to -1.04; 387 participants, 5 studies; moderate-quality evidence). A narrative synthesis of evidence revealed that simple aspiration led to fewer adverse events (245 participants, 3 studies; low-quality evidence), but data suggest no differences between groups in terms of one-year success rate (RR 1.07, 95% CI 0.96 to 1.18; 318 participants, 4 studies; moderate-quality evidence), hospitalization rate (RR 0.60, 95% CI 0.25 to 1.47; 245 participants, 3 studies; very low-quality evidence), and patient satisfaction (median between-group difference of 0.5 on a scale from 1 to 10; 48 participants, 1 study; low-quality evidence). No studies provided data on cost-effectiveness. AUTHORS' CONCLUSIONS Available trials showed low to moderate-quality evidence that intercostal tube drainage produced higher rates of immediate success, while simple aspiration resulted in a shorter duration of hospitalization. Although adverse events were reported more commonly for patients treated with tube drainage, the low quality of the evidence warrants caution in interpreting these findings. Similarly, although this review observed no differences between groups when early failure rate, one-year success rate, or hospital admission rate was evaluated, this too needs to be put into the perspective of the quality of evidence, specifically, for evidence of very low and low quality for hospitalization rate and patient satisfaction, respectively. Future adequately powered research is needed to strengthen the evidence presented in this review.
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Affiliation(s)
- Kristin V Carson‐Chahhoud
- The University of South AustraliaSchool of Health SciencesCity East Campus, Frome RoadAdelaideAustralia5001
| | - Abel Wakai
- Division of Population Health Sciences (PHS), Royal College of Surgeons in Ireland (RCSI)Emergency Care Research Unit (ECRU)123 St. Stephen's GreenDublin 2Ireland
| | | | - Brian J Smith
- The Queen Elizabeth Hospital, Central Adelaide Local Health NetworkRespiratory Medicine UnitAdelaideAustralia
| | - Grainne McCabe
- Royal College of Surgeons in IrelandMercer Library23 St. Stephens Green,DublinIreland2
| | - Malcolm P Brinn
- The University of QueenslandHabit Research Group, School of Public HealthPublic Health Building, Herston RoadHerston RoadBrisbaneQueenslandAustralia4030
| | - Ronan O'Sullivan
- Cork University HospitalCorkIreland
- Our Lady's Children's Hospital CrumlinNational Children's Research CentreDublinIreland12
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Bidad N, MacDonald L, Winters ZE, Edwards SJL, Emson M, Griffin CL, Bliss J, Horne R. How informed is declared altruism in clinical trials? A qualitative interview study of patient decision-making about the QUEST trials (Quality of Life after Mastectomy and Breast Reconstruction). Trials 2016; 17:431. [PMID: 27590594 PMCID: PMC5009536 DOI: 10.1186/s13063-016-1550-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 08/12/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) often fail to recruit sufficient participants, despite altruism being cited as their motivation. Previous investigations of factors influencing participation decisions have been methodologically limited. This study evaluated how women weigh up different motivations after initially expressing altruism, and explored their understanding of a trial and its alternatives. The trial was the 'Quality of Life after Mastectomy and Breast Reconstruction' (QUEST) trial. METHODS Thirty-nine women participated in qualitative interviews 1 month post-surgery. Twenty-seven women (10 trial decliners and 17 acceptors) who spontaneously mentioned 'altruism' were selected for thematic analysis. Verbatim transcripts were coded independently by two researchers. Participants' motivations to accept or decline randomisation were cross-referenced with their understanding of the QUEST trials and the process of randomisation. RESULTS The seven emerging themes were: (1) altruism expressed by acceptors and decliners; (2) overriding personal needs in decliners; (3) pure altruism in acceptors; (4) 'hypothetical altruism' amongst acceptors; (5) weak altruism amongst acceptors; (6) conditional altruism amongst acceptors; and (7) sense of duty to participate. Poor understanding of the trial rationale and its implications was also evident. CONCLUSIONS Altruism was a motivating factor for participation in the QUEST randomised controlled trials where the main outcomes comprised quality of life and allocated treatments comprised established surgical procedures. Women's decisions were influenced by their understanding of the trial. Both acceptors and decliners of the trial expressed 'altruism', but most acceptors lacked an obvious treatment preference, hoped for personal benefits regarding a treatment allocation, or did not articulate complete understanding of the trial. TRIAL REGISTRATION QUEST A, ISRCTN38846532 ; Date assigned 6 January 2010. QUEST B, ISRCTN92581226 ; Date assigned 6 January 2010.
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Affiliation(s)
- Natalie Bidad
- Department of Practice and Policy, Centre for Behavioural Medicine, School of Pharmacy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Tavistock Square, London, WC1H 9JP UK
| | - Lindsay MacDonald
- Department of Practice and Policy, Centre for Behavioural Medicine, School of Pharmacy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Tavistock Square, London, WC1H 9JP UK
| | - Zoë E. Winters
- Breast Cancer Surgery Clinical and Patient Reported Outcomes Research, School of Clinical Sciences, University of Bristol, Level 2 Learning and Research, Southmead Hospital, Bristol, BS10 5NB UK
| | - Sarah J. L. Edwards
- Centre for Health Humanities, University College London, Gower Street, London, WC1E 6BT UK
| | - Marie Emson
- Division of Clinical Studies, The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), London, SM2 5NG UK
| | - Clare L. Griffin
- Division of Clinical Studies, The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), London, SM2 5NG UK
| | - Judith Bliss
- Division of Clinical Studies, The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), London, SM2 5NG UK
| | - Rob Horne
- Department of Practice and Policy, Centre for Behavioural Medicine, School of Pharmacy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Tavistock Square, London, WC1H 9JP UK
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22
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An Overview of Challenges and Approaches to Minimize Bias in Randomized Controlled Trials in Perioperative Medicine. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0172-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Papachristofi O, Klein A, Sharples L. Evaluation of the effects of multiple providers in complex surgical interventions. Stat Med 2016; 35:5222-5246. [PMID: 27507043 DOI: 10.1002/sim.7057] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 06/22/2016] [Accepted: 07/04/2016] [Indexed: 11/09/2022]
Abstract
In contrast to new medicinal products, surgical interventions have many features that complicate their formal assessment through Randomised Clinical Trials. For example, surgery is delivered by multidisciplinary teams; hence, differential effects on the outcome are not solely caused by differences in the leading operator's skill but are also induced by surgical team differences and patient characteristics. This study focuses on how statistical methods can be used to accommodate the multicomponent nature of the delivery of surgical interventions. Hierarchical models with cross-classifications between components of surgery, applied to historic datasets, can be used during the trial planning phase to establish the effects and interactions between different components. Methods are illustrated using two influential components of the intervention, the surgeon and the anaesthetist, in a cohort of cardiac surgery cases. The statistical implications for trial design and analysis are presented. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Olympia Papachristofi
- MRC Biostatistics Unit, University of Cambridge, Cambridge, U.K.. .,Comprehensive Health Research Division, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, U.K..
| | - Andrew Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, CB23 8RE, U.K
| | - Linda Sharples
- MRC Biostatistics Unit, University of Cambridge, Cambridge, U.K.,Comprehensive Health Research Division, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, U.K
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24
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Liu JP, Chen KJ. Methodology guideline for clinical studies investigating traditional Chinese medicine and integrative medicine: executive summary. Complement Ther Med 2016; 23:751-6. [PMID: 26615617 DOI: 10.1016/j.ctim.2015.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This guideline aims to provide a methodological guidance for clinical studies in TCM and integrative medicine in terms of study design, execution, and reporting. The commonly used methods including experimental and observational methods were introduced in this guideline such as randomized clinical trials, cohort study, case-control study, case series, and qualitative method which can be incorporated into above quantitative methods. The guideline can be used for the evaluation of therapeutic effect of TCM therapies or their combination with conventional therapy. TCM therapy refers to one of the followings or their combination: herbal medicine, acupuncture, moxibustion, cupping, Taichi/Qigong, and Guasha,Tuina (therapeutic massage). It is also suitable for research and development of ethnopharmaceuticals or folk medicine.
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Affiliation(s)
- Jian-Ping Liu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Bei San Huan Dong Lu 11, Chaoyang District, Beijing 100029, China. Jianping
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