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Seidler AL, Aberoumand M, Hunter KE, Barba A, Libesman S, Williams JG, Shrestha N, Aagerup J, Sotiropoulos JX, Montgomery AA, Gyte GML, Duley L, Askie LM. Deferred cord clamping, cord milking, and immediate cord clamping at preterm birth: a systematic review and individual participant data meta-analysis. Lancet 2023; 402:2209-2222. [PMID: 37977169 DOI: 10.1016/s0140-6736(23)02468-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Umbilical cord clamping strategies at preterm birth have the potential to affect important health outcomes. The aim of this study was to compare the effectiveness of deferred cord clamping, umbilical cord milking, and immediate cord clamping in reducing neonatal mortality and morbidity at preterm birth. METHODS We conducted a systematic review and individual participant data meta-analysis. We searched medical databases and trial registries (from database inception until Feb 24, 2022; updated June 6, 2023) for randomised controlled trials comparing deferred (also known as delayed) cord clamping, cord milking, and immediate cord clamping for preterm births (<37 weeks' gestation). Quasi-randomised or cluster-randomised trials were excluded. Authors of eligible studies were invited to join the iCOMP collaboration and share individual participant data. All data were checked, harmonised, re-coded, and assessed for risk of bias following prespecified criteria. The primary outcome was death before hospital discharge. We performed intention-to-treat one-stage individual participant data meta-analyses accounting for heterogeneity to examine treatment effects overall and in prespecified subgroup analyses. Certainty of evidence was assessed with Grading of Recommendations Assessment, Development, and Evaluation. This study is registered with PROSPERO, CRD42019136640. FINDINGS We identified 2369 records, of which 48 randomised trials provided individual participant data and were eligible for our primary analysis. We included individual participant data on 6367 infants (3303 [55%] male, 2667 [45%] female, two intersex, and 395 missing data). Deferred cord clamping, compared with immediate cord clamping, reduced death before discharge (odds ratio [OR] 0·68 [95% CI 0·51-0·91], high-certainty evidence, 20 studies, n=3260, 232 deaths). For umbilical cord milking compared with immediate cord clamping, no clear evidence was found of a difference in death before discharge (OR 0·73 [0·44-1·20], low certainty, 18 studies, n=1561, 74 deaths). Similarly, for umbilical cord milking compared with deferred cord clamping, no clear evidence was found of a difference in death before discharge (0·95 [0·59-1·53], low certainty, 12 studies, n=1303, 93 deaths). We found no evidence of subgroup differences for the primary outcome, including by gestational age, type of delivery, multiple birth, study year, and perinatal mortality. INTERPRETATION This study provides high-certainty evidence that deferred cord clamping, compared with immediate cord clamping, reduces death before discharge in preterm infants. This effect appears to be consistent across several participant-level and trial-level subgroups. These results will inform international treatment recommendations. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Anna Lene Seidler
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia.
| | - Mason Aberoumand
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Kylie E Hunter
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Angie Barba
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Sol Libesman
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | | | - Nipun Shrestha
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Jannik Aagerup
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | | | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lisa M Askie
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
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Seidler AL, Libesman S, Hunter KE, Barba A, Aberoumand M, Williams JG, Shrestha N, Aagerup J, Sotiropoulos JX, Montgomery AA, Gyte GML, Duley L, Askie LM. Short, medium, and long deferral of umbilical cord clamping compared with umbilical cord milking and immediate clamping at preterm birth: a systematic review and network meta-analysis with individual participant data. Lancet 2023; 402:2223-2234. [PMID: 37977170 DOI: 10.1016/s0140-6736(23)02469-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Deferred (also known as delayed) cord clamping can improve survival of infants born preterm (before 37 weeks of gestation), but the optimal duration of deferral remains unclear. We conducted a systematic review and individual participant data network meta-analysis with the aim of comparing the effectiveness of umbilical cord clamping strategies with different timings of clamping or with cord milking for preterm infants. METHODS We searched medical databases and trial registries from inception until Feb 24, 2022 (updated June 6, 2023) for randomised controlled trials comparing cord clamping strategies for preterm infants. Individual participant data were harmonised and assessed for risk of bias and quality. Interventions were grouped into immediate clamping, short deferral (≥15 s to <45 s), medium deferral (≥45 s to <120 s), long deferral (≥120 s), and intact cord milking. The primary outcome was death before hospital discharge. We calculated one-stage, intention-to-treat Bayesian random-effects individual participant data network meta-analysis. This study was registered with PROSPERO, CRD42019136640. FINDINGS We included individual participant data from 47 trials with 6094 participants. Of all interventions, long deferral reduced death before discharge the most (compared with immediate clamping; odds ratio 0·31 [95% credibility interval] 0·11-0·80; moderate certainty). The risk of bias was low for 10 (33%) of 30 trials, 14 (47%) had some concerns, and 6 (20%) were rated as having a high risk of bias. Heterogeneity was low, with no indication of inconsistency. INTERPRETATION This study found that long deferral of clamping leads to reduced odds of death before discharge in preterm infants. In infants assessed as requiring immediate resuscitation, this finding might only be generalisable if there are provisions for such care with the cord intact. These results are based on thoroughly cleaned and checked individual participant data and can inform future guidelines and practice. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Anna Lene Seidler
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, Camperdown, NSW, Australia.
| | - Sol Libesman
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, Camperdown, NSW, Australia
| | - Kylie E Hunter
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, Camperdown, NSW, Australia
| | - Angie Barba
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, Camperdown, NSW, Australia
| | - Mason Aberoumand
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, Camperdown, NSW, Australia
| | - Jonathan G Williams
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, Camperdown, NSW, Australia
| | - Nipun Shrestha
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, Camperdown, NSW, Australia
| | - Jannik Aagerup
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, Camperdown, NSW, Australia
| | - James X Sotiropoulos
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, Camperdown, NSW, Australia
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lisa M Askie
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, Camperdown, NSW, Australia
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Kahan BC, Hall SS, Beller EM, Birchenall M, Chan AW, Elbourne D, Little P, Fletcher J, Golub RM, Goulao B, Hopewell S, Islam N, Zwarenstein M, Juszczak E, Montgomery AA. Reporting of Factorial Randomized Trials: Extension of the CONSORT 2010 Statement. JAMA 2023; 330:2106-2114. [PMID: 38051324 DOI: 10.1001/jama.2023.19793] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Importance Transparent reporting of randomized trials is essential to facilitate critical appraisal and interpretation of results. Factorial trials, in which 2 or more interventions are assessed in the same set of participants, have unique methodological considerations. However, reporting of factorial trials is suboptimal. Objective To develop a consensus-based extension to the Consolidated Standards of Reporting Trials (CONSORT) 2010 Statement for factorial trials. Design Using the Enhancing the Quality and Transparency of Health Research (EQUATOR) methodological framework, the CONSORT extension for factorial trials was developed by (1) generating a list of reporting recommendations for factorial trials using a scoping review of methodological articles identified using a MEDLINE search (from inception to May 2019) and supplemented with relevant articles from the personal collections of the authors; (2) a 3-round Delphi survey between January and June 2022 to identify additional items and assess the importance of each item, completed by 104 panelists from 14 countries; and (3) a hybrid consensus meeting attended by 15 panelists to finalize the selection and wording of items for the checklist. Findings This CONSORT extension for factorial trials modifies 16 of the 37 items in the CONSORT 2010 checklist and adds 1 new item. The rationale for the importance of each item is provided. Key recommendations are (1) the reason for using a factorial design should be reported, including whether an interaction is hypothesized, (2) the treatment groups that form the main comparisons should be clearly identified, and (3) for each main comparison, the estimated interaction effect and its precision should be reported. Conclusions and Relevance This extension of the CONSORT 2010 Statement provides guidance on the reporting of factorial randomized trials and should facilitate greater understanding of and transparency in their reporting.
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Affiliation(s)
| | - Sophie S Hall
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Elaine M Beller
- Institute for Evidence-Based Healthcare, Bond University, Queensland, Australia
| | - Megan Birchenall
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - An-Wen Chan
- Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Diana Elbourne
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Paul Little
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - John Fletcher
- The BMJ, BMA House, Tavistock Square, London, United Kingdom
| | - Robert M Golub
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Beatriz Goulao
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Sally Hopewell
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, United Kingdom
| | - Nazrul Islam
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- The BMJ, BMA House, Tavistock Square, London, United Kingdom
| | - Merrick Zwarenstein
- Centre For Studies in Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Edmund Juszczak
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, United Kingdom
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Kahan BC, Hall SS, Beller EM, Birchenall M, Elbourne D, Juszczak E, Little P, Fletcher J, Golub RM, Goulao B, Hopewell S, Islam N, Zwarenstein M, Chan AW, Montgomery AA. Consensus Statement for Protocols of Factorial Randomized Trials: Extension of the SPIRIT 2013 Statement. JAMA Netw Open 2023; 6:e2346121. [PMID: 38051535 DOI: 10.1001/jamanetworkopen.2023.46121] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
Importance Trial protocols outline a trial's objectives as well as the methods (design, conduct, and analysis) that will be used to meet those objectives, and transparent reporting of trial protocols ensures objectives are clear and facilitates appraisal regarding the suitability of study methods. Factorial trials, in which 2 or more interventions are assessed in the same set of participants, have unique methodological considerations. However, no extension of the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 Statement, which provides guidance on reporting of trial protocols, for factorial trials is available. Objective To develop a consensus-based extension to the SPIRIT 2013 Statement for factorial trials. Evidence Review The SPIRIT extension for factorial trials was developed using the Enhancing the Quality and Transparency of Health Research (EQUATOR) methodological framework. First, a list of reporting recommendations was generated using a scoping review of methodological articles identified using a MEDLINE search (inception to May 2019), which was supplemented with relevant articles from the personal collections of the authors. Second, a 3-round Delphi survey (January to June 2022, completed by 104 panelists from 14 countries) was conducted to assess the importance of items and identify additional recommendations. Third, a hybrid consensus meeting was held, attended by 15 panelists to finalize selection and wording of the checklist. Findings This SPIRIT extension for factorial trials modified 9 of the 33 items in the SPIRIT 2013 checklist. Key reporting recommendations were that the rationale for using a factorial design should be provided, including whether an interaction is hypothesized; the treatment groups that will form the main comparisons should be identified; and statistical methods for each main comparison should be provided, including how interactions will be assessed. Conclusions and Relevance In this consensus statement, 9 factorial-specific items were provided that should be addressed in all protocols of factorial trials to increase the trial's utility and transparency.
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Affiliation(s)
| | - Sophie S Hall
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Elaine M Beller
- Institute for Evidence-Based Healthcare, Bond University, Robina, Australia
| | - Megan Birchenall
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Diana Elbourne
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Edmund Juszczak
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Paul Little
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | | | - Robert M Golub
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Beatriz Goulao
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Sally Hopewell
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, United Kingdom
| | - Nazrul Islam
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- The BMJ, London, United Kingdom
| | - Merrick Zwarenstein
- Centre For Studies in Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - An-Wen Chan
- Women's College Research Institute, University of Toronto, Toronto, Canada
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, United Kingdom
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Sach TH, Lartey ST, Davies C, Chalmers JR, Haines RH, Bradshaw LE, Montgomery AA, Thomas KS, Brown SJ, Ridd MJ, Lawton S, Cork MJ, Flohr C, Mitchell E, Swinden R, Wyatt L, Tarr S, Davies-Jones S, Jay N, Kelleher MM, Perkin MR, Boyle RJ, Williams HC. Emollients for preventing atopic eczema: Cost-effectiveness analysis of the BEEP trial. Clin Exp Allergy 2023; 53:1011-1019. [PMID: 37574761 DOI: 10.1111/cea.14381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/19/2023] [Accepted: 06/28/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Recent discoveries have led to the suggestion that enhancing skin barrier from birth might prevent eczema and food allergy. OBJECTIVE To determine the cost-effectiveness of daily all-over-body application of emollient during the first year of life for preventing atopic eczema in high-risk children at 2 years from a health service perspective. We also considered a 5-year time horizon as a sensitivity analysis. METHODS A within-trial economic evaluation using data on health resource use and quality of life captured as part of the BEEP trial alongside the trial data. Parents/carers of 1394 infants born to families at high risk of atopic disease were randomised 1:1 to the emollient group, which were advised to apply emollient (Doublebase Gel or Diprobase Cream) to their child at least once daily to the whole body during the first year of life or usual care. Both groups received advice on general skin care. The main economic outcomes were incremental cost-effectiveness ratio (ICER), defined as incremental cost per percentage decrease in risk of eczema in the primary cost-effectiveness analysis. Secondary analysis, undertaken as a cost-utility analysis, reports incremental cost per Quality-Adjusted Life Year (QALY) where child utility was elicited using the proxy CHU-9D at 2 years. RESULTS At 2 years, the adjusted incremental cost was £87.45 (95% CI -54.31, 229.27) per participant, whilst the adjusted proportion without eczema was 0.0164 (95% CI -0.0329, 0.0656). The ICER was £5337 per percentage decrease in risk of eczema. Adjusted incremental QALYs were very slightly improved in the emollient group, 0.0010 (95% CI -0.0069, 0.0089). At 5 years, adjusted incremental costs were lower for the emollient group, -£106.89 (95% CI -354.66, 140.88) and the proportion without eczema was -0.0329 (95% CI -0.0659, 0.0002). The 5-year ICER was £3201 per percentage decrease in risk of eczema. However, when inpatient costs due to wheezing were excluded, incremental costs were lower and incremental effects greater in the usual care group. CONCLUSIONS In line with effectiveness endpoints, advice given in the BEEP trial to apply daily emollient during infancy for eczema prevention in high-risk children does not appear cost-effective.
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Affiliation(s)
- Tracey H Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Stella T Lartey
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Charlotte Davies
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Rachel H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sara J Brown
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Mike J Cork
- Sheffield Dermatology Research, Department of Infection and Immunity, University of Sheffield, Sheffield, UK
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Eleanor Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Richard Swinden
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Laura Wyatt
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Stella Tarr
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Susan Davies-Jones
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola Jay
- Sheffield Children's Hospital, Sheffield, UK
| | - Maeve M Kelleher
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael R Perkin
- Population Health Research Institute, St. George's University of London, London, UK
| | - Robert J Boyle
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
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Woodhouse LJ, Montgomery AA, Pocock S, James M, Ranta A, Bath PM. Optimising the analysis of vascular prevention trials: Re-Assessment of the TARDIS trial, the first prevention trial to adopt an ordinal primary outcome measure. Contemp Clin Trials Commun 2023; 35:101186. [PMID: 37745289 PMCID: PMC10517366 DOI: 10.1016/j.conctc.2023.101186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 05/19/2023] [Accepted: 07/03/2023] [Indexed: 09/26/2023] Open
Abstract
Background Ordinalised vascular outcomes incorporating event severity are more informative than binary outcomes that just include event numbers. The TARDIS trial was the first vascular prevention study to use an ordinalised vascular outcome as its primary efficacy and safety measures and collected severity information for other vascular events. Methods TARDIS was an international prospective randomised open-label blinded-endpoint trial assessing one month of intensive versus guideline antiplatelet therapy in patients with acute non-cardioembolic stroke or TIA. Vascular events and their severity were recorded up to final follow-up at 90 days post randomisation. For each outcome, statistical techniques compared ordinal/continuous (10 models) and dichotomous (5 models) analyses; results were then ranked with the smallest p-value being given the smallest rank. Outcomes were also assessed within the pre-defined subgroup of participants with mild stroke (NIHSS≤3), or TIA recruited within 24 h. Results Ordinal versions of vascular event outcomes were created in 3096 participants for stroke, myocardial infarction, major cardiac events, bleeding events, serious adverse events and venous thromboembolism (VTE), with 32 outcomes being created overall (29 in the subgroup population due to the absence of VTE events). Overall, the tests run on ordinal outcomes tended to rank higher than tests performed on binary outcomes. 764 (24.7%) participants were recruited within 24 h of a mild stroke/TIA; again, tests run on ordinal outcomes ranked higher. Conclusions In TARDIS, tests performed on ordinal vascular outcomes tended to attain a higher rank than those performed on binary outcomes. Trial registration ISRCTN47823388.
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Affiliation(s)
- Lisa J. Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, D Floor South Block, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Stuart Pocock
- London School of Hygiene & Tropical Medicine, Keppel St., London, WC1E 7HT, UK
| | - Marilyn James
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Anna Ranta
- Department of Medicine, University of Otago Wellington, Wellington, 6242, New Zealand
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, D Floor South Block, Queen's Medical Centre, Nottingham, NG7 2UH, UK
- Stroke, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - for the TARDIS Investigators
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, D Floor South Block, Queen's Medical Centre, Nottingham, NG7 2UH, UK
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
- London School of Hygiene & Tropical Medicine, Keppel St., London, WC1E 7HT, UK
- Department of Medicine, University of Otago Wellington, Wellington, 6242, New Zealand
- Stroke, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, UK
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Woodhouse LJ, Appleton JP, Christensen H, Dineen RA, England TJ, James M, Krishnan K, Montgomery AA, Ranta A, Robinson TG, Sprigg N, Bath PM. Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia. Sci Rep 2023; 13:11717. [PMID: 37474599 PMCID: PMC10359249 DOI: 10.1038/s41598-023-38474-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 07/09/2023] [Indexed: 07/22/2023] Open
Abstract
Intensive antiplatelet therapy did not reduce recurrent stroke/transient ischaemic attack (TIA) events as compared with guideline treatment in the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial, but did increase the frequency and severity of bleeding. In this pre-specified analysis, we investigated predictors of bleeding and the association of bleeding with outcome. TARDIS was an international prospective randomised open-label blinded-endpoint trial in participants with ischaemic stroke or TIA within 48 h of onset. Participants were randomised to 30 days of intensive antiplatelet therapy (aspirin, clopidogrel, dipyridamole) or guideline-based therapy (either clopidogrel alone or combined aspirin and dipyridamole). Bleeding was defined using the International Society on Thrombosis and Haemostasis five-level ordered categorical scale: fatal, major, moderate, minor, none. Of 3,096 participants, bleeding severity was: fatal 0.4%, major 1.5%, moderate 1.2%, minor 11.4%, none 85.5%. Major/fatal bleeding was increased with intensive as compared with guideline therapy: 39 vs. 17 participants, adjusted hazard ratio 2.21, 95% CI 1.24-3.93, p = 0.007. Bleeding events diverged between treatment groups in the 8-35 day period but not in the 0-7 or 36-90 day epochs. In multivariate analysis more, and more severe, bleeding events were seen with increasing age, female sex, pre-morbid dependency, increased time to randomisation, prior major bleed, prior antiplatelet therapy and in those randomised to triple vs guideline antiplatelet therapy. More severe bleeding was associated with worse clinical outcomes across multiple physical, emotional and quality of life domains.Trial registration ISRCTN47823388 .
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Affiliation(s)
- Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Jason P Appleton
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Hanne Christensen
- Bispebjerg and Frederiksberg Hospital, Department of Neurology, University of Copenhagen, Copenhagen, Denmark
| | - Rob A Dineen
- Radiological Sciences, Mental Health and Clinical Neuroscience, School of Medicine, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Derby Stroke Centre, University Hospitals of Derby and Burton, Derby, DE22 3NE, UK
| | - Marilyn James
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK.
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
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Abstract
BACKGROUND Central adjudication of outcomes is common in randomized clinical trials in stroke. The rationale for adjudication is clear; centrally adjudicated outcomes should have less random and systematic errors than outcomes assessed locally by site investigators. However, adjudication brings added complexities to a clinical trial and can be costly. AIM To assess the evidence for outcome adjudication in stroke trials. SUMMARY OF REVIEW We identified 12 studies evaluating central adjudication in stroke trials. The majority of these were secondary analyses of trials, and the results of all of these would have remained unchanged had central adjudication not taken place, even for trials without sufficient blinding. The largest differences between site-assessed and adjudicator-assessed outcomes were between the most subjective outcomes, such as causality of serious adverse events. We found that the cost of adjudication could be upward of £100,000 for medium to large prevention trials. These findings suggest that the cost of central adjudication may outweigh the advantages it brings in many cases. However, through simulation, we found that only a small amount of bias is required in site investigators' outcome assessments before adjudication becomes important. CONCLUSION Central adjudication may not be necessary in stroke trials with blinded outcome assessment. However, for open-label studies, central adjudication may be more important.
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Affiliation(s)
- Peter J Godolphin
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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9
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Bradshaw LE, Wyatt LA, Brown SJ, Haines RH, Montgomery AA, Perkin MR, Lawton S, Sach TH, Chalmers JR, Ridd MJ, Flohr C, Brooks J, Swinden R, Mitchell EJ, Tarr S, Jay N, Thomas KS, Allen H, Cork MJ, Kelleher MM, Simpson EL, Lartey ST, Davies-Jones S, Boyle RJ, Williams HC. Emollients for prevention of atopic dermatitis; 5-year findings from the BEEP randomised trial. Allergy 2022; 78:995-1006. [PMID: 36263451 DOI: 10.1111/all.15555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/14/2022] [Accepted: 09/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The effectiveness of emollients for preventing atopic dermatitis/eczema is controversial. The Barrier Enhancement for Eczema Prevention trial evaluated the effects of daily emollients during the first year of life on atopic dermatitis and atopic conditions to age 5 years. METHODS 1394 term infants with a family history of atopic disease were randomised (1:1) to daily emollient plus standard skin-care advice (693 emollient group) or standard skin-care advice alone (701 controls). Long-term follow-up at ages 3, 4 and 5 years was via parental questionnaires. Main outcomes were parental report of a clinical diagnosis of atopic dermatitis and food allergy. RESULTS Parents reported more frequent moisturiser application in the emollient group through to 5 years. A clinical diagnosis of atopic dermatitis between 12 and 60 months was reported for 188/608 (31%) in the emollient group and 178/631 (28%) in the control group (adjusted relative risk 1.10, 95% confidence interval 0.93 to 1.30). Although more parents in the emollient group reported food reactions in the previous year at 3 and 4 years, cumulative incidence of doctor diagnosed food allergy by 5 years was similar between groups (92/609 (15%) emollients and 87/632 (14%) controls, adjusted relative risk 1.11, 95% confidence interval 0.84 to 1.45). Findings were similar for cumulative incidence of asthma and hay fever. CONCLUSIONS Daily emollient application during the first year of life does not prevent atopic dermatitis, food allergy, asthma or hay fever.
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Affiliation(s)
- Lucy E Bradshaw
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Laura A Wyatt
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sara J Brown
- Skin Research Group, School of Medicine, University of Dundee, Dundee, UK.,Department of Dermatology, Ninewells Hospital and Medical School, Dundee.,Centre for Genomic and Experimental Medicine, University of Edinburgh, Edinburgh, UK.,Department of Dermatology, NHS Lothian, Edinburgh, UK
| | - Rachel H Haines
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Michael R Perkin
- Population Health Research Institute, St. George's, University of London, London, UK
| | | | - Tracey H Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust and King's College London, UK
| | - Joanne Brooks
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Richard Swinden
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Eleanor J Mitchell
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Stella Tarr
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola Jay
- Sheffield Children's Hospital, Sheffield, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Hilary Allen
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael J Cork
- Sheffield Dermatology Research, Department of Infection and Immunity, University of Sheffield, Sheffield, UK
| | - Maeve M Kelleher
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Eric L Simpson
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Stella T Lartey
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Susan Davies-Jones
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Robert J Boyle
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
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10
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Batchelor JM, Gran S, Leighton P, Howells L, Montgomery AA, Tan W, Ahmed I, Thomas KS. Using the Vitiligo Noticeability Scale in clinical trials: construct validity, interpretability, reliability and acceptability. Br J Dermatol 2022; 187:548-556. [PMID: 35596714 PMCID: PMC9796274 DOI: 10.1111/bjd.21671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 05/15/2022] [Accepted: 05/16/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Validated outcome measures are needed for vitiligo trials. OBJECTIVES To assess construct validity, interpretability, reliability and acceptability of the Vitiligo Noticeability Scale (VNS). METHODS We used images of vitiligo before and after treatment, plus outcome data, from the HI-Light Vitiligo trial. We compared outcome assessments made by trial participants with assessments of images by clinicians and people with vitiligo who were not trial participants [Patient and Public Involvement (PPI) panel]. Hypothesis testing assessed psychometric properties of the VNS, with κ statistics to assess agreement between outcomes. Three focus groups and two online discussion groups provided insight into the use of VNS by people with vitiligo. RESULTS Our hypothesis of a positive association between VNS and participant-reported global treatment success was supported for trial participants (κ = 0·41 if VNS success was defined as ≥ 4; κ = 0·71 if VNS success was defined as ≥ 3), but not for the blinded PPI panel (κ = 0·28). As hypothesized, the association with participant-reported global success was higher for VNS (κ = 0·41) than for clinician-reported percentage repigmentation (κ = 0·17). Seventy-five per cent of trial participants valued a VNS of 3 (partial response) as a treatment success. Test-retest reliability was good: κ = 0·69 (95% confidence interval 0·63-0·74). Age and skin phototype did not influence interpretation of the VNS scores. To people with vitiligo, the VNS is an acceptable and meaningful patient-reported outcome measure. CONCLUSIONS Trial participants may assess their vitiligo differently compared with blinded assessors. A VNS score of 3 may be more highly valued by people undergoing vitiligo treatment than was previously thought. What is already known about this topic? Vitiligo is a common condition, and can have a considerable psychological impact. A Vitiligo Core Outcome Set is being developed, to enable the results of vitiligo trials to be compared and combined more easily. The Vitiligo Noticeability Scale (VNS) is a patient-reported outcome measure (PROM) developed in partnership with people with vitiligo; initial validation studies have been promising. What does this study add? The VNS shows good construct validity, reliability and acceptability; it can be used in all ages and skin phototypes. All five levels of the VNS scale should be reported for transparency, to aid interpretation of trial findings, and to facilitate meta-analysis in systematic reviews. VNS assessments made by trial participants and independent observers are likely to be qualitatively different, making blinded assessment of VNS by independent observers difficult to interpret. Blinding of participants to trial interventions is recommended whenever possible. What are the clinical implications of the work? The VNS can be used as a PROM to assess the cosmetic acceptability of repigmentation at individual patches of vitiligo. A VNS score of 3 or more is likely to be valued by patients as a treatment success.
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Affiliation(s)
- Jonathan M. Batchelor
- Centre of Evidence Based Dermatology, School of MedicineUniversity of NottinghamNottinghamUK,Department of DermatologyKing’s College Hospital NHS Foundation Trust, Beckenham BeaconBeckenhamBR3 3QLUK
| | - Sonia Gran
- Centre of Evidence Based Dermatology, School of MedicineUniversity of NottinghamNottinghamUK
| | - Paul Leighton
- Centre of Evidence Based Dermatology, School of MedicineUniversity of NottinghamNottinghamUK
| | - Laura Howells
- Centre of Evidence Based Dermatology, School of MedicineUniversity of NottinghamNottinghamUK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, School of MedicineUniversity of NottinghamNottinghamUK
| | - Wei Tan
- Nottingham Clinical Trials Unit, School of MedicineUniversity of NottinghamNottinghamUK
| | - Isma Ahmed
- Centre of Evidence Based Dermatology, School of MedicineUniversity of NottinghamNottinghamUK
| | - Kim S. Thomas
- Centre of Evidence Based Dermatology, School of MedicineUniversity of NottinghamNottinghamUK
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11
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Bath PM, Mhlanga I, Woodhouse LJ, Doubal F, Oatey K, Montgomery AA, Wardlaw JM. Cilostazol and isosorbide mononitrate for the prevention of progression of cerebral small vessel disease: baseline data and statistical analysis plan for the Lacunar Intervention Trial-2 (LACI-2) (ISRCTN14911850). Stroke Vasc Neurol 2022; 8:134-143. [PMID: 36219567 PMCID: PMC10176977 DOI: 10.1136/svn-2022-001816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/16/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Cerebral small vessel disease (SVD) causes lacunar strokes (25% of all ischaemic strokes), physical frailty and cognitive impairment and vascular and mixed dementia. There is no specific treatment to prevent progression of SVD. METHODS The LACunar Intervention Trial-2 is an investigator-initiated prospective randomised open-label blinded-endpoint phase II feasibility study assessing cilostazol and isosorbide mononitrate for preventing SVD progression. We aimed to recruit 400 patients with clinically evident lacunar ischaemic stroke and randomised to cilostazol, isosorbide mononitrate, both or neither, in addition to guideline secondary ischaemic stroke prevention, in a partial factorial design. The primary outcome is feasibility of recruitment and adherence to medication; key secondary outcomes include: drug tolerability; recurrent vascular events, cognition and function at 1 year after randomisation; and safety (bleeding, falls, death). Data are number (%) and median (IQR). RESULTS The trial commenced on 5 February 2018 and ceased recruitment on 31 May 2021 with 363 patients randomised, with the following baseline characteristics: average age 64 (56.0, 72.0) years, female 112 (30.9%), stroke onset to randomisation 79.0 (27.0, 244.0) days, hypertension 267 (73.6%), median blood pressures 143.0 (130.0, 157.0)/83.0 (75.0, 90.0) mm Hg, current smokers 67 (18.5%), educationally achieved end of school examinations (A-level) or higher 118 (32.5%), modified Rankin scale 1.0 (0.0, 1.0), National Institutes Health stroke scale 1.0 (1.4), Montreal Cognitive Assessment 26.0 (23.0, 28.0) and total SVD score on brain imaging 1.0 (0.0, 2.0). This publication summarises the baseline data and presents the statistical analysis plan. SUMMARY The trial is currently in follow-up which will complete on 31 May 2022 with results expected in October 2022. TRIAL REGISTRATION NUMBER ISRCTN14911850.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | - Iris Mhlanga
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Fergus Doubal
- Centre for Clinical Brain Sciences, UK Dementia Research Institute Centre, University of Edinburgh, Edinburgh, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute Centre, University of Edinburgh, Edinburgh, UK
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12
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Bath PM, Skinner CJC, Bath CS, Woodhouse LJ, Korovesi AAK, Long H, Havard D, Coleman CM, England TJ, Leyland V, Lim WS, Montgomery AA, Royal S, Avery A, Webb AJ, Gordon AL. Dietary nitrate supplementation for preventing and reducing the severity of winter infections, including COVID-19, in care homes (BEET-Winter): a randomised placebo-controlled feasibility trial. Eur Geriatr Med 2022; 13:1343-1355. [PMID: 36385690 PMCID: PMC9668238 DOI: 10.1007/s41999-022-00714-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 10/31/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE Infections cause considerable care home morbidity and mortality. Nitric oxide (NO) has broad-spectrum anti-viral, bacterial and yeast activity in vitro. We assessed the feasibility of supplementing dietary nitrate (NO substrate) intake in care home residents. METHODS We performed a cluster-randomised placebo-controlled trial in UK residential and nursing care home residents and compared nitrate containing (400 mg) versus free (0 mg daily) beetroot juice given for 60 days. Outcomes comprised feasibility of recruitment, adherence, salivary and urinary nitrate, and ordinal infection/clinical events. RESULTS Of 30 targeted care homes in late 2020, 16 expressed interest and only 6 participated. 49 residents were recruited (median 8 [interquartile range 7-12] per home), mean (standard deviation) age 82 (8) years, with proxy consent 41 (84%), advance directive for hospital non-admission 8 (16%) and ≥ 1 doses of COVID-19 vaccine 37 (82%). Background dietary nitrate was < 30% of acceptable daily intake. 34 (76%) residents received > 50% of juice. Residents randomised to nitrate vs placebo had higher urinary nitrate levels, median 50 [18-175] v 18 [10-50] mg/L, difference 25 [0-90]. Data paucity precluded clinical between-group comparisons; the outcome distribution was as follows: no infection 32 (67%), uncomplicated infection 0, infection requiring healthcare support 11 (23%), all-cause hospitalisation 5 (10%), all-cause mortality 0. Urinary tract infections were most common. CONCLUSIONS Recruiting UK care homes during the COVID-19 pandemic was partially successful. Supplemented dietary nitrate was tolerated and elevated urinary nitrate. Together, infections, hospitalisations and deaths occurred in 33% of residents over 60 days. A larger trial is now required. TRIAL REGISTRATION ISRCTN51124684. Application date 7/12/2020; assignment date 13/1/2021.
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Affiliation(s)
- Philip M. Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK ,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH Nottinghamshire UK
| | - Cameron J. C. Skinner
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK
| | - Charlotte S. Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK
| | | | - Hongjiang Long
- School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD UK
| | - Diane Havard
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK
| | - Christopher M. Coleman
- Division of Infection, Immunity and Microbes, School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH UK
| | - Timothy J. England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK ,Department of Stroke, University Hospitals of Derby and Burton, Derby, DE22 3NE UK
| | | | - Wei Shen Lim
- Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB UK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, NG7 2RD UK
| | - Simon Royal
- University of Nottingham Health Service, Cripps Health Centre, University Park, Nottingham, NG7 2QW UK
| | - Amanda Avery
- School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD UK
| | - Andrew J. Webb
- Clinical Pharmacology, School of Cardiovascular Medicine and Sciences, Kings College London and British Heart Foundation Centre of Research Excellence, St Thomas’ Hospital, London, SE1 7EH UK
| | - Adam L. Gordon
- Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Derby, DE22 3NE Derbyshire UK ,NIHR Applied Research Collaboration-East Midlands (ARC-EM), Nottingham, UK
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13
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Woodhouse LJ, Montgomery AA, Mant J, Davis BR, Algra A, Mas JL, Staessen JA, Thijs L, Tonkin A, Kirby A, Pocock SJ, Chalmers J, Hankey GJ, Spence JD, Sandercock P, Diener HC, Uchiyama S, Sprigg N, Bath PM. Statistical reanalysis of vascular event outcomes in primary and secondary vascular prevention trials. BMC Med Res Methodol 2021; 21:218. [PMID: 34657596 PMCID: PMC8520648 DOI: 10.1186/s12874-021-01388-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vascular prevention trials typically use dichotomous event outcomes although this may be inefficient statistically and gives no indication of event severity. We assessed whether ordinal outcomes would be more efficient and how to best analyse them. METHODS Chief investigators of vascular prevention randomised controlled trials that showed evidence of either benefit or harm, or were included in a systematic review that overall showed benefit or harm, shared individual participant data from their trials. Ordered categorical versions of vascular event outcomes (such as stroke and myocardial infarction) were analysed using 15 statistical techniques and their results then ranked, with the result with the smallest p-value given the smallest rank. Friedman and Duncan's multiple range tests were performed to assess differences between tests by comparing the average ranks for each statistical test. RESULTS Data from 35 trials (254,223 participants) were shared with the collaboration. 13 trials had more than two treatment arms, resulting in 59 comparisons. Analysis approaches (Mann Whitney U, ordinal logistic regression, multiple regression, bootstrapping) that used ordinal outcome data had a smaller average rank and therefore appeared to be more efficient statistically than those that analysed the original binary outcomes. CONCLUSIONS Ordinal vascular outcome measures appear to be more efficient statistically than binary outcomes and provide information on the severity of event. We suggest a potential role for using ordinal outcomes in vascular prevention trials.
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Affiliation(s)
- Lisa J Woodhouse
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Jonathan Mant
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Barry R Davis
- The University of Texas Health Science Center at Houston, Houston, USA
| | - Ale Algra
- University Medical Center Utrecht, Utrecht, Netherlands
| | - Jean-Louis Mas
- Hopital Sainte-Anne, Université Paris-Descartes, Paris, France
| | - Jan A Staessen
- Department of Cardiovascular Sciences, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Lutgarde Thijs
- Department of Cardiovascular Sciences, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Andrew Tonkin
- Chronic Disease & Aging Unit, Monash University, Clayton, Australia
| | - Adrienne Kirby
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | | | - John Chalmers
- George Institute for Global Health, Sydney, Australia
| | - Graeme J Hankey
- Department of Neurology, University of Western Australia, Crawley, Australia
| | | | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Nikola Sprigg
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK.
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14
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Cole MJ, Tan W, Fifer H, Brittain C, Duley L, Hepburn T, Lawrence T, Montgomery AA, Sprange K, Thandi S, Churchward C, Tripodo F, Woodford N, Ross JDC. Gentamicin, azithromycin and ceftriaxone in the treatment of gonorrhoea: the relationship between antibiotic MIC and clinical outcome. J Antimicrob Chemother 2021; 75:449-457. [PMID: 31670808 DOI: 10.1093/jac/dkz436] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 09/05/2019] [Accepted: 09/23/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To investigate the relationship between MIC and clinical outcome in a randomized controlled trial that compared gentamicin 240 mg plus azithromycin 1 g with ceftriaxone 500 mg plus azithromycin 1 g. MIC analysis was performed on Neisseria gonorrhoeae isolates from all participants who were culture positive before they received treatment. METHODS Viable gonococcal cultures were available from 279 participants, of whom 145 received ceftriaxone/azithromycin and 134 received gentamicin/azithromycin. Four participants (6 isolates) and 14 participants (17 isolates) did not clear infection in the ceftriaxone/azithromycin and gentamicin/azithromycin arms, respectively. MICs were determined by Etest on GC agar base with 1% Vitox. The geometric mean MICs of azithromycin, ceftriaxone and gentamicin were compared using logistic and linear regression according to treatment received and N. gonorrhoeae clearance. RESULTS As the azithromycin MIC increased, gentamicin/azithromycin treatment was less effective than ceftriaxone/azithromycin at clearing N. gonorrhoeae. There was a higher geometric mean MIC of azithromycin for isolates from participants who had received gentamicin/azithromycin and did not clear infection compared with those who did clear infection [ratio 1.95 (95% CI 1.28-2.97)], but the use of categorical MIC breakpoints did not accurately predict the treatment response. The geometric mean MIC of azithromycin was higher in isolates from the pharynx compared with genital isolates. CONCLUSIONS We found that categorical resistance to azithromycin or ceftriaxone in vitro, and higher gentamicin MICs in the absence of breakpoints, were poorly predictive of treatment failure.
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Affiliation(s)
| | - Wei Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Clare Brittain
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Tessa Lawrence
- University Hospitals Birmingham NHS Foundation Trust, Whittall Street Clinic, Birmingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Sukhwinder Thandi
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | | | | | - Jonathan D C Ross
- University Hospitals Birmingham NHS Foundation Trust, Whittall Street Clinic, Birmingham, UK
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15
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Lincoln NB, Bradshaw LE, Constantinescu CS, Day F, Drummond AE, Fitzsimmons D, Harris S, Montgomery AA, das Nair R. Group cognitive rehabilitation to reduce the psychological impact of multiple sclerosis on quality of life: the CRAMMS RCT. Health Technol Assess 2021; 24:1-182. [PMID: 31934845 DOI: 10.3310/hta24040] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND People with multiple sclerosis have problems with memory and attention. The effectiveness of cognitive rehabilitation has not been established. OBJECTIVES The objectives were to assess the clinical effectiveness and cost-effectiveness of a cognitive rehabilitation programme for people with multiple sclerosis. DESIGN This was a multicentre, randomised controlled trial in which participants were randomised in a ratio of 6 : 5 to receive cognitive rehabilitation plus usual care or usual care alone. Participants were assessed at 6 and 12 months after randomisation. SETTING The trial was set in hospital neurology clinics and community services. PARTICIPANTS Participants were people with multiple sclerosis who had cognitive problems, were aged 18-69 years, could travel to attend group sessions and gave informed consent. INTERVENTION The intervention was a group cognitive rehabilitation programme delivered weekly by an assistant psychologist to between four and six participants for 10 weeks. MAIN OUTCOME MEASURES The primary outcome was the Multiple Sclerosis Impact Scale - Psychological subscale at 12 months. Secondary outcomes included results from the Everyday Memory Questionnaire, the 30-Item General Health Questionnaire, the EuroQol-5 Dimensions, five-level version and a service use questionnaire from participants, and the Everyday Memory Questionnaire - relative version and the Modified Carer Strain Index from a relative or friend of the participant. RESULTS Of the 449 participants randomised, 245 were allocated to cognitive rehabilitation (intervention group) and 204 were allocated to usual care (control group). Of these, 214 in the intervention group and 173 in the control group were included in the primary analysis. There was no clinically important difference in the Multiple Sclerosis Impact Scale - Psychological subscale score between the two groups at the 12-month follow-up (adjusted difference in means -0.6, 95% confidence interval -1.5 to 0.3; p = 0.20). There were no important differences between the groups in relation to cognitive abilities, fatigue, employment, or carer strain at follow-up. However, there were differences, although small, between the groups in the Multiple Sclerosis Impact Scale - Psychological subscale score at 6 months (adjusted difference in means -0.9, 95% confidence interval -1.7 to -0.1; p = 0.03) and in everyday memory on the Everyday Memory Questionnaire as reported by participants at 6 (adjusted difference in means -5.3, 95% confidence interval -8.7 to -1.9) and 12 months (adjusted difference in means -4.4, 95% confidence interval -7.8 to -0.9) and by relatives at 6 (adjusted difference in means -5.4, 95% confidence interval -9.1 to -1.7) and 12 months (adjusted difference in means -5.5, 95% confidence interval -9.6 to -1.5) in favour of the cognitive rehabilitation group. There were also differences in mood on the 30-Item General Health Questionnaire at 6 (adjusted difference in means -3.4, 95% confidence interval -5.9 to -0.8) and 12 months (adjusted difference in means -3.4, 95% confidence interval -6.2 to -0.6) in favour of the cognitive rehabilitation group. A qualitative analysis indicated perceived benefits of the intervention. There was no evidence of a difference in costs (adjusted difference in means -£574.93, 95% confidence interval -£1878.93 to £729.07) or quality-adjusted life-year gain (adjusted difference in means 0.00, 95% confidence interval -0.02 to 0.02). No safety concerns were raised and no deaths were reported. LIMITATIONS The trial included a sample of participants who had relatively severe cognitive problems in daily life. The trial was not powered to perform subgroup analyses. Participants could not be blinded to treatment allocation. CONCLUSIONS This cognitive rehabilitation programme had no long-term benefits on quality of life for people with multiple sclerosis. FUTURE WORK Future research should evaluate the selection of those who may benefit from cognitive rehabilitation. TRIAL REGISTRATION Current Controlled Trials ISRCTN09697576. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 4. See the National Institute for Health Research Journals Library website for further project information.
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Affiliation(s)
- Nadina B Lincoln
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Florence Day
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | | | - Shaun Harris
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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Csipke E, Shafayat A, Sprange K, Bradshaw L, Montgomery AA, Ogollah R, Moniz-Cook E, Orrell M. Promoting Independence in Dementia (PRIDE): A Feasibility Randomized Controlled Trial. Clin Interv Aging 2021; 16:363-378. [PMID: 33664568 PMCID: PMC7921631 DOI: 10.2147/cia.s281139] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/13/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND There is a need for interventions to foster and maintain independence for people with dementia to support community living, improve morale, and reduce stigma. We investigated a social intervention to promote living well and enhance independence for people with mild dementia. METHODS In this two arm parallel group, feasibility RCT at six sites in England, participants were randomized (1:1) to the PRIDE intervention (encompassing social, physical, and cognitive domains supported by a facilitator over three sessions) compared to usual care only. The main objective was to determine the feasibility of a main trial with respect to measures of recruitment, retention, and adherence to the intervention. RESULTS During a 7-month period, 402 people were invited to the trial, 148 were screened (37%, 95% confidence interval (CI)=32-42%), 137 were eligible at pre-consent, 94 consented to the trial (69% of those eligible, 95% CI=60-76%), and 92 were randomized (46 to each group). Of those allocated to the intervention, 42 (91%) received at least one of three intervention sessions. Outcome assessment follow-up visits were completed for 73 participants at 6 months (79%, 95% CI=70-87%), and this was similar for both groups. CONCLUSION A large multi-center trial of the PRIDE intervention in community-dwelling people with mild dementia is feasible using systematic recruitment strategies. The intervention was successfully delivered and well received by participants. Findings from this study will be used to refine the design and processes for a definitive RCT. TRIAL REGISTRATION ISRCTN, ISRCTN11288961, registered on 23 October 2018.
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Affiliation(s)
- Emese Csipke
- Division of Psychiatry, University College London, London, UK
| | - Aisha Shafayat
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lucy Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Reuben Ogollah
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Martin Orrell
- Institute of Mental Health, University of Nottingham, Nottingham, UK
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17
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Thomas KS, Batchelor JM, Akram P, Chalmers JR, Haines RH, Meakin GD, Duley L, Ravenscroft JC, Rogers A, Sach TH, Santer M, Tan W, White J, Whitton ME, Williams HC, Cheung ST, Hamad H, Wright A, Ingram JR, Levell NJ, Goulding JMR, Makrygeorgou A, Bewley A, Ogboli M, Stainforth J, Ferguson A, Laguda B, Wahie S, Ellis R, Azad J, Rajasekaran A, Eleftheriadou V, Montgomery AA. Randomized controlled trial of topical corticosteroid and home-based narrowband ultraviolet B for active and limited vitiligo: results of the HI-Light Vitiligo Trial. Br J Dermatol 2020; 184:828-839. [PMID: 33006767 DOI: 10.1111/bjd.19592] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evidence for the effectiveness of vitiligo treatments is limited. OBJECTIVES To determine the effectiveness of (i) handheld narrowband UVB (NB-UVB) and (ii) a combination of potent topical corticosteroid (TCS) and NB-UVB, compared with TCS alone, for localized vitiligo. METHODS A pragmatic, three-arm, placebo-controlled randomized controlled trial (9-month treatment, 12-month follow-up). Adults and children, recruited from secondary care and the community, aged ≥ 5 years and with active vitiligo affecting < 10% of skin, were randomized 1 : 1 : 1 to receive TCS (mometasone furoate 0·1% ointment + dummy NB-UVB), NB-UVB (NB-UVB + placebo TCS) or a combination (TCS + NB-UVB). TCS was applied once daily on alternating weeks; NB-UVB was administered on alternate days in escalating doses, adjusted for erythema. The primary outcome was treatment success at 9 months at a target patch assessed using the participant-reported Vitiligo Noticeability Scale, with multiple imputation for missing data. The trial was registered with number ISRCTN17160087 on 8 January 2015. RESULTS In total 517 participants were randomized to TCS (n = 173), NB-UVB (n = 169) and combination (n = 175). Primary outcome data were available for 370 (72%) participants. The proportions with target patch treatment success were 17% (TCS), 22% (NB-UVB) and 27% (combination). Combination treatment was superior to TCS: adjusted between-group difference 10·9% (95% confidence interval 1·0%-20·9%; P = 0·032; number needed to treat = 10). NB-UVB alone was not superior to TCS: adjusted between-group difference 5·2% (95% CI - 4·4% to 14·9%; P = 0·29; number needed to treat = 19). Participants using interventions with ≥ 75% expected adherence were more likely to achieve treatment success, but the effects were lost once treatment stopped. Localized grade 3 or 4 erythema was reported in 62 (12%) participants (including three with dummy light). Skin thinning was reported in 13 (2·5%) participants (including one with placebo ointment). CONCLUSIONS Combination treatment with home-based handheld NB-UVB plus TCS is likely to be superior to TCS alone for treatment of localized vitiligo. Combination treatment was relatively safe and well tolerated but was successful in only around one-quarter of participants.
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Affiliation(s)
- K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - J M Batchelor
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - P Akram
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - R H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - G D Meakin
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - L Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - J C Ravenscroft
- Department of Paediatric Dermatology, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Rogers
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - T H Sach
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - M Santer
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - W Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - J White
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - M E Whitton
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - S T Cheung
- Cannock Chase Hospital and New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - H Hamad
- Cannock Chase Hospital and New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - A Wright
- St Luke's Hospital, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - J R Ingram
- Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - N J Levell
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - J M R Goulding
- Solihull Hospital, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Makrygeorgou
- West Glasgow Ambulatory Care Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - A Bewley
- Barts Health NHS Trust and Queen Mary University London, London, UK
| | - M Ogboli
- Birmingham Children's Hospital, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - J Stainforth
- York Hospital, York Teaching Hospital NHS Foundation Trust, York, UK
| | - A Ferguson
- Royal Derby Hospital and the London Road Community Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - B Laguda
- Chelsea and Westminster Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - S Wahie
- University Hospital of North Durham, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - R Ellis
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - J Azad
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - A Rajasekaran
- Birmingham City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - A A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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Foss A, Haydock R, Childs M, Duley LM, Empeslidis T, Dhar-Munshi S, Montgomery AA, Ogollah R, Ozolins M, Tesha P, Mitchell E. TANDEM TRIAL: a factorial randomised controlled trial of dose and review schedule of bevacizumab (Avastin) for neovascular macular degeneration in the East Midlands. BMJ Open Ophthalmol 2020; 5:e000588. [PMID: 33344775 PMCID: PMC7725082 DOI: 10.1136/bmjophth-2020-000588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 11/26/2022] Open
Abstract
Objective Neovascular age-related macular degeneration (nAMD) causes damage to the macula and severe vision loss. Bevacizumab is the most cost-effective nAMD treatment. The TANDEM trial was designed to determine whether, in patients with nAMD, low-dose bevacizumab is non-inferior to the standard dose in terms of visual deterioration and whether a bimonthly regimen is non-inferior to monthly, treatment as required, regimens. Methods This was a multicentre, 2×2 factorial, double-masked, non-inferiority randomised trial with patients considered eligible if they met the National Institute for Health and Care Excellence criteria for nAMD treatment with ranibizumab. Participants were randomly assigned to standard (1.25 mg) or low (0.625 mg) dose bevacizumab and either monthly or bimonthly review regimen. The primary outcome was time to vision deterioration, defined as reduction of ≥15 letters (three lines) during the loading phase (visual acuity scores at visits B and C compared with the initial visit A), or ≥6 letters (one line) during the maintenance phase (visual acuity scores at subsequent visits compared with mean vision at visits A–C). Results In total 812 participants (918 eyes) were randomised into the trial. The low dose showed some evidence of being non-inferior to standard dose (HR 1.07; 95% CI 0.80 to 1.42), however, there was no strong evidence of bimonthly review being non-inferior to monthly review (HR 1.45; 95% CI 1.09 to 1.94). There was no difference in visual acuity when assessed at 9 months and no major differences in the frequency of serious adverse events or reactions between the groups. Conclusion The standard dose of bevacizumab can be halved without compromising efficacy. Bimonthly review cannot be considered to be no worse than monthly review.
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Affiliation(s)
- Alexander Foss
- Department of Ophthalmology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rebecca Haydock
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Margaret Childs
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Lelia M Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Theo Empeslidis
- Department of Ophthalmology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sushma Dhar-Munshi
- Department of Ophthalmology, Kings Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-In-Ashfield, Nottinghamshire, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Reuben Ogollah
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Mara Ozolins
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Paul Tesha
- Department of Ophthalmology, Lincoln County Hospital, United Lincolnshire Hospitals NHS Trust, Lincoln, Lincolnshire, UK
| | - Eleanor Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
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Husbands S, Elliott D, Davis TRC, Blazeby JM, Harrison EF, Montgomery AA, Sprange K, Duley L, Karantana A, Hollingworth W, Mills N. Optimising recruitment to the HAND-1 RCT feasibility study: integration of the QuinteT Recruitment Intervention (QRI). Pilot Feasibility Stud 2020; 6:173. [PMID: 33292646 PMCID: PMC7650179 DOI: 10.1186/s40814-020-00710-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 10/16/2020] [Indexed: 12/04/2022] Open
Abstract
Background Recruitment to randomised controlled trials (RCTs) can be challenging, with most trials not reaching recruitment targets. Randomised feasibility studies can be set up prior to a main trial to identify and overcome recruitment obstacles. This paper reports on an intervention—the QuinteT Recruitment Intervention (QRI)—to optimise recruitment within a randomised feasibility study of surgical treatments for patients with Dupuytren’s contracture (the HAND-1 study). Methods The QRI was introduced in 2-phases: phase 1 sought to understand the recruitment challenges by interviewing trial staff, scrutinising screening logs and analysing audio-recorded patient consultations; in phase 2 a tailored plan of action consisting of recruiter feedback and training was delivered to address the identified challenges. Results Two key recruitment obstacles emerged: (1) issues with the recruitment pathway, in particular methods to identify potentially eligible patients and (2) equipoise of recruiters and patients. These were addressed by liaising with centres to share good practice and refine their pathway and by providing bespoke feedback and training on consent discussions to individual recruiters and centres whilst recruitment was ongoing. The HAND-1 study subsequently achieved its recruitment target. Conclusions Transferable lessons learnt from the QRI in the feasibility study will be implemented in the definitive RCT, enabling a “head start” in the tackling of wider issues around screening methods and consent discussions in the set up/early recruitment study phases, with ongoing QRI addressing specific issues with new centres and recruiters. Findings from this study are likely to be relevant to other surgical and similar trials that are anticipated to encounter issues around patient and recruiter equipoise of treatments and variation in recruitment pathways across centres. The study also highlights the value of feasibility studies in fine-tuning design and conduct issues for definitive RCTs. Embedding a QRI in an RCT, at feasibility or main stage, offers an opportunity for a detailed and nuanced understanding of key recruitment challenges and the chance to address them in “real-time” as recruitment proceeds.
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Affiliation(s)
- Samantha Husbands
- Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK.
| | - Daisy Elliott
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Tim R C Davis
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Jane M Blazeby
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Eleanor F Harrison
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Alexia Karantana
- Department of Academic Orthopaedics, Trauma and Sports Medicine, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
| | - William Hollingworth
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Nicola Mills
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
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20
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Sach TH, Thomas KS, Batchelor JM, Perways A, Chalmers JR, Haines RH, Meakin GD, Duley L, Ravenscroft JC, Rogers A, Santer M, Tan W, White J, Whitton ME, Williams HC, Cheung ST, Hamad H, Wright A, Ingram JR, Levell N, Goulding JMR, Makrygeorgou A, Bewley A, Ogboli M, Stainforth J, Ferguson A, Laguda B, Wahie S, Ellis R, Azad J, Rajasekaran A, Eleftheriadou V, Montgomery AA. An economic evaluation of the randomized controlled trial of topical corticosteroid and home-based narrowband ultraviolet B for active and limited vitiligo (the HI-Light Vitiligo Trial). Br J Dermatol 2020; 184:840-848. [PMID: 32920824 DOI: 10.1111/bjd.19554] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Economic evidence for vitiligo treatments is absent. OBJECTIVES To determine the cost-effectiveness of (i) handheld narrowband ultraviolet B (NB-UVB) and (ii) a combination of topical corticosteroid (TCS) and NB-UVB compared with TCS alone for localized vitiligo. METHODS Cost-effectiveness analysis alongside a pragmatic, three-arm, placebo-controlled randomized controlled trial with 9 months' treatment. In total 517 adults and children (aged ≥ 5 years) with active vitiligo affecting < 10% of skin were recruited from secondary care and the community and were randomized 1: 1: 1 to receive TCS, NB-UVB or both. Cost per successful treatment (measured on the Vitiligo Noticeability Scale) was estimated. Secondary cost-utility analyses measured quality-adjusted life-years using the EuroQol 5 Dimensions 5 Levels for those aged ≥ 11 years and the Child Health Utility 9D for those aged 5 to < 18 years. The trial was registered with number ISRCTN17160087 on 8 January 2015. RESULTS The mean ± SD cost per participant was £775 ± 83·7 for NB-UVB, £813 ± 111.4 for combination treatment and £600 ± 96·2 for TCS. In analyses adjusted for age and target patch location, the incremental difference in cost for combination treatment compared with TCS was £211 (95% confidence interval 188-235), corresponding to a risk difference of 10·9% (number needed to treat = 9). The incremental cost was £1932 per successful treatment. The incremental difference in cost for NB-UVB compared with TCS was £173 (95% confidence interval 151-196), with a risk difference of 5·2% (number needed to treat = 19). The incremental cost was £3336 per successful treatment. CONCLUSIONS Combination treatment, compared with TCS alone, has a lower incremental cost per additional successful treatment than NB-UVB only. Combination treatment would be considered cost-effective if decision makers are willing to pay £1932 per additional treatment success.
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Affiliation(s)
- T H Sach
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - J M Batchelor
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - A Perways
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - R H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - G D Meakin
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - L Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - J C Ravenscroft
- Department of Paediatric Dermatology, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Rogers
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - M Santer
- Primary Care, Population Sciences & Medical Education, University of Southampton, Southampton, UK
| | - W Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - J White
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - M E Whitton
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - S T Cheung
- Cannock Chase Hospital and New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - H Hamad
- Cannock Chase Hospital and New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - A Wright
- St Luke's Hospital, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - J R Ingram
- Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - N Levell
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - J M R Goulding
- Solihull Hospital, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Makrygeorgou
- West Glasgow Ambulatory Care Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - A Bewley
- Whipps Cross Hospital and The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - M Ogboli
- Birmingham Children's Hospital, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - J Stainforth
- York Hospital, York Teaching Hospital NHS Foundation Trust, York, UK
| | - A Ferguson
- Royal Derby Hospital and the London Road Community Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - B Laguda
- Chelsea and Westminster Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - S Wahie
- University Hospital of North Durham, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - R Ellis
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - J Azad
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - A Rajasekaran
- Birmingham City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - A A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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Batchelor JM, Thomas KS, Akram P, Azad J, Bewley A, Chalmers JR, Cheung ST, Duley L, Eleftheriadou V, Ellis R, Ferguson A, Goulding JM, Haines RH, Hamad H, Ingram JR, Laguda B, Leighton P, Levell N, Makrygeorgou A, Meakin GD, Millington A, Ogboli M, Rajasekaran A, Ravenscroft JC, Rogers A, Sach TH, Santer M, Stainforth J, Tan W, Wahie S, White J, Whitton ME, Williams HC, Wright A, Montgomery AA. Home-based narrowband UVB, topical corticosteroid or combination for children and adults with vitiligo: HI-Light Vitiligo three-arm RCT. Health Technol Assess 2020; 24:1-128. [PMID: 33245043 PMCID: PMC7750863 DOI: 10.3310/hta24640] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Systematic reviews suggest that narrowband ultraviolet B light combined with treatments such as topical corticosteroids may be more effective than monotherapy for vitiligo. OBJECTIVE To explore the clinical effectiveness and cost-effectiveness of topical corticosteroid monotherapy compared with (1) hand-held narrowband ultraviolet B light monotherapy and (2) hand-held narrowband ultraviolet B light/topical corticosteroid combination treatment for localised vitiligo. DESIGN Pragmatic, three-arm, randomised controlled trial with 9 months of treatment and a 12-month follow-up. SETTING Sixteen UK hospitals - participants were recruited from primary and secondary care and the community. PARTICIPANTS Adults and children (aged ≥ 5 years) with active non-segmental vitiligo affecting ≤ 10% of their body area. INTERVENTIONS Topical corticosteroids [mometasone furoate 0.1% (Elocon®, Merck Sharp & Dohme Corp., Merck & Co., Inc., Whitehouse Station, NJ, USA) plus dummy narrowband ultraviolet B light]; narrowband ultraviolet B light (narrowband ultraviolet B light plus placebo topical corticosteroids); or combination (topical corticosteroids plus narrowband ultraviolet B light). Topical corticosteroids were applied once daily on alternate weeks and narrowband ultraviolet B light was administered every other day in escalating doses, with a dose adjustment for erythema. All treatments were home based. MAIN OUTCOME MEASURES The primary outcome was self-assessed treatment success for a chosen target patch after 9 months of treatment ('a lot less noticeable' or 'no longer noticeable' on the Vitiligo Noticeability Scale). Secondary outcomes included blinded assessment of primary outcome and percentage repigmentation, onset and maintenance of treatment response, quality of life, side effects, treatment burden and cost-effectiveness (cost per additional successful treatment). RESULTS In total, 517 participants were randomised (adults, n = 398; and children, n = 119; 52% male; 57% paler skin types I-III, 43% darker skin types IV-VI). At the end of 9 months of treatment, 370 (72%) participants provided primary outcome data. The median percentage of narrowband ultraviolet B light treatment-days (actual/allocated) was 81% for topical corticosteroids, 77% for narrowband ultraviolet B light and 74% for combination groups; and for ointment was 79% for topical corticosteroids, 83% for narrowband ultraviolet B light and 77% for combination. Target patch location was head and neck (31%), hands and feet (32%), and rest of the body (37%). Target patch treatment 'success' was 20 out of 119 (17%) for topical corticosteroids, 27 out of 123 (22%) for narrowband ultraviolet B light and 34 out of 128 (27%) for combination. Combination treatment was superior to topical corticosteroids (adjusted risk difference 10.9%, 95% confidence interval 1.0% to 20.9%; p = 0.032; number needed to treat = 10). Narrowband ultraviolet B light was not superior to topical corticosteroids (adjusted risk difference 5.2%, 95% confidence interval -4.4% to 14.9%; p = 0.290; number needed to treat = 19). The secondary outcomes supported the primary analysis. Quality of life did not differ between the groups. Participants who adhered to the interventions for > 75% of the expected treatment protocol were more likely to achieve treatment success. Over 40% of participants had lost treatment response after 1 year with no treatment. Grade 3 or 4 erythema was experienced by 62 participants (12%) (three of whom were using the dummy) and transient skin thinning by 13 participants (2.5%) (two of whom were using the placebo). We observed no serious adverse treatment effects. For combination treatment compared with topical corticosteroids, the unadjusted incremental cost-effectiveness ratio was £2328.56 (adjusted £1932) per additional successful treatment (from an NHS perspective). LIMITATIONS Relatively high loss to follow-up limits the interpretation of the trial findings, especially during the post-intervention follow-up phase. CONCLUSION Hand-held narrowband ultraviolet B light plus topical corticosteroid combination treatment is superior to topical corticosteroids alone for treatment of localised vitiligo. Combination treatment was relatively safe and well tolerated, but was effective in around one-quarter of participants only. Whether or not combination treatment is cost-effective depends on how much decision-makers are willing to pay for the benefits observed. FUTURE WORK Development and testing of new vitiligo treatments with a greater treatment response and longer-lasting effects are needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN17160087. 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. 64. See the NIHR Journals Library website for further project information.
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Ross JD, Harding J, Duley L, Montgomery AA, Hepburn T, Tan W, Brittain C, Meakin G, Sprange K, Thandi S, Jackson L, Roberts T, Wilson J, White J, Dewsnap C, Cole M, Lawrence T. Gentamicin as an alternative to ceftriaxone in the treatment of gonorrhoea: the G-TOG non-inferiority RCT. Health Technol Assess 2020; 23:1-104. [PMID: 31099330 DOI: 10.3310/hta23200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Gonorrhoea is a common sexually transmitted infection that can cause pain and discomfort, affect fertility in women and lead to epididymo-orchitis in men. Current treatment is with ceftriaxone, but there is increasing evidence of antimicrobial resistance reducing its effectiveness. Gentamicin is a potential alternative treatment requiring further evaluation. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of gentamicin as an alternative treatment to ceftriaxone in the treatment of gonorrhoea. DESIGN A multicentre, parallel-group, blinded, non-inferiority randomised controlled trial. SETTING Fourteen sexual health clinics in England. PARTICIPANTS Adults aged 16-70 years with a diagnosis of uncomplicated, untreated genital, pharyngeal or rectal gonorrhoea based on a positive Gram-stained smear on microscopy or a positive nucleic acid amplification test (NAAT). RANDOMISATION AND BLINDING Participants were randomised using a secure web-based system, stratified by clinic. Participants, investigators and research staff assessing participants were blinded to treatment allocation. INTERVENTIONS Allocation was to either 240 mg of gentamicin (intervention) or 500 mg of ceftriaxone (standard treatment), both administered as a single intramuscular injection. All participants also received 1 g of oral azithromycin. MAIN OUTCOME MEASURE The primary outcome measure was clearance of Neisseria gonorrhoeae at all infected sites, confirmed by a negative Aptima Combo 2® (Hologic Inc., Marlborough, MA, USA) NAAT, at 2 weeks post treatment. RESULTS We randomised 720 participants, of whom 81% were men. There were 358 participants in the gentamicin group and 362 in the ceftriaxone group; 292 (82%) and 306 (85%) participants, respectively, were included in the primary analysis. Non-inferiority of gentamicin to ceftriaxone could not be demonstrated [adjusted risk difference for microbiological clearance -6.4%, 95% confidence interval (CI) -10.4% to -2.4%]. Clearance of genital infection was similar in the two groups, at 94% in the gentamicin group and 98% in the ceftriaxone group, but clearance of pharyngeal infection and rectal infection was lower in the gentamicin group (80% vs. 96% and 90% vs. 98%, respectively). Reported pain at the injection site was higher for gentamicin than for ceftriaxone. The side-effect profiles were comparable between the groups. Only one serious adverse event was reported and this was deemed not to be related to the trial medication. The economic analysis found that treatment with gentamicin is not cost neutral compared with standard care, with average patient treatment costs higher for those allocated to gentamicin (£13.90, 95% CI £2.47 to £37.34) than to ceftriaxone (£6.72, 95% CI £1.36 to £17.84). LIMITATIONS Loss to follow-up was 17% but was similar in both treatment arms. Twelve per cent of participants had a negative NAAT for gonorrhoea at their baseline visit but this was balanced between treatment groups and unlikely to have biased the trial results. CONCLUSIONS The trial was unable to demonstrate non-inferiority of gentamicin compared with ceftriaxone in the clearance of gonorrhoea at all infected sites. Clearance at pharyngeal and rectal sites was lower for participants allocated to gentamicin than for those allocated to ceftriaxone, but was similar for genital sites in both groups. Gentamicin was associated with more severe injection site pain. However, both gentamicin and ceftriaxone appeared to be well tolerated. FUTURE WORK Exploration of the genetic determinants of antibiotic resistance in N. gonorrhoeae will help to identify accurate markers of decreased susceptibility. Greater understanding of the immune response to infection can assist gonococcal vaccine development. TRIAL REGISTRATION Current Controlled Trials ISRCTN51783227. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 20. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jonathan Dc Ross
- Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jan Harding
- Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Wei Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Clare Brittain
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Garry Meakin
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Sukhwinder Thandi
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Louise Jackson
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Tracy Roberts
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - John White
- Burrell Street Clinic, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Michelle Cole
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI), National Infection Service, Public Health England, London, UK
| | - Tessa Lawrence
- Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Scutt P, Woodhouse LJ, Montgomery AA, Bath PM. Data sharing: experience of accessing individual patient data from completed randomised controlled trials in vascular and cognitive medicine. BMJ Open 2020; 10:e038765. [PMID: 32912955 PMCID: PMC7482449 DOI: 10.1136/bmjopen-2020-038765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/10/2020] [Accepted: 07/01/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Meta-analysis based on individual patient data (IPD) from randomised trials is superior to using published summary data since it facilitates subgroup and multiple variable analyses. Guidelines and funders expect that researchers share IPD for bona fide analyses, but in practice, this is done variably. Here, we report the experience of obtaining IPD for two collaborative analysis studies. SETTING Two linked studies required IPD from published randomised trials. The leading researchers for eligible trials were approached and asked to share IPD including trial characteristics, patient demographics, baseline clinical data and outcome measures. PARTICIPANTS Participants in eligible randomised controlled trials included patients with or at risk of cognitive decline/vascular events. PRIMARY AND SECONDARY OUTCOME MEASURES Numbers (%) of trials where the leading researcher responded favourably/negatively or did not respond. If negative, reasons behind the response were collected. If positive, methods used to share IPD were recorded. RESULTS Across the two studies, 391 completed trials were identified. Email addresses for researchers were found for 313 (80%) of the trials. One hundred and forty-eight (47%) researchers did not respond despite being sent multiple emails. Following contact, positive initial responses were received from 92 researchers, resulting in IPD being shared for 78 trials. Eighty-seven (28%) researchers declined to share data; justifications were recorded. The median time from first request to accessing data in one study was 241 (IQR 383.3) days. IPD sources included: direct from researcher, via academic trial funders repository and a website requiring remote analysis of commercial data. Where data were shared, a variety of methods were used to transfer data. CONCLUSION Sharing of IPD from trials is desirable and a requirement of many funding bodies. However, accessing IPD faces multiple challenges including refusals to share, delays in access to data and having to perform analyses on a remote website. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Polly Scutt
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Hearing Sciences, NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Philip M Bath
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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24
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das Nair R, Bradshaw LE, Carpenter H, Clarke S, Day F, Drummond A, Fitzsimmons D, Harris S, Montgomery AA, Newby G, Sackley C, Lincoln NB. A group memory rehabilitation programme for people with traumatic brain injuries: the ReMemBrIn RCT. Health Technol Assess 2020; 23:1-194. [PMID: 31032782 DOI: 10.3310/hta23160] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND People with traumatic brain injuries (TBIs) commonly report memory impairments. These are persistent, debilitating and reduce quality of life, but patients do not routinely receive memory rehabilitation after discharge from hospital. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of a group memory rehabilitation programme for people with TBI. DESIGN Multicentre, pragmatic, cluster randomised controlled trial. Qualitative and health economic evaluations were also undertaken. SETTING Community settings in nine sites in England. PARTICIPANTS Participants were aged 18-69 years, had undergone a TBI > 3 months prior to recruitment, reported memory problems, were able to travel to a site to attend group sessions, could communicate in English and gave informed consent. RANDOMISATION AND BLINDING Clusters of four to six participants were randomised to the memory rehabilitation arm or the usual-care arm on a 1 : 1 ratio. Randomisation was based on a computer-generated pseudo-random code using random permuted blocks of randomly varying size, stratified by study site. Participants and therapists were aware of the treatment allocation whereas outcome assessors were blinded. INTERVENTIONS In the memory rehabilitation arm 10 weekly sessions of a manualised memory rehabilitation programme were provided in addition to usual care. Participants were taught restitution strategies to retrain impaired memory functions and compensation strategies to enable them to cope with memory problems. The usual-care arm received usual care only. MAIN OUTCOME MEASURES Outcomes were assessed at 6 and 12 months after randomisation. Primary outcome: patient-completed Everyday Memory Questionnaire - patient version (EMQ-p) at 6 months' follow-up. Secondary outcomes: Rivermead Behavioural Memory Test - third edition (RBMT-3), General Health Questionnaire 30-item version, European Brain Injury Questionnaire, Everyday Memory Questionnaire - relative version and individual goal attainment. Costs (based on a UK NHS and Personal Social Services perspective) were collected using a service use questionnaire, with the EuroQol-5 Dimensions, five-level version, used to derive quality-adjusted life-years (QALYs). A Markov model was developed to explore cost-effectiveness at 5 and 10 years, with a 3.5% discount applied. RESULTS We randomised 328 participants (memory rehabilitation, n = 171; usual care, n = 157), with 129 in the memory rehabilitation arm and 122 in the usual-care arm included in the primary analysis. We found no clinically important difference on the EMQ-p between the two arms at 6 months' follow-up (adjusted difference in mean scores -2.1, 95% confidence interval -6.7 to 2.5; p = 0.37). For secondary outcomes, differences favouring the memory rehabilitation arm were observed at 6 months' follow-up for the RBMT-3 and goal attainment, but remained only for goal attainment at 12 months' follow-up. There were no differences between arms in mood or quality of life. The qualitative results suggested positive experiences of participating in the trial and of attending the groups. Participants reported that memory rehabilitation was not routinely accessible in usual care. The primary health economics outcome at 12 months found memory rehabilitation to be £26.89 cheaper than usual care but less effective, with an incremental QALY loss of 0.007. Differences in costs and effects were not statistically significant and non-parametric bootstrapping demonstrated considerable uncertainty in these findings. No safety concerns were raised and no deaths were reported. LIMITATIONS As a pragmatic trial, we had broad inclusion criteria and, therefore, there was considerable heterogeneity within the sample. The study was not powered to perform further subgroup analyses. Participants and therapists could not be blinded to treatment allocation. CONCLUSIONS The group memory rehabilitation delivered in this trial is very unlikely to lead to clinical benefits or to be a cost-effective treatment for people with TBI in the community. Future studies should examine the selection of participants who may benefit most from memory rehabilitation. TRIAL REGISTRATION Current Controlled Trials ISRCTN65792154. 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. 23, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Roshan das Nair
- Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK.,Institute of Mental Health, Nottingham, UK.,Department of Clinical Psychology and Neuropsychology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Hannah Carpenter
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Sara Clarke
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Florence Day
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Avril Drummond
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Shaun Harris
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Gavin Newby
- Newby Psychological Services Ltd, Northwich, UK
| | - Catherine Sackley
- Division of Health and Social Care, King's College London, London, UK
| | - Nadina B Lincoln
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
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Godolphin PJ, Bath PM, Algra A, Berge E, Chalmers J, Eliasziw M, Hankey GJ, Hosomi N, Ranta A, Weimar C, Woodhouse LJ, Montgomery AA. Cost-benefit of outcome adjudication in nine randomised stroke trials. Clin Trials 2020; 17:576-580. [PMID: 32650688 DOI: 10.1177/1740774520939231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Central adjudication of outcomes is common for randomised trials and should control for differential misclassification. However, few studies have estimated the cost of the adjudication process. METHODS We estimated the cost of adjudicating the primary outcome in nine randomised stroke trials (25,436 participants). The costs included adjudicators' time, direct payments to adjudicators, and co-ordinating centre costs (e.g. uploading cranial scans and general set-up costs). The number of events corrected after adjudication was our measure of benefit. We calculated cost per corrected event for each trial and in total. RESULTS The primary outcome in all nine trials was either stroke or a composite that included stroke. In total, the adjudication process associated with this primary outcome cost in excess of £100,000 for a third of the trials (3/9). Mean cost per event corrected by adjudication was £2295.10 (SD: £1482.42). CONCLUSIONS Central adjudication is a time-consuming and potentially costly process. These costs need to be considered when designing a trial and should be evaluated alongside the potential benefits adjudication brings to determine whether they outweigh this expense.
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Affiliation(s)
- Peter J Godolphin
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK.,MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Ale Algra
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - John Chalmers
- The George Institute for Global Health, University of NSW, Sydney, NSW, Australia
| | - Misha Eliasziw
- Department of Public Health and Community Medicine, Tufts University, Boston, MA, USA
| | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - Naohisa Hosomi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | | | - Christian Weimar
- Universitätsklinikum Essen, Klinik für Neurologie, Hufelandstr, Essen, Germany
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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26
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Bradshaw LE, Montgomery AA, Williams HC, Chalmers JR, Haines RH. Two-by-two factorial randomised study within a trial (SWAT) to evaluate strategies for follow-up in a randomised prevention trial. Trials 2020; 21:529. [PMID: 32546180 PMCID: PMC7296963 DOI: 10.1186/s13063-020-04373-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/05/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Failure to collect outcome data in randomised trials can result in bias and loss of statistical power. Further evaluations of strategies to increase retention are required. We assessed the effectiveness of two strategies for retention in a randomised prevention trial using a two-by-two factorial randomised study within a trial (SWAT). METHODS Parents of babies included in the host trial were randomised to (1) short message service (SMS) notification prior to sending questionnaires at 3, 6, 12 and 18 months versus no SMS notification and (2) a £10 voucher sent with the invitation letter for the primary follow-up visit at 24 months or given at the visit. The two co-primary outcomes were collection of host trial (1) questionnaire data at interim follow-up times and (2) primary outcome at 24 months during a home/clinic visit with a research nurse. RESULTS Between November 2014 and November 2016, 1394 participants were randomised: 350 to no SMS + voucher at visit, 345 to SMS + voucher at visit, 352 to no SMS + voucher before visit and 347 to SMS + voucher before visit. Overall questionnaire data was collected at interim follow-up times for 75% in both the group allocated to the prior SMS notification and the group allocated to no SMS notification (odds ratio (OR) SMS versus none 1.02, 95% CI 0.83 to 1.25). Host trial primary outcome data was collected at a visit for 557 (80%) allocated to the voucher before the visit in the invitation letter and for 566 (81%) whose parents were allocated to receive the voucher at the visit (OR before versus at visit 0.89, 95% CI 0.69 to 1.17). CONCLUSION There was no evidence of a difference in retention according to SMS notification or voucher timing. Future synthesis of SWAT results is required to be able to detect small but important incremental effects of retention strategies. TRIAL REGISTRATION ISRCTN registry, ID: ISRCTN21528841. Registered on 25 July 2014. SWAT Repository Store ID 25.
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Affiliation(s)
- Lucy E. Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2RD UK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2RD UK
| | - Hywel C. Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR UK
| | - Joanne R. Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR UK
| | - Rachel H. Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2RD UK
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27
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Godolphin PJ, Bath PM, Partlett C, Berge E, Brown MM, Eliasziw M, Sandset PM, Serena J, Montgomery AA. Outcome assessment by central adjudicators in randomised stroke trials: Simulation of differential and non-differential misclassification. Eur Stroke J 2020; 5:174-183. [PMID: 32637651 PMCID: PMC7313361 DOI: 10.1177/2396987320910047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/04/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Adjudication of the primary outcome in randomised trials is thought to control misclassification. We investigated the amount of misclassification needed before adjudication changed the primary trial results.Patients (or materials) and methods: We included data from five randomised stroke trials. Differential misclassification was introduced for each primary outcome until the estimated treatment effect was altered. This was simulated 1000 times. We calculated the between-simulation mean proportion of participants that needed to be differentially misclassified to alter the treatment effect. In addition, we simulated hypothetical trials with a binary outcome and varying sample size (1000-10,000), overall event rate (10%-50%) and treatment effect (0.67-0.90). We introduced non-differential misclassification until the treatment effect was non-significant at 5% level. RESULTS For the five trials, the range of unweighted kappa values were reduced from 0.89-0.97 to 0.65-0.85 before the treatment effect was altered. This corresponded to 2.1%-6% of participants misclassified differentially for trials with a binary outcome. For the hypothetical trials, those with a larger sample size, stronger treatment effect and overall event rate closer to 50% needed a higher proportion of events non-differentially misclassified before the treatment effect became non-significant. DISCUSSION We found that only a small amount of differential misclassification was required before adjudication altered the primary trial results, whereas a considerable proportion of participants needed to be misclassified non-differentially before adjudication changed trial conclusions. Given that differential misclassification should not occur in trials with sufficient blinding, these results suggest that central adjudication is of most use in studies with unblinded outcome assessment. CONCLUSION For trials without adequate blinding, central adjudication is vital to control for differential misclassification. However, for large blinded trials, adjudication is of less importance and may not be necessary.
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Affiliation(s)
- Peter J Godolphin
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Martin M Brown
- Stroke Research Group, UCL Institute of Neurology, University College London, London, UK
| | - Misha Eliasziw
- Department of Public Health and Community Medicine, Tufts University, Boston, MA, USA
| | - Per Morten Sandset
- Department of Haematology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Joaquín Serena
- Stroke Unit, Department of Neurology, IDIBGI, Hospital Josep Trueta, Girona, Spain
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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28
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Chalmers JR, Haines RH, Bradshaw LE, Montgomery AA, Thomas KS, Brown SJ, Ridd MJ, Lawton S, Simpson EL, Cork MJ, Sach TH, Flohr C, Mitchell EJ, Swinden R, Tarr S, Davies-Jones S, Jay N, Kelleher MM, Perkin MR, Boyle RJ, Williams HC. Daily emollient during infancy for prevention of eczema: the BEEP randomised controlled trial. Lancet 2020; 395:962-972. [PMID: 32087126 PMCID: PMC7086156 DOI: 10.1016/s0140-6736(19)32984-8] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/14/2019] [Accepted: 11/21/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Skin barrier dysfunction precedes eczema development. We tested whether daily use of emollient in the first year could prevent eczema in high-risk children. METHODS We did a multicentre, pragmatic, parallel-group, randomised controlled trial in 12 hospitals and four primary care sites across the UK. Families were approached via antenatal or postnatal services for recruitment of term infants (at least 37 weeks' gestation) at high risk of developing eczema (ie, at least one first-degree relative with parent-reported eczema, allergic rhinitis, or asthma, diagnosed by a doctor). Term newborns with a family history of atopic disease were randomly assigned (1:1) to application of emollient daily (either Diprobase cream or DoubleBase gel) for the first year plus standard skin-care advice (emollient group) or standard skin-care advice only (control group). The randomisation schedule was created using computer-generated code (stratified by recruiting centre and number of first-degree relatives with atopic disease) and participants were assigned to groups using an internet-based randomisation system. The primary outcome was eczema at age 2 years (defined by UK working party criteria) with analysis as randomised regardless of adherence to allocation for participants with outcome data collected, and adjusting for stratification variables. This trial is registered with ISRCTN, ISRCTN21528841. Data collection for long-term follow-up is ongoing, but the trial is closed to recruitment. FINDINGS 1394 newborns were randomly assigned to study groups between Nov 19, 2014, and Nov 18, 2016; 693 were assigned to the emollient group and 701 to the control group. Adherence in the emollient group was 88% (466 of 532) at 3 months, 82% (427 of 519) at 6 months, and 74% (375 of 506) at 12 months in those with complete questionnaire data. At age 2 years, eczema was present in 139 (23%) of 598 infants with outcome data collected in the emollient group and 150 (25%) of 612 infants in the control group (adjusted relative risk 0·95 [95% CI 0·78 to 1·16], p=0·61; adjusted risk difference -1·2% [-5·9 to 3·6]). Other eczema definitions supported the results of the primary analysis. Mean number of skin infections per child in year 1 was 0·23 (SD 0·68) in the emollient group versus 0·15 (0·46) in the control group; adjusted incidence rate ratio 1·55 (95% CI 1·15 to 2·09). INTERPRETATION We found no evidence that daily emollient during the first year of life prevents eczema in high-risk children and some evidence to suggest an increased risk of skin infections. Our study shows that families with eczema, asthma, or allergic rhinitis should not use daily emollients to try and prevent eczema in their newborn. FUNDING National Institute for Health Research Health Technology Assessment.
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Affiliation(s)
- Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Rachel H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Sara J Brown
- Skin Research Group, School of Medicine, University of Dundee, Dundee, UK; Department of Dermatology, Ninewells Hospital and Medical School, Dundee, UK
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Michael J Cork
- Sheffield Dermatology Research, Department of Infection and Immunity, University of Sheffield, Sheffield, UK
| | - Tracey H Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Eleanor J Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Richard Swinden
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Stella Tarr
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Susan Davies-Jones
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Nicola Jay
- Sheffield Children's Hospital, Sheffield, UK
| | - Maeve M Kelleher
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Robert J Boyle
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK.
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29
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Adams CE, Montgomery AA, Aburrow T, Bloomfield S, Briley PM, Carew E, Chatterjee-Woolman S, Feddah G, Friedel J, Gibbard J, Haynes E, Hussein M, Jayaram M, Naylor S, Perry L, Schmidt L, Siddique U, Tabaksert AS, Taylor D, Velani A, White D, Xia J. Adding evidence of the effects of treatments into relevant Wikipedia pages: a randomised trial. BMJ Open 2020; 10:e033655. [PMID: 32086355 PMCID: PMC7045027 DOI: 10.1136/bmjopen-2019-033655] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To investigate the effects of adding high-grade quantitative evidence of outcomes of treatments into relevant Wikipedia pages on further information-seeking behaviour by the use of routinely collected data. SETTING Wikipedia, Cochrane summary pages and the Cochrane Library. DESIGN Randomised trial. PARTICIPANTS Wikipedia pages which were highly relevant to up-to-date Cochrane Schizophrenia systematic reviews that contained a Summary of Findings table. INTERVENTIONS Eligible Wikipedia pages in the intervention group were seeded with tables of best evidence of the effects of care and hyperlinks to the source Cochrane review. Eligible Wikipedia pages in the control group were left unchanged. MAIN OUTCOME MEASURES Routinely collected data on access to the full text and summary web page (after 12 months). RESULTS We randomised 70 Wikipedia pages (100% follow-up). Six of the 35 Wikipedia pages in the intervention group had the tabular format deleted during the study but all pages continued to report the same data within the text. There was no evidence of effect on either of the coprimary outcomes: full-text access adjusted ratio of geometric means 1.30, 95% CI: 0.71 to 2.38; page views 1.14, 95% CI: 0.6 to 2.13. Results were similar for all other outcomes, with exception of Altmetric score for which there was some evidence of clear effect (1.36, 95% CI: 1.05 to 1.78). CONCLUSIONS The pursuit of fair balance within Wikipedia healthcare pages is impressive and its reach unsurpassed. For every person who sought and clicked the reference on the 'intervention' Wikipedia page to seek more information (the primary outcome), many more are likely to have been informed by the page alone. Enriching Wikipedia content is, potentially, a powerful way to improve health literacy and it is possible to test the effects of seeding pages with evidence. This trial should be replicated, expanded and developed. TRIAL REGISTRATION NUMBER IRCT2017070330407N2.
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Affiliation(s)
- Clive E Adams
- Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Tony Aburrow
- Health Sciences, Research, John Wiley Ltd, Chichester, UK
| | - Sophie Bloomfield
- Department of Critical Care, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, UK
| | - Paul M Briley
- Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
| | - Ebun Carew
- General Medicine, Nottingham University Hospitals Healthcare NHS Trust, Nottingham, Nottinghamshire, UK
| | | | - Ghalia Feddah
- Emergency Department, Gold Coast University Hospitals, Gold Coast, Queensland, Australia
| | - Johannes Friedel
- Faculty Management and Business Science, University of Aalen, Aalen, Germany
| | - Josh Gibbard
- The Acute Stroke Unit - Huggett Suite, Royal Lancaster Infirmary, Lancaster, UK
| | - Euan Haynes
- Haematology, Gateshead Health NHS Foundation Trust, Gateshead, Gateshead, UK
| | - Mohsin Hussein
- Department of Radiology, University Hospitals of Leicester NHS Trust, Leicester, Leicester, UK
| | - Mahesh Jayaram
- Psychaitry, University of Melbourne, Melbourne, Victoria, Australia
| | - Samuel Naylor
- Emergency Department, Gold Coast University Hospitals, Gold Coast, Queensland, Australia
| | - Luke Perry
- Department of Anaesthesia, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Lena Schmidt
- Bristol Medical School, University of Bristol Faculty of Health Sciences, Bristol, Bristol, UK
- Fakultät Gesundheit, Sicherheit und Gesellschaft, Hochschule Furtwangen University, Furtwangen, Germany
| | - Umer Siddique
- Community Recovery Psychiatry, North East London NHS Foundation Trust, London, UK
| | - Ayla Serena Tabaksert
- Liaison Psychiatry, Northumbria Healthcare NHS Foundation Trust, North Shields, Tyne and Wear, UK
| | | | - Aarti Velani
- Acute Medicine, Lewisham and Greenwich NHS Trust, London, UK
| | - Douglas White
- Accident and Emergency, Epsom and Saint Helier University Hospitals NHS Trust Epsom Hospital, Epsom, Surrey, UK
| | - Jun Xia
- Nottingham Ningbo GRADE Centre, Nottingham China Health Institute, The University of Nottingham Ningbo, Ningbo, China
- Division of Epidemiology and Public Health, School of Medicine, The University of Nottingham, Nottingham, UK
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Kelleher MM, Jay N, Perkin MR, Haines RH, Batt R, Bradshaw LE, Montgomery AA, Chalmers JR, Williams HC, Boyle RJ. An algorithm for diagnosing IgE‐mediated food allergy in study participants who do not undergo food challenge. Clin Exp Allergy 2020; 50:334-342. [DOI: 10.1111/cea.13577] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/11/2020] [Accepted: 01/27/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Maeve M. Kelleher
- Section of Inflammation, Repair & Development National Heart & Lung Institute Imperial College London London UK
| | - Nicola Jay
- Children’s Allergy Dept. Sheffield Children’s NHS Foundation Trust Sheffield UK
| | - Michael R. Perkin
- Population Health Research Institute St George's University of London London UK
| | - Rachel H. Haines
- Nottingham Clinical Trials Unit University of Nottingham Nottingham UK
| | - Rebecca Batt
- Children’s Allergy Service Evelina Children’s Hospital London London UK
| | - Lucy E. Bradshaw
- Nottingham Clinical Trials Unit University of Nottingham Nottingham UK
| | | | - Joanne R. Chalmers
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
| | - Hywel C. Williams
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
| | - Robert J. Boyle
- Section of Inflammation, Repair & Development National Heart & Lung Institute Imperial College London London UK
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
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Davis TRC, Tan W, Harrison EF, Hollingworth W, Karantana A, Mills N, Hepburn T, Sprange K, Duley L, Blazeby JM, Bainbridge CG, Murali SR, Montgomery AA. A randomised feasibility trial comparing needle fasciotomy with limited fasciectomy treatment for Dupuytren's contractures. Pilot Feasibility Stud 2020; 6:7. [PMID: 32021696 PMCID: PMC6993423 DOI: 10.1186/s40814-019-0546-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 12/20/2019] [Indexed: 11/16/2022] Open
Abstract
Purpose The purpose of this study is to assess the feasibility of conducting a large, multicentre randomised controlled trial (RCT) comparing needle fasciotomy with limited fasciectomy for treatment of Dupuytren’s contractures. Design The design of this study is a parallel, two-arm, multicentre, randomised feasibility trial with embedded QuinteT Recruitment Intervention. Participants Patients aged 18 years or over who were referred from primary to secondary care for treatment of a hand with Dupuytren’s contractures of one or more fingers of more than 30° at the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joints and well-defined cord(s). Patients were excluded if they had undergone previous Dupuytren’s contracture surgery on the same hand. Methods Potential participants were screened for eligibility. Recruited participants randomised (1:1) to treatment with either needle fasciotomy or limited fasciectomy and followed-up for up to 6 months after treatment. Data on recruitment rates, completion of follow-up, and procedure costs were collected. Four patient reported outcome measures (PROMs) and objective outcome measures were collected before intervention and 6 weeks and 6 months afterwards. Results One hundred and fifty-three of 267 (57%) primary-care referrals for Dupuytren’s contractures met the eligibility criteria for the study. Seventy-one of the 153 (46%) agreed to participate and were randomly allocated to treatment with needle fasciotomy or limited fasciectomy. Sixty-seven of these underwent their allocated treatment, two were crossovers from limited fasciectomy to needle fasciotomy, and two (both allocated limited fasciectomy) received no treatment. Fifty-nine participants (85%) completed 6-month follow-up PROMs. Participants felt the MYMOP, PEM and URAM PROMs allowed them to better describe how their treatment affected their hand function than the DASH PROM. The estimated costs of limited fasciectomy (in an operating theatre) and needle fasciotomy (in a clinic room) were £777 and £111 respectively. Conclusion A large RCT comparing treatment of Dupuytren’s contractures by needle fasciotomy and limited fasciectomy is feasible. Data from this study will help determine the number of sites and duration of recruitment required to complete an adequately powered RCT and will assist the selection of PROMs in future studies on the treatment of Dupuytren’s contractures. (Level 1 feasibility study). Trial registration Trial registered with ISRCTN (registration number: ISRCTN11164292), date assigned - 28/08/2015.
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Affiliation(s)
- T R C Davis
- 1Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH UK
| | - W Tan
- 2Nottingham Clinical Trials Unit, University of Nottingham, Building 42, University Park, Nottingham, NG7 2RD UK
| | - E F Harrison
- 2Nottingham Clinical Trials Unit, University of Nottingham, Building 42, University Park, Nottingham, NG7 2RD UK
| | - W Hollingworth
- 3Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - A Karantana
- 4Centre for Evidence Based Hand Surgery, Academic Orthopaedics Trauma and Sports Medicine, School of Medicine, University of Nottingham, Nottingham, NG7 2UH UK
| | - N Mills
- 3Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - T Hepburn
- 2Nottingham Clinical Trials Unit, University of Nottingham, Building 42, University Park, Nottingham, NG7 2RD UK
| | - K Sprange
- 2Nottingham Clinical Trials Unit, University of Nottingham, Building 42, University Park, Nottingham, NG7 2RD UK
| | - L Duley
- 2Nottingham Clinical Trials Unit, University of Nottingham, Building 42, University Park, Nottingham, NG7 2RD UK
| | - J M Blazeby
- 3Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - C G Bainbridge
- 5Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby, DE22 3NE UK
| | - S R Murali
- 6Wrightington, Wigan and Leigh NHS Foundation Trust, Hall Lane, Appley Bridge, Wigan, Lancashire WN6 9EP UK
| | - A A Montgomery
- 2Nottingham Clinical Trials Unit, University of Nottingham, Building 42, University Park, Nottingham, NG7 2RD UK
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Shafayat A, Csipke E, Bradshaw L, Charlesworth G, Day F, Leung P, Moniz-Cook E, Montgomery AA, Morris S, Mountain G, Ogollah R, Sprange K, Yates L, Orrell M. Promoting Independence in Dementia (PRIDE): protocol for a feasibility randomised controlled trial. Trials 2019; 20:709. [PMID: 31829232 PMCID: PMC6907171 DOI: 10.1186/s13063-019-3838-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Memory services often see people with early stage dementia who are largely independent and able to participate in community activities but who run the risk of reducing activities and social networks. PRIDE is a self-management intervention designed to promote living well and enhance independence for people with mild dementia. This study aims to examine the feasibility of conducting a definitive randomised trial comparing the clinical and cost-effectiveness of the PRIDE intervention offered in addition to usual care or with usual care alone. METHODS/DESIGN PRIDE is a parallel, two-arm, multicentre, feasibility, randomised controlled trial (RCT). Eligible participants aged 18 or over who have mild dementia (defined as a score of 0.5 or 1 on the Clinical Dementia Rating Scale) who can participate in the intervention and provide informed consent will be randomised (1:1) to treatment with the PRIDE intervention delivered in addition to usual care, or usual care only. Participants will be followed-up at 3 and 6 month's post-randomisation. There will be an option for a supporter to join each participant. Each supporter will be provided with questionnaires at baseline and follow-ups at 3 to 6 months. Embedded qualitative research with both participants and supporters will explore their perspectives on the intervention investigating a range of themes including acceptability and barriers and facilitators to delivery and participation. The feasibility of conducting a full RCT associated with participant recruitment and follow-up of both conditions, intervention delivery including the recruitment, training, retention of PRIDE trained facilitators, clinical outcomes, intervention and resource use costs and the acceptability of the intervention and study related procedures will be examined. DISCUSSION This study will assess whether a definitive randomised trial comparing the clinical and cost-effectiveness of whether the PRIDE intervention offered in addition to usual care is feasible in comparison to usual care alone, and if so, will provide data to inform the design and conduct of a future trial. TRIAL REGISTRATION ISRCTN, ISRCTN11288961, registered on 23 October 2019, http://www.isrctn.com/ISRCTN12345678 Protocol V2.1 dated 19 June 2019.
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Affiliation(s)
- Aisha Shafayat
- Nottingham Clinical Trials Unit, University of Nottingham, Building 42, University Park, Nottingham, NG7 2RD UK
| | - Emese Csipke
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
| | - Lucy Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Building 42, University Park, Nottingham, NG7 2RD UK
| | - Georgina Charlesworth
- North East London NHS Foundation Trust, Goodmayes Hospital, 1st Floor, Maggie Lillie Suite, Ilford, IG3 8XJ UK
| | - Florence Day
- Nottingham Clinical Trials Unit, University of Nottingham, Building 42, University Park, Nottingham, NG7 2RD UK
| | - Phuong Leung
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
| | - Esme Moniz-Cook
- Psychology Ageing & Dementia Care Research, Faculty of Health Sciences, Department of Psychological Health, Wellbeing and Social Work, University of Hull, Hull, HU6 7RX UK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Building 42, University Park, Nottingham, NG7 2RD UK
| | - Steve Morris
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, WC1E 7HB UK
| | - Gail Mountain
- Faculty of Health Studies, University of Bradford, Richmond Road, Bradford, BD7 1DP UK
| | - Reuben Ogollah
- Nottingham Clinical Trials Unit, University of Nottingham, Building 42, University Park, Nottingham, NG7 2RD UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, University of Nottingham, Building 42, University Park, Nottingham, NG7 2RD UK
| | - Lauren Yates
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
| | - Martin Orrell
- Division of Psychiatry and Applied Psychology, University of Nottingham, Room D07, Institute of Mental Health Innovation Park, Triumph Road, Nottingham, NG7 2TU UK
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Lincoln NB, Bradshaw LE, Constantinescu CS, Day F, Drummond AER, Fitzsimmons D, Harris S, Montgomery AA, das Nair R, Morgan M, Scott J, Evans S, McKeown S, Bharadia T, Moore P, Young C, Sharrack B, Isaac C, Griffths D, Fixter V, Hanley L, Evans S, Palmer L, Tyrell T, Gaughan S, Elliot G, Keogh S, Oldknow H, Edwards C, Schofield N, Clarke S, Crossley K, Griffiths H, Knight C, Martin K, Cunliffe A, Pollard C, Wilson J, Trigg E, Vanzan S, Dalton J, Pegnall S, Carpenter H, Cogger H, Harnell R, Klein O, Mhizha-Murira J, Powers K, Squires L, Sprange K, Evans A, Hobbs J, Wakefield N, Barnes B, Crone M, Foster M, Rumsey C, Erven A, Moss-Morris R, Bowen A, O’Connor R, Freeman J, Taylor R, Rose A. Cognitive rehabilitation for attention and memory in people with multiple sclerosis: a randomized controlled trial (CRAMMS). Clin Rehabil 2019; 34:229-241. [DOI: 10.1177/0269215519890378] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To assess the clinical and cost-effectiveness of cognitive rehabilitation for attention and memory problems in people with multiple sclerosis. Design: Multicentre, pragmatic, randomized controlled trial. Setting: Community Participants: People with multiple sclerosis aged 18–69 years, who reported cognitive problems in daily life and had cognitive problems on standardized assessment. Interventions: A group cognitive rehabilitation programme delivered in 10 weekly sessions in comparison with usual care. Main measures: The primary outcome was the Multiple Sclerosis Impact Scale Psychological subscale at 12 months after randomization. Secondary outcomes included measures of everyday memory problems, mood, fatigue, cognitive abilities and employment at 6 and 12 months after randomization. Results: In all, 245 participants were allocated to cognitive rehabilitation and 204 to usual care. Mean Multiple Sclerosis Impact Scale Psychological at 12 months was 22.2 (SD = 6.1) for cognitive rehabilitation and 23.4 (SD = 6.0) for usual care group; adjusted difference −0.6, 95% confidence interval (CI) = −1.5 to 0.3, P = 0.20. No differences were observed in cognitive abilities, fatigue or employment. There were small differences in favour of cognitive rehabilitation for the Multiple Sclerosis Impact Scale Psychological at 6 months and everyday memory and mood at 6 and 12 months. There was no evidence of an effect on costs (−£808; 95% CI = −£2248 to £632) or on quality-adjusted life year gain (0.00; 95% CI = −0.01 to 0.02). Conclusion: This rehabilitation programme had no long-term benefits on the impact of multiple sclerosis on quality of life, but there was some evidence of an effect on everyday memory problems and mood.
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Affiliation(s)
- Nadina B Lincoln
- Division of Rehabilitation and Ageing, Queen’s Medical Centre, University of Nottingham, Nottingham, UK
| | - Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Florence Day
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | | | - Shaun Harris
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Roshan das Nair
- Division of Psychiatry & Applied Psychology, University of Nottingham, Nottingham, UK
- Institute of Mental Health, Nottingham, UK
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Bath PM, Woodhouse LJ, Krishnan K, Appleton JP, Anderson CS, Berge E, Cala L, Dixon M, England TJ, Godolphin PJ, Hepburn T, Mair G, Montgomery AA, Phillips SJ, Potter J, Price CI, Randall M, Robinson TG, Roffe C, Rothwell PM, Sandset EC, Sanossian N, Saver JL, Siriwardena AN, Venables G, Wardlaw JM, Sprigg N. Prehospital Transdermal Glyceryl Trinitrate for Ultra-Acute Intracerebral Hemorrhage: Data From the RIGHT-2 Trial. Stroke 2019; 50:3064-3071. [PMID: 31587658 PMCID: PMC6824503 DOI: 10.1161/strokeaha.119.026389] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Supplemental Digital Content is available in the text. Pilot trials suggest that glyceryl trinitrate (GTN; nitroglycerin) may improve outcome when administered early after stroke onset.
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Affiliation(s)
- Philip M Bath
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.).,Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, City Hospital Campus, United Kingdom (P.M.B., K.K., N.S.)
| | - Lisa J Woodhouse
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.)
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, City Hospital Campus, United Kingdom (P.M.B., K.K., N.S.)
| | - Jason P Appleton
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.)
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (C.S.A.).,The George Institute China at Peking University Health Science Center, Beijing, China (C.S.A.).,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, NSW, Australia (C.S.A.)
| | - Eivind Berge
- Department of Internal Medicine (E.B., A.N.S), Oslo University Hospital, Norway.,Department of Neurology (E.C.S.), Oslo University Hospital, Norway
| | - Lesley Cala
- Faculty of Health and Medical Sciences, University of Western Australia (L.C.)
| | - Mark Dixon
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.).,East Midlands Ambulance Service NHS Trust, Nottingham, United Kingdom (M.D.)
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences, GEM, Royal Derby Hospital Centre (T.J.E.), University of Nottingham, United Kingdom
| | - Peter J Godolphin
- Nottingham Clinical Trials Unit, Queen's Medical Centre (P.J.G., T.H., A.A.M.), University of Nottingham, United Kingdom
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, Queen's Medical Centre (P.J.G., T.H., A.A.M.), University of Nottingham, United Kingdom
| | - Grant Mair
- Centre for Clinical Brain Sciences, Edinburgh Imaging and UK Dementia Research Institute at the University of Edinburgh, Chancellor's Building (G.M., J.M.W.)
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, Queen's Medical Centre (P.J.G., T.H., A.A.M.), University of Nottingham, United Kingdom
| | - Stephen J Phillips
- Department of Medicine, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Canada (S.J.P.)
| | - John Potter
- Bob Champion Research and Education Building, University of East Anglia, Norwich, United Kingdom (J.P.)
| | - Chris I Price
- Institute of Neuroscience, Newcastle University, United Kingdom (C.I.P.)
| | - Marc Randall
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, United Kingdom (M.R.)
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, United Kingdom (T.G.R.)
| | - Christine Roffe
- Stroke Research in Stoke, Institute for Science and Technology in Medicine, Keele University, Stoke-on-Trent, United Kingdom (C.R.)
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom (P.M.R.)
| | - Else C Sandset
- Research and Development, The Norwegian Air Ambulance Foundation, Oslo, Norway (E.C.S.)
| | - Nerses Sanossian
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles (N.S.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA (J.L.S.)
| | - A Niroshan Siriwardena
- Department of Internal Medicine (E.B., A.N.S), Oslo University Hospital, Norway.,Community and Health Research Unit, University of Lincoln, United Kingdom (A.N.S.)
| | - Graham Venables
- Department of Neurology, Royal Hallamshire Hospital, Sheffield, United Kingdom (G.V.)
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, Edinburgh Imaging and UK Dementia Research Institute at the University of Edinburgh, Chancellor's Building (G.M., J.M.W.)
| | - Nikola Sprigg
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.).,Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, City Hospital Campus, United Kingdom (P.M.B., K.K., N.S.)
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Gureje O, Oladeji BD, Montgomery AA, Araya R, Bello T, Chisholm D, Groleau D, Kirmayer LJ, Kola L, Olley LB, Tan W, Zelkowitz P. High- versus low-intensity interventions for perinatal depression delivered by non-specialist primary maternal care providers in Nigeria: cluster randomised controlled trial (the EXPONATE trial). Br J Psychiatry 2019; 215:528-535. [PMID: 30767826 DOI: 10.1192/bjp.2019.4] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Contextually appropriate interventions delivered by primary maternal care providers (PMCPs) might be effective in reducing the treatment gap for perinatal depression. AIM To compare high-intensity treatment (HIT) with low-intensity treatment (LIT) for perinatal depression. METHOD Cluster randomised clinical trial, conducted in Ibadan, Nigeria between 18 June 2013 and 11 December 2015 in 29 maternal care clinics allocated by computed-generated random sequence (15 HIT; 14 LIT). Interventions were delivered individually to antenatal women with DSM-IV (1994) major depression by trained PMCPs. LIT consisted of the basic psychosocial treatment specifications in the World Health Organization Mental Health Gap Action Programme - Intervention Guide. HIT comprised LIT plus eight weekly problem-solving therapy sessions with possible additional sessions determined by scores on the Edinburgh Postnatal Depression Scale (EPDS). The primary outcome was remission of depression at 6 months postpartum (EPDS < 6). RESULTS There were 686 participants; 452 and 234 in HIT and LIT arms, respectively, with both groups similar at baseline. Follow-up assessments, completed on 85%, showed remission rates of 70% with HIT and 66% with LIT: risk difference 4% (95% CI -4.1%, 12.0%), adjusted odds ratio 1.12 (95% CI 0.73, 1.72). HIT was more effective for severe depression (odds ratio 2.29; 95% CI 1.01, 5.20; P = 0.047) and resulted in a higher rate of exclusive breastfeeding. Infant outcomes, cost-effectiveness and adverse events were similar. CONCLUSIONS Except among severely depressed perinatal women, we found no strong evidence to recommend high-intensity in preference to low-intensity psychological intervention in routine primary maternal care. DECLARATION OF INTERESTS None.
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Affiliation(s)
- Oye Gureje
- Professor of Psychiatry, Director, World Health Organization Collaborating Center for Research and Training in Mental Health, Neuroscience and Substance Abuse, Department of Psychiatry, College of Medicine, University of Ibadan, Nigeria
| | - Bibilola D Oladeji
- Senior Lecturer, Consultant Psychiatrist, Department of Psychiatry, College of Medicine, University of Ibadan, Nigeria
| | - Alan A Montgomery
- Professor of Medical Statistics and Clinical Trials, Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, UK
| | - Ricardo Araya
- Director, Centre for Global Mental Health, Department of Health Services and Population Research, King's College London, UK
| | - Toyin Bello
- Biostatistician, Department of Psychiatry, College of Medicine, University of Ibadan, Nigeria
| | - Dan Chisholm
- Programme Manager, Division of Noncommunicable Diseases, Department of Mental Health and Substance Abuse, World Health Organization, Switzerland
| | - Danielle Groleau
- Associate Professor, Senior Investigator, Division of Social and Transcultural Psychiatry, McGill University; and Director, Department of Psychiatry, Jewish General Hospital, Canada
| | - Laurence J Kirmayer
- Professor, Director, Division of Social and Transcultural Psychiatry, McGill University; and Department of Psychiatry, Jewish General Hospital, Canada
| | - Lola Kola
- Medical Sociologist, Department of Psychiatry, College of Medicine, University of Ibadan, Nigeria
| | - Lydia B Olley
- Project Coordinator, Department of Psychiatry, College of Medicine, University of Ibadan, Nigeria
| | - Wei Tan
- Medical Statistician, Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, UK
| | - Phyllis Zelkowitz
- Associate Professor, Division of Social and Transcultural Psychiatry, McGill University; and Research Director, Department of Psychiatry, Jewish General Hospital, Canada
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Godolphin PJ, Bath PM, Algra A, Berge E, Brown MM, Chalmers J, Duley L, Eliasziw M, Gregson J, Greving JP, Hankey GJ, Hosomi N, Johnston SC, Patsko E, Ranta A, Sandset PM, Serena J, Weimar C, Montgomery AA. Outcome Assessment by Central Adjudicators Versus Site Investigators in Stroke Trials: A Systematic Review and Meta-Analysis. Stroke 2019; 50:2187-2196. [PMID: 33755494 DOI: 10.1161/strokeaha.119.025019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- In randomized stroke trials, central adjudication of a trial's primary outcome is regularly implemented. However, recent evidence questions the importance of central adjudication in randomized trials. The aim of this review was to compare outcomes assessed by central adjudicators with outcomes assessed by site investigators. Methods- We included randomized stroke trials where the primary outcome had undergone an assessment by site investigators and central adjudicators. We searched MEDLINE, EMBASE, CENTRAL (Cochrane Central Register of Controlled Trials), Web of Science, PsycINFO, and Google Scholar for eligible studies. We extracted information about the adjudication process as well as the treatment effect for the primary outcome, assessed both by central adjudicators and by site investigators. We calculated the ratio of these treatment effects so that a ratio of these treatment effects >1 indicated that central adjudication resulted in a more beneficial treatment effect than assessment by the site investigator. A random-effects meta-analysis model was fitted to estimate a pooled effect. Results- Fifteen trials, comprising 69 560 participants, were included. The primary outcomes included were stroke (8/15, 53%), a composite event including stroke (6/15, 40%) and functional outcome after stroke measured on the modified Rankin Scale (1/15, 7%). The majority of site investigators were blind to treatment allocation (9/15, 60%). On average, there was no difference in treatment effect estimates based on data from central adjudicators and site investigators (pooled ratio of these treatment effects=1.02; 95% CI, [0.95-1.09]). Conclusions- We found no evidence that central adjudication of the primary outcome in stroke trials had any impact on trial conclusions. This suggests that potential advantages of central adjudication may not outweigh cost and time disadvantages in stroke studies if the primary purpose of adjudication is to ensure validity of trial findings.
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Affiliation(s)
- Peter J Godolphin
- From the Nottingham Clinical Trials Unit (P.J.G., L.D., A.A.M.), University of Nottingham, United Kingdom.,Stroke Trials Unit, Division of Clinical Neuroscience (P.J.G., P.M.B.), University of Nottingham, United Kingdom
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience (P.J.G., P.M.B.), University of Nottingham, United Kingdom
| | - Ale Algra
- Department of Neurology and Neurosurgery (A.A.), University Medical Center Utrecht, Utrecht University, the Netherlands.,Julius Center for Health Sciences and Primary Care (A.A., J.P.G.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Eivind Berge
- Department of Internal Medicine (E.B.), Oslo University Hospital, Norway
| | - Martin M Brown
- Stroke Research Group, UCL Institute of Neurology, UCL, London, United Kingdom (M.M.B.)
| | - John Chalmers
- The George Institute for Global Health, University of NSW, Sydney, Australia (J.C.)
| | - Lelia Duley
- From the Nottingham Clinical Trials Unit (P.J.G., L.D., A.A.M.), University of Nottingham, United Kingdom
| | - Misha Eliasziw
- Department of Public Health and Community Medicine, Tufts University, Boston, MA (M.E.)
| | - John Gregson
- Department of Medical Statistics, LSHTM, London, United Kingdom (J.G.)
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care (A.A., J.P.G.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth (G.J.H.)
| | - Naohisa Hosomi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Japan (N.H.)
| | | | - Emily Patsko
- Diabetes Research Centre, University of Leicester, United Kingdom (E.P.)
| | | | | | - Joaquín Serena
- Department of Neurology, Stroke Unit, Hospital Josep Trueta, IDIBGI, Girona, Spain (J.S.)
| | - Christian Weimar
- Universitätsklinikum Essen, Klinik für Neurologie, Essen, Germany (C.W.)
| | - Alan A Montgomery
- From the Nottingham Clinical Trials Unit (P.J.G., L.D., A.A.M.), University of Nottingham, United Kingdom
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das Nair R, Bradshaw LE, Day FEC, Drummond A, Harris SRS, Fitzsimmons D, Montgomery AA, Newby G, Sackley C, Lincoln NB. Clinical and cost effectiveness of memory rehabilitation following traumatic brain injury: a pragmatic cluster randomized controlled trial. Clin Rehabil 2019; 33:1171-1184. [PMID: 30977398 PMCID: PMC6585159 DOI: 10.1177/0269215519840069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 02/28/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the clinical and cost effectiveness of a group-based memory rehabilitation programme for people with traumatic brain injury. DESIGN Multicentre, pragmatic, observer-blinded, randomized controlled trial in England. SETTING Community. PARTICIPANTS People with memory problems following traumatic brain injury, aged 18-69 years, able to travel to group sessions, communicate in English, and give consent. INTERVENTIONS A total of 10 weekly group sessions of manualized memory rehabilitation plus usual care (intervention) vs. usual care alone (control). MAIN MEASURES The primary outcome was the patient-reported Everyday Memory Questionnaire (EMQ-p) at six months post randomization. Secondary outcomes were assessed at 6 and 12 months post randomization. RESULTS We randomized 328 participants. There were no clinically important differences in the primary outcome between arms at six-month follow-up (mean EMQ-p score: 38.8 (SD 26.1) in intervention and 44.1 (SD 24.6) in control arms, adjusted difference in means: -2.1, 95% confidence interval (CI): -6.7 to 2.5, p = 0.37) or 12-month follow-up. Objectively assessed memory ability favoured the memory rehabilitation arm at the 6-month, but not at the 12-month outcome. There were no between-arm differences in mood, experience of brain injury, or relative/friend assessment of patient's everyday memory outcomes, but goal attainment scores favoured the memory rehabilitation arm at both outcome time points. Health economic analyses suggested that the intervention was unlikely to be cost effective. No safety concerns were raised. CONCLUSION This memory rehabilitation programme did not lead to reduced forgetting in daily life for a heterogeneous sample of people with traumatic brain injury. Further research will need to examine who benefits most from such interventions.
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Affiliation(s)
- Roshan das Nair
- Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Florence EC Day
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Avril Drummond
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Shaun RS Harris
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | | | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Gavin Newby
- Newby Psychological Services Ltd, Northwich, UK
| | - Catherine Sackley
- School of Population Health & Environmental Sciences, King’s College London, London, UK
| | - Nadina B Lincoln
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
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Ross JDC, Brittain C, Cole M, Dewsnap C, Harding J, Hepburn T, Jackson L, Keogh M, Lawrence T, Montgomery AA, Roberts TE, Sprange K, Tan W, Thandi S, White J, Wilson J, Duley L. Gentamicin compared with ceftriaxone for the treatment of gonorrhoea (G-ToG): a randomised non-inferiority trial. Lancet 2019; 393:2511-2520. [PMID: 31056291 PMCID: PMC6620599 DOI: 10.1016/s0140-6736(18)32817-4] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 10/12/2018] [Accepted: 10/25/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gonorrhoea is a common sexually transmitted infection for which ceftriaxone is the current first-line treatment, but antimicrobial resistance is emerging. The objective of this study was to assess the effectiveness of gentamicin as an alternative to ceftriaxone (both combined with azithromycin) for treatment of gonorrhoea. METHODS G-ToG was a multicentre, parallel-group, pragmatic, randomised, non-inferiority trial comparing treatment with gentamicin to treatment with ceftriaxone for patients with gonorrhoea. The patients, treating physician, and assessing physician were masked to treatment but the treating nurse was not. The trial took place at 14 sexual health clinics in England. Adults aged 16-70 years were eligible for participation if they had a diagnosis of uncomplicated genital, pharyngeal, or rectal gonorrhoea. Participants were randomly assigned to receive a single intramuscular dose of either gentamicin 240 mg (gentamicin group) or ceftriaxone 500 mg (ceftriaxone group). All participants also received a single 1 g dose of oral azithromycin. Randomisation (1:1) was stratified by clinic and performed using a secure web-based system. The primary outcome was clearance of Neisseria gonorrhoeae at all initially infected sites, defined as a negative nucleic acid amplification test 2 weeks post treatment. Primary outcome analyses included only participants who had follow-up data, irrespective of the baseline visit N gonorrhoeae test result. The margin used to establish non-inferiority was a lower confidence limit of 5% for the risk difference. This trial is registered with ISRCTN, number ISRCTN51783227. FINDINGS Of 1762 patients assessed, we enrolled 720 participants between Oct 7, 2014, and Nov 14, 2016, and randomly assigned 358 to gentamicin and 362 to ceftriaxone. Primary outcome data were available for 306 (85%) of 362 participants allocated to ceftriaxone and 292 (82%) of 358 participants allocated to gentamicin. At 2 weeks after treatment, infection had cleared for 299 (98%) of 306 participants in the ceftriaxone group compared with 267 (91%) of 292 participants in the gentamicin group (adjusted risk difference -6·4%, 95% CI -10·4% to -2·4%). Of the 328 participants who had a genital infection, 151 (98%) of 154 in the ceftriaxone group and 163 (94%) of 174 in the gentamicin group had clearance at follow-up (adjusted risk difference -4·4%, -8·7 to 0). For participants with a pharyngeal infection, a greater proportion receiving ceftriaxone had clearance at follow-up (108 [96%] in the ceftriaxone group compared with 82 [80%] in the gentamicin group; adjusted risk difference -15·3%, -24·0 to -6·5). Similarly, a greater proportion of participants with rectal infection in the ceftriaxone group had clearance (134 [98%] in the ceftriaxone group compared with 107 [90%] in the gentamicin group; adjusted risk difference -7·8%, -13·6 to -2·0). Thus, we did not find that a single dose of gentamicin 240 mg was non-inferior to a single dose of ceftriaxone 500 mg for the treatment of gonorrhoea, when both drugs were combined with a 1 g dose of oral azithromycin. The side-effect profiles were similar between groups, although severity of pain at the injection site was higher for gentamicin (mean visual analogue pain score 36 of 100 in the gentamicin group vs 21 of 100 in the ceftriaxone group). INTERPRETATION Gentamicin is not appropriate as first-line treatment for gonorrhoea but remains potentially useful for patients with isolated genital infection, or for patients who are allergic or intolerant to ceftriaxone, or harbour a ceftriaxone-resistant isolate. Further research is required to identify and test new alternatives to ceftriaxone for the treatment of gonorrhoea. FUNDING UK National Institute for Health Research.
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Affiliation(s)
- Jonathan D C Ross
- Department of Sexual Health and HIV, Birmingham University Hospitals NHS Foundation Trust, Birmingham, UK.
| | - Clare Brittain
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Michelle Cole
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, Public Health England, London, UK
| | - Claire Dewsnap
- Sexual Health Clinic, Sheffield Royal Hallamshire Hospital, Sheffield, UK
| | - Jan Harding
- Department of Sexual Health and HIV, Birmingham University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Louise Jackson
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Matthew Keogh
- Patient and public involvement representative, Birmingham, UK
| | - Tessa Lawrence
- Department of Sexual Health and HIV, Birmingham University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Tracy E Roberts
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Wei Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Sukhwinder Thandi
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - John White
- Sexual Health Clinic, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Janet Wilson
- Sexual Health Clinic, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
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Gureje O, Oladeji BD, Montgomery AA, Bello T, Kola L, Ojagbemi A, Chisholm D, Araya R. Effect of a stepped-care intervention delivered by lay health workers on major depressive disorder among primary care patients in Nigeria (STEPCARE): a cluster-randomised controlled trial. Lancet Glob Health 2019; 7:e951-e960. [PMID: 31097414 PMCID: PMC6559947 DOI: 10.1016/s2214-109x(19)30148-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 02/04/2019] [Accepted: 02/27/2019] [Indexed: 11/29/2022]
Abstract
Background Little is known about how to scale up care for depression in settings where non-physician lay workers constitute the bulk of frontline providers. We aimed to compare a stepped-care intervention package for depression with usual care enhanced by use of the WHO Mental Health Gap Action Programme intervention guide (mhGAP-IG). Methods We did a cluster-randomised trial in primary care clinics in Ibadan, Nigeria. Eligible clinics were those with adequate staffing to provide various 24-h clinical services and with regular physician supervision. Clinics (clusters), anonymised and stratified by local government area, were randomly allocated (1:1) with a computer-generated random number sequence to one of two groups: an intervention group in which patients received a stepped-care intervention (eight sessions of individual problem-solving therapy, with an extra two to four sessions if needed) plus enhanced usual care, and a control group in which patients received enhanced usual care only. Patients from enrolled clinics could participate if they were aged 18 years or older, not pregnant, and had moderate to severe depression (scoring ≥11 on the nine-item patient health questionnaire [PHQ-9]). The primary outcome was the proportion of patients with remission of depression at 12 months (a score of ≤6 on the PHQ-9, with assessors masked to group allocation) in the intention-to-treat population. This trial is registered with the International Standard Randomised Controlled Trials Number registry (ISRCTN46754188) and is completed. Findings 35 of 97 clinics approached were eligible and agreed to participate, of which 18 were allocated to the intervention group and 17 to the control group. 1178 patients (631 [54%] in the intervention group and 547 [46%] in the control group) were recruited between Dec 2, 2013, and June 29, 2015, among whom 976 (83%) were female and baseline mean PHQ-9 score was 13·7 (SD 2·6). Of the 562 (89%) patients in the intervention group and 473 (86%) in the control group who completed 12-month follow-up, similar proportions in each group had remission of depression (425 [76%] in the intervention group vs 366 [77%] in the control group; adjusted odds ratio 1·0 [95% CI 0·70–1·40]). At 12 months, 17 (3%) deaths, one (<1%) psychotic illness, and one (<1%) case of bipolar disorder in the intervention group, and 16 deaths (3%) and one (<1%) case of bipolar disorder in the control group were recorded. No adverse events were judged to be related to the study procedures. Interpretation For patients with moderate to severe depression receiving care from non-physician primary health-care workers in Nigeria, a stepped-care, problem-solving intervention combined with enhanced usual care is similarly effective to enhanced usual care alone. Enhancing usual care with mhGAP-IG might provide simple and affordable approach to scaling up depression care in sub-Saharan Africa. Funding UK Medical Research Council.
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Affiliation(s)
- Oye Gureje
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria.
| | - Bibilola D Oladeji
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Toyin Bello
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Lola Kola
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Akin Ojagbemi
- Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Dan Chisholm
- Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Ricardo Araya
- Department of Health Services and Population Research, King's College London, London, UK
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40
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Bath PM, Woodhouse LJ, Appleton JP, Beridze M, Christensen H, Dineen RA, Flaherty K, Duley L, England TJ, Havard D, Heptinstall S, James M, Kasonde C, Krishnan K, Markus HS, Montgomery AA, Pocock S, Randall M, Ranta A, Robinson TG, Scutt P, Venables GS, Sprigg N. Triple versus guideline antiplatelet therapy to prevent recurrence after acute ischaemic stroke or transient ischaemic attack: the TARDIS RCT. Health Technol Assess 2019; 22:1-76. [PMID: 30179153 DOI: 10.3310/hta22480] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Two antiplatelet agents are better than one for preventing recurrent stroke after acute ischaemic stroke or transient ischaemic attack (TIA). Therefore, intensive treatment with three agents might be better still, providing it does not cause undue bleeding. OBJECTIVE To compare the safety and efficacy of intensive therapy with guideline antiplatelet therapy for acute ischaemic stroke and TIA. DESIGN International prospective randomised open-label blinded end-point parallel-group superiority clinical trial. SETTING Acute hospitals at 106 sites in four countries. PARTICIPANTS Patients > 50 years of age with acute non-cardioembolic ischaemic stroke or TIA within 48 hours of ictus (stroke). INTERVENTIONS Participants were allocated at random by computer to 1 month of intensive (combined aspirin, clopidogrel and dipyridamole) or guideline (combined aspirin and dipyridamole, or clopidogrel alone) antiplatelet agents, and followed for 90 days. MAIN OUTCOME MEASURES The primary outcome was the incidence and severity of any recurrent stroke (ischaemic, haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days by blinded telephone follow-up. Analysis using ordinal logistic regression was by intention to treat. Other outcomes included bleeding and its severity, death, myocardial infarction (MI), disability, mood, cognition and quality of life. RESULTS The trial was stopped early on the recommendation of the Data Monitoring Committee after recruitment of 3096 participants (intensive, n = 1556; guideline, n = 1540) from 106 hospitals in four countries between April 2009 and March 2016. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy in 3070 (99.2%) participants with data [93 vs. 105 stroke/TIA events; adjusted common odds ratio 0.90, 95% confidence interval (CI) 0.67 to 1.20; p = 0.47]. Major (encompassing fatal) bleeding was increased with intensive as compared with guideline therapy [39 vs. 17 participants; adjusted hazard ratio (aHR) 2.23, 95% CI 1.25 to 3.96; p = 0.006]. There were no differences between the treatment groups in all-cause mortality, or the composite of death, stroke, MI and major bleeding (aHR 1.02, 95% CI 0.77 to 1.35; p = 0.88). LIMITATIONS Patients and investigators were not blinded to treatment. The comparator group comprised two guideline strategies because of changes in national guidelines during the trial. The trial was stopped early, thereby reducing its statistical power. CONCLUSIONS The use of three antiplatelet agents is associated with increased bleeding without any significant reduction in recurrence of stroke or TIA. FUTURE WORK The safety and efficacy of dual antiplatelet therapy (combined aspirin and clopidogrel) versus aspirin remains to be defined. Further research is required on identifying individual patient response to antiplatelets, and the relationship between response and the subsequent risks of vascular recurrent events and bleeding complications. TRIAL REGISTRATION Current Controlled Trials ISRCTN47823388. 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. 22, No. 48. See the NIHR Journal Library website for further project information. The Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) vanguard phase was funded by the British Heart Foundation (grant PG/08/083/25779, from 1 April 2009 to 30 September 2012) and indirect funding was provided by the Stroke Association through its funding of the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK. There was no commercial support for the trial and antiplatelet drugs were sourced locally at each site. The trial was sponsored by the University of Nottingham.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Maia Beridze
- Department of Neurology, Hospital of War Veterans, Tbilisi, Georgia
| | - Hanne Christensen
- Department of Neurology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Robert A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - Diane Havard
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Stan Heptinstall
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Marilyn James
- Health Economics, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | | | - Kailash Krishnan
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Hugh S Markus
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Stuart Pocock
- Medical Statistics Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Marc Randall
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Annamarei Ranta
- Department of Neurology, Wellington Hospital and University of Otago, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Graham S Venables
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Abstract
OBJECTIVE To assess the effects of using health social media on different days of the working week on web activity. DESIGN Individually randomised controlled parallel group superiority trial. SETTING Twitter and Weibo. PARTICIPANTS 194 Cochrane Schizophrenia Group full reviews with an abstract and plain language summary web page. There were no human participants. INTERVENTIONS Three randomly ordered slightly different messages (maximum of 140 characters), each containing a short URL to the freely accessible summary page, were sent on specific times on a single day. Each of these messages sent on Tuesday, Wednesday, Thursday and Friday was compared with the one sent on Monday. OUTCOME The primary outcome was visits to the relevant Cochrane summary web page at 1 week. Secondary outcomes were other metrics of web activity at 1 week. RESULTS There was no evidence that disseminating microblogs on different days of the working week resulted in any differences in target website activity as measured by Google Analytics (n=194, all page views, adjusted ratios of geometric means 0.86 (95% CI 0.63 to 1.18), 0.88 (95% CI 0.64 to 1.21), 0.88 (95% CI 0.65 to 1.21), 0.91 (95% CI 0.66 to 1.24) for Tuesday-Friday, respectively, overall p=0.89). There were consistent findings for all outcomes. However, activity on the review site substantially increased compared with weeks preceding the intervention. CONCLUSION There are no clear differences in the effect when 1 weekday is compared with another, but our study suggests that using microblogging social media such as Twitter and Weibo do increase information-seeking behaviour on health. Tweet any day but do Tweet.
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Affiliation(s)
- Mahesh Jayaram
- Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia
- Psychiatry, Melbourne Health, Melbourne, Victoria, Australia
| | - Clive E Adams
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Johannes S Friedel
- Hochschule Furtwangen University of Applied Sciences, Furtwangen, Baden-Württemberg, Germany
| | - Eimear McClenaghan
- Medical School, University of Aberdeen Institute of Applied Health Sciences, Aberdeen, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Maritta Välimäki
- Department of Nursing Science, University of Turku, Turku, Finland
- Department of Nursing, The Hong Kong Polytechnic University, Hong Kong, Hong Kong
| | - Lena Schmidt
- Hochschule Furtwangen University of Applied Sciences, Furtwangen, Baden-Württemberg, Germany
| | - Jun Xia
- Systematic Review Solutions Limited, University of Nottingham, Nottingham, UK
- Nottingham Health China, The University of Nottingham, Ningbo, China
| | - Sai Zhao
- Systematic Review Solutions Limited, Ningbo, China
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42
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Appleton JP, Scutt P, Dixon M, Howard H, Haywood L, Havard D, Hepburn T, England T, Sprigg N, Woodhouse LJ, Wardlaw JM, Montgomery AA, Pocock S, Bath PM. Ambulance-delivered transdermal glyceryl trinitrate versus sham for ultra-acute stroke: Rationale, design and protocol for the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) trial (ISRCTN26986053). Int J Stroke 2019; 14:191-206. [PMID: 28762896 DOI: 10.1177/1747493017724627] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
RATIONALE Vascular nitric oxide levels are low in acute stroke and donors such as glyceryl trinitrate have shown promise when administered very early after stroke. Potential mechanisms of action include augmentation of cerebral reperfusion, thrombolysis and thrombectomy, lowering blood pressure, and cytoprotection. AIM To test the safety and efficacy of four days of transdermal glyceryl trinitrate (5 mg/day) versus sham in patients with ultra-acute presumed stroke who are recruited by paramedics prior to hospital presentation. SAMPLE SIZE ESTIMATES The sample size of 850 patients will allow a shift in the modified Rankin Scale with odds ratio 0.70 (glyceryl trinitrate versus sham, ordinal logistic regression) to be detected with 90% power at 5% significance (two-sided). DESIGN The Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) is a multicentre UK prospective randomized sham-controlled outcome-blinded parallel-group trial in 850 patients with ultra-acute (≤4 h of onset) FAST-positive presumed stroke and systolic blood pressure ≥120 mmHg who present to the ambulance service following a 999 emergency call. Data collection is performed via a secure internet site with real-time data validation. STUDY OUTCOMES The primary outcome is the modified Rankin Scale measured centrally by telephone at 90 days and masked to treatment. Secondary outcomes include: blood pressure, impairment, recurrence, dysphagia, neuroimaging markers of the acute lesion including vessel patency, discharge disposition, length of stay, death, cognition, quality of life, and mood. Neuroimaging and serious adverse events are adjudicated blinded to treatment. DISCUSSION RIGHT-2 has recruited more than 500 participants from seven UK ambulance services. STATUS Trial is ongoing. FUNDING British Heart Foundation. REGISTRATION ISRCTN26986053.
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Affiliation(s)
- Jason P Appleton
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Polly Scutt
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Mark Dixon
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Harriet Howard
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lee Haywood
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Diane Havard
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Trish Hepburn
- 2 Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Tim England
- 3 Division of Medical Sciences, University of Nottingham, Derby, UK
| | - Nikola Sprigg
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lisa J Woodhouse
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Alan A Montgomery
- 2 Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Stuart Pocock
- 5 Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Philip M Bath
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Godolphin PJ, Bath PM, Montgomery AA. Short email with attachment versus long email without attachment when contacting authors to request unpublished data for a systematic review: a nested randomised trial. BMJ Open 2019; 9:e025273. [PMID: 30705243 PMCID: PMC6359874 DOI: 10.1136/bmjopen-2018-025273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/02/2018] [Accepted: 11/28/2018] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Systematic reviews often rely on the acquisition of unpublished analyses or data. We carried out a nested randomised trial comparing two different approaches for contacting authors to request additional data for a systematic review. PARTICIPANTS Participants were authors of published reports of prevention or treatment trials in stroke in which there was central adjudication of events. A primary and secondary research active author were selected as contacts for each trial. INTERVENTIONS Authors were randomised to be sent either a short email with a protocol of the systematic review attached ('Short') or a longer email that contained detailed information and without the protocol attached ('Long'). A maximum of two emails were sent to each author to obtain a response. The unit of analysis was trial, accounting for clustering by author. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was whether a response was received from authors. Secondary outcomes included time to response, number of reminders needed before a response was received and whether authors agreed to collaborate. RESULTS 88 trials with 76 primary authors were identified in the systematic review, and of these, 36 authors were randomised to Short (trials=45) and 40 to Long (trials=43). Responses were received for 69 trials. There was no evidence of a difference in response rate between trial arms (Short vs Long, OR 1.10, 95% CI 0.36 to 3.33). There was no evidence of a difference in time to response between trial arms (Short vs Long, HR 0.91, 95% CI 0.55 to 1.51). In total, 27% of authors responded within a day and 22% of authors never responded. CONCLUSIONS There was no evidence to suggest that email format had an impact on the number of responses received when acquiring data for a systematic review involving stroke trials or the time taken to receive these responses.
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Affiliation(s)
- Peter J Godolphin
- Nottingham Clinical Trials Unit, The University of Nottingham, Nottingham, UK
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, The University of Nottingham, Nottingham, UK
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Hull MA, Sprange K, Hepburn T, Tan W, Shafayat A, Rees CJ, Clifford G, Logan RF, Loadman PM, Williams EA, Whitham D, Montgomery AA. Eicosapentaenoic acid and aspirin, alone and in combination, for the prevention of colorectal adenomas (seAFOod Polyp Prevention trial): a multicentre, randomised, double-blind, placebo-controlled, 2 × 2 factorial trial. Lancet 2018; 392:2583-2594. [PMID: 30466866 PMCID: PMC6294731 DOI: 10.1016/s0140-6736(18)31775-6] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/25/2018] [Accepted: 07/26/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND The omega-3 polyunsaturated fatty acid eicosapentaenoic acid (EPA) and aspirin both have proof of concept for colorectal cancer chemoprevention, aligned with an excellent safety profile. Therefore, we aimed to test the efficacy of EPA and aspirin, alone and in combination and compared with a placebo, in individuals with sporadic colorectal neoplasia detected at colonoscopy. METHODS In a multicentre, randomised, double-blind, placebo-controlled, 2 × 2 factorial trial, patients aged 55-73 years who were identified during colonoscopy as being at high risk in the English Bowel Cancer Screening Programme (BCSP; ≥3 adenomas if at least one was ≥10 mm in diameter or ≥5 adenomas if these were <10 mm in diameter) were recruited from 53 BCSP endoscopy units in England, UK. Patients were randomly allocated (1:1:1:1) using a secure web-based server to receive 2 g EPA-free fatty acid (FFA) per day (either as the FFA or triglyceride), 300 mg aspirin per day, both treatments in combination, or placebo for 12 months using random permuted blocks of randomly varying size, and stratified by BCSP site. Research staff and participants were masked to group assignment. The primary endpoint was the adenoma detection rate (ADR; the proportion of participants with any adenoma) at 1 year surveillance colonoscopy analysed in all participants with observable follow-up data using a so-called at-the-margins approach, adjusted for BCSP site and repeat endoscopy at baseline. The safety population included all participants who received at least one dose of study drug. The trial is registered with the International Standard Randomised Controlled Trials Number registry, number ISRCTN05926847. FINDINGS Between Nov 11, 2011, and June 10, 2016, 709 participants were randomly assigned to four treatment groups (176 to placebo, 179 to EPA, 177 to aspirin, and 177 to EPA plus aspirin). Adenoma outcome data were available for 163 (93%) patients in the placebo group, 153 (85%) in the EPA group, 163 (92%) in the aspirin group, and 161 (91%) in the EPA plus aspirin group. The ADR was 61% (100 of 163) in the placebo group, 63% (97 of 153) in the EPA group, 61% (100 of 163) in the aspirin group, and 61% (98 of 161) in the EPA plus aspirin group, with no evidence of any effect for EPA (risk ratio [RR] 0·98, 95% CI 0·87 to 1·12; risk difference -0·9%, -8·8 to 6·9; p=0·81) or aspirin (RR 0·99 (0·87 to 1·12; risk difference -0·6%, -8·5 to 7·2; p=0·88). EPA and aspirin were well tolerated (78 [44%] of 176 had ≥1 adverse event in the placebo group compared with 82 [46%] in the EPA group, 68 [39%] in the aspirin group, and 76 [45%] in the EPA plus aspirin group), although the number of gastrointestinal adverse events was increased in the EPA alone group at 146 events (compared with 85 in the placebo group, 86 in the aspirin group, and 68 in the aspirin plus placebo group). Six upper-gastrointestinal bleeding events were reported across the treatment groups (two in the EPA group, three in the aspirin group, and one in the placebo group). INTERPRETATION Neither EPA nor aspirin treatment were associated with a reduction in the proportion of patients with at least one colorectal adenoma. Further research is needed regarding the effect on colorectal adenoma number according to adenoma type and location. Optimal use of EPA and aspirin might need a precision medicine approach to adenoma recurrence. FUNDING Efficacy and Mechanism Evaluation Programme, a UK Medical Research Council and National Institute for Health Research partnership.
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Affiliation(s)
- Mark A Hull
- Institute of Biomedical and Clinical Sciences, University of Leeds, St James's University Hospital, Leeds, UK.
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Wei Tan
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Aisha Shafayat
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Colin J Rees
- Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne, UK
| | - Gayle Clifford
- South Tyneside NHS Foundation Trust, South Tyneside District Hospital, Tyne and Wear, UK
| | - Richard F Logan
- Nottingham Digestive Diseases Centre, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Paul M Loadman
- School of Pharmacy and Medical Sciences, Institute of Cancer Therapeutics, University of Bradford, Bradford, UK
| | | | - Diane Whitham
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
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Godolphin PJ, Hepburn T, Sprigg N, Walker L, Berge E, Collins R, Gommans J, Ntaios G, Pocock S, Prasad K, Wardlaw JM, Bath PM, Montgomery AA. Central masked adjudication of stroke diagnosis at trial entry offered no advantage over diagnosis by local clinicians: Secondary analysis and simulation. Contemp Clin Trials Commun 2018; 12:176-181. [PMID: 30533551 PMCID: PMC6249966 DOI: 10.1016/j.conctc.2018.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/25/2018] [Accepted: 11/05/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Central adjudication of stroke type is commonly implemented in large multicentre clinical trials. We investigated the effect of central adjudication of diagnosis of stroke type at trial entry in the Efficacy of Nitric Oxide in Stroke (ENOS) trial. METHODS ENOS recruited patients with acute ischaemic or haemorrhagic stroke, and diagnostic adjudication was carried out using cranial scans. For this study, diagnoses made by local site clinicians were compared with those by central, masked adjudicators using kappa statistics. The trial primary analysis and subgroup analysis by stroke type were re-analysed using stroke diagnosis made by local clinicians, and simulations were used to assess the impact of increased non-differential misclassification and subgroup effects. RESULTS Agreement on stroke type (Ischaemic, Intracerebral Haemorrhage, Unknown stroke type, No-stroke) was high (κ = 0.92). Adjudication of stroke type had no impact on the primary outcome or subgroup analysis by stroke type. With misclassification increased to 10 times the level observed in ENOS and a simulated subgroup effect present, adjudication would have affected trial conclusions. CONCLUSIONS Stroke type at trial entry was diagnosed accurately by local clinicians in ENOS. Adjudication of stroke type by central adjudicators had no measurable effect on trial conclusions. Diagnostic adjudication may be important if diagnosis is complex and a treatment-diagnosis interaction is expected.
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Affiliation(s)
- Peter J. Godolphin
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Liz Walker
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | | | - John Gommans
- Hawke's Bay District Health Board, Hastings, New Zealand
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Joanna M. Wardlaw
- Neuroimaging Sciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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Godolphin PJ, Montgomery AA, Woodhouse LJ, Bereczki D, Berge E, Collins R, Díez-Tejedor E, Gommans J, Lees KR, Ozturk S, Phillips S, Pocock S, Prasad K, Szatmari S, Wang Y, Bath PM, Sprigg N. Central adjudication of serious adverse events did not affect trial's safety results: Data from the Efficacy of Nitric Oxide in Stroke (ENOS) trial. PLoS One 2018; 13:e0208142. [PMID: 30475912 PMCID: PMC6258247 DOI: 10.1371/journal.pone.0208142] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 11/02/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Central adjudication of serious adverse events (SAEs) can be undertaken in clinical trials, especially for open-label studies where outcome assessment may be at risk of bias. This study explored the effect of central adjudication of SAEs on the safety results of the Efficacy of Nitric Oxide in Stroke (ENOS) Trial. METHODS ENOS assigned patients with acute stroke at random to receive either transdermal glyceryl trinitrate (GTN) or no GTN and to Stop or Continue previous antihypertensive treatment. SAEs were reported by local investigators who were not blinded to treatment allocation. Central adjudicators, blinded to treatment allocation, reviewed the investigators reports and used evidence available to confirm or re-categorise the classification of event, likely causality, diagnosis and expectedness of event. RESULTS Of 4011 patients enrolled in ENOS, 1473 SAEs were reported by local investigators; this was reduced to 1444 after the review by adjudicators, with 29 re-classified as not an SAE. There was fair agreement between investigators and adjudicators regarding likely causality, with 808 agreements and 644 disagreements (56% crude agreement, weighted kappa, κ = 0.31). Agreement increased upon dichotomisation of the causality categories, with 1432 agreements and 20 disagreements (99% crude agreement, kappa = 0.54). Repeating the main trial safety analysis with investigator reported events showed that adjudication had no effect on the main trial safety conclusions. CONCLUSIONS In a large trial, with many SAEs reported, central adjudication of these events did not affect trial conclusions. This suggests that adjudication of SAEs in a clinical trial where the intervention already has a well-established safety profile may not be necessary. Potential efficiency savings (financial, logistical) can be made through not adjudicating SAEs.
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Affiliation(s)
- Peter J. Godolphin
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Exuperio Díez-Tejedor
- Department of Neurology, La Paz University Hospital–Autonoma University of Madrid, Madrid, Spain
| | | | | | | | - Stephen Phillips
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
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Whitham D, Turzanski J, Bradshaw L, Clarke M, Culliford L, Duley L, Shaw L, Skea Z, Treweek SP, Walker K, Williamson PR, Montgomery AA. Development of a standardised set of metrics for monitoring site performance in multicentre randomised trials: a Delphi study. Trials 2018; 19:557. [PMID: 30326967 PMCID: PMC6192223 DOI: 10.1186/s13063-018-2940-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/26/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Site performance is key to the success of large multicentre randomised trials. A standardised set of clear and accessible summaries of site performance could facilitate the timely identification and resolution of potential problems, minimising their impact. The aim of this study was to identify and agree a core set of key performance metrics for managing multicentre randomised trials. METHODS We used a mixed methods approach to identify potential metrics and to achieve consensus about the final set, adapting methods that are recommended by the COMET Initiative for developing core outcome sets in health care. We used performance metrics identified from our systematic search and focus groups to create an online Delphi survey. We invited respondents to score each metric for inclusion in the final core set, over three survey rounds. Metrics scored as critical by ≥70% and unimportant by <15% of respondents were taken forward to a consensus meeting of representatives from key UK-based stakeholders. Participants in the consensus meeting discussed and voted on each metric, using anonymous electronic voting. Metrics with >50% of participants voting for inclusion were retained. RESULTS Round 1 of the Delphi survey presented 28 performance metrics, and a further six were added in round 2. Of 294 UK-based stakeholders who registered for the Delphi survey, 211 completed all three rounds. At the consensus meeting, 17 metrics were discussed and voted on: 15 metrics were retained following survey round 3, plus two others that were preferred by consensus meeting participants. Consensus was reached on a final core set of eight performance metrics in three domains: (1) recruitment and retention, (2) data quality and (3) protocol compliance. A simple tool for visual reporting of the metrics is available from the Nottingham Clinical Trials Unit website. CONCLUSIONS We have established a core set of metrics for measuring the performance of sites in multicentre randomised trials. These metrics could improve trial conduct by enabling researchers to identify and address problems before trials are adversely affected. Future work could evaluate the effectiveness of using the metrics and reporting tool.
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Affiliation(s)
- Diane Whitham
- Nottingham Clinical Trials Unit, Queens Medical Centre, C Floor, South Block, Nottingham, NG7 2UH UK
| | - Julie Turzanski
- Nottingham Clinical Trials Unit, Queens Medical Centre, C Floor, South Block, Nottingham, NG7 2UH UK
| | - Lucy Bradshaw
- Nottingham Clinical Trials Unit, Queens Medical Centre, C Floor, South Block, Nottingham, NG7 2UH UK
| | - Mike Clarke
- School of Medicine, Dentistry and Biomedical Sciences, Institute of Health Sciences, Queen’s University, Belfast, UK
| | - Lucy Culliford
- CTEU Bristol, University of Bristol, Bristol Royal Infirmary, Bristol, BS2 8HW UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, Queens Medical Centre, C Floor, South Block, Nottingham, NG7 2UH UK
| | - Lisa Shaw
- Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Zoe Skea
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Shaun P. Treweek
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Kate Walker
- Nottingham Clinical Trials Unit, Queens Medical Centre, C Floor, South Block, Nottingham, NG7 2UH UK
| | - Paula R. Williamson
- MRC North West Hub for Trials Methodology Research, Department Biostatistics, University of Liverpool, Block F Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, Queens Medical Centre, C Floor, South Block, Nottingham, NG7 2UH UK
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Crawford MJ, Sanatinia R, Barrett B, Cunningham G, Dale O, Ganguli P, Lawrence-Smith G, Leeson V, Lemonsky F, Lykomitrou G, Montgomery AA, Morriss R, Munjiza J, Paton C, Skorodzien I, Singh V, Tan W, Tyrer P, Reilly JG. The Clinical Effectiveness and Cost-Effectiveness of Lamotrigine in Borderline Personality Disorder: A Randomized Placebo-Controlled Trial. Am J Psychiatry 2018; 175:756-764. [PMID: 29621901 DOI: 10.1176/appi.ajp.2018.17091006] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined whether lamotrigine is a clinically effective and cost-effective treatment for people with borderline personality disorder. METHOD This was a multicenter, double-blind, placebo-controlled randomized trial. Between July 2013 and November 2016, the authors recruited 276 people age 18 or over who met diagnostic criteria for borderline personality disorder. Individuals with coexisting bipolar affective disorder or psychosis, those already taking a mood stabilizer, and women at risk of pregnancy were excluded. A web-based randomization service was used to allocate participants randomly in a 1:1 ratio to receive either an inert placebo or up to 400 mg/day of lamotrigine. The primary outcome measure was score on the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) at 52 weeks. Secondary outcome measures included depressive symptoms, deliberate self-harm, social functioning, health-related quality of life, resource use and costs, side effects of treatment, and adverse events. RESULTS A total of 195 (70.6%) participants were followed up at 52 weeks, at which point 49 (36%) of those in the lamotrigine group and 58 (42%) of those in the placebo group were taking study medication. The mean ZAN-BPD score was 11.3 (SD=6.6) among those in the lamotrigine group and 11.5 (SD=7.7) among those in the placebo group (adjusted difference in means=0.1, 95% CI=-1.8, 2.0). There was no evidence of any differences in secondary outcomes. Costs of direct care were similar in the two groups. CONCLUSIONS The results suggest that treating people with borderline personality disorder with lamotrigine is not a clinically effective or cost-effective use of resources.
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Affiliation(s)
- Mike J Crawford
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Rahil Sanatinia
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Barbara Barrett
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Gillian Cunningham
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Oliver Dale
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Poushali Ganguli
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Geoff Lawrence-Smith
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Verity Leeson
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Fenella Lemonsky
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Georgia Lykomitrou
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Alan A Montgomery
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Richard Morriss
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Jasna Munjiza
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Carol Paton
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Iwona Skorodzien
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Vineet Singh
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Wei Tan
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Peter Tyrer
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
| | - Joseph G Reilly
- From the Centre for Psychiatry, Imperial College London, Hammersmith Campus, London; the Centre for the Economics of Mental and Physical Health, King's College London; Tees, Esk and Wear Valley NHS Trust, Middlesbrough, U.K.; West London NHS Mental Health Trust, Southall; Oxleas NHS Foundation Trust, Dartford, U.K.; the Division of Psychiatry and Applied Psychology and the Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, U.K.; the Central and North West London NHS Foundation Trust, London; and the Derbyshire Healthcare NHS Foundation Trust, Derby, U.K
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Haines RH, Thomas KS, Montgomery AA, Ravenscroft JC, Akram P, Chalmers JR, Whitham D, Duley L, Eleftheriadou V, Meakin G, Mitchell EJ, White J, Rogers A, Sach T, Santer M, Tan W, Hepburn T, Williams HC, Batchelor J. Home interventions and light therapy for the treatment of vitiligo (HI-Light Vitiligo Trial): study protocol for a randomised controlled trial. BMJ Open 2018; 8:e018649. [PMID: 29615444 PMCID: PMC5893933 DOI: 10.1136/bmjopen-2017-018649] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Vitiligo is a condition resulting in white patches on the skin. People with vitiligo can suffer from low self-esteem, psychological disturbance and diminished quality of life. Vitiligo is often poorly managed, partly due to lack of high-quality evidence to inform clinical care. We describe here a large, independent, randomised controlled trial (RCT) assessing the comparative effectiveness of potent topical corticosteroid, home-based hand-held narrowband ultraviolet B-light (NB-UVB) or combination of the two, for the management of vitiligo. METHODS AND ANALYSIS The HI-Light Vitiligo Trial is a multicentre, three-arm, parallel group, pragmatic, placebo-controlled RCT. 516 adults and children with actively spreading, but limited, vitiligo are randomised (1:1:1) to one of three groups: mometasone furoate 0.1% ointment plus dummy NB-UVB light, vehicle ointment plus NB-UVB light or mometasone furoate 0.1% ointment plus NB-UVB light. Treatment of up to three patches of vitiligo is continued for up to 9 months with clinic visits at baseline, 3, 6 and 9 months and four post-treatment questionnaires.The HI-Light Vitiligo Trial assesses outcomes included in the vitiligo core outcome set and places emphasis on participants' views of treatment success. The primary outcome is proportion of participants achieving treatment success (patient-rated Vitiligo Noticeability Scale) for a target patch of vitiligo at 9 months with further independent blinded assessment using digital images of the target lesion before and after treatment. Secondary outcomes include time to onset of treatment response, treatment success by body region, percentage repigmentation, quality of life, time-burden of treatment, maintenance of response, safety and within-trial cost-effectiveness. ETHICS AND DISSEMINATION Approvals were granted by East Midlands-Derby Research Ethics Committee (14/EM/1173) and the MHRA (EudraCT 2014-003473-42). The trial was registered 8 January 2015 ISRCTN (17160087). Results will be published in full as open access in the NIHR Journal library and elsewhere. TRIAL REGISTRATION NUMBER ISRCTN17160087.
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Affiliation(s)
- Rachel H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Jane C Ravenscroft
- Department of Paediatric Dermatology, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Perways Akram
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Diane Whitham
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham Health Science Partners, Queen's Medical Centre, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham Health Science Partners, Queen's Medical Centre, Nottingham, UK
| | | | - Garry Meakin
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Eleanor J Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Jennifer White
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Andy Rogers
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Tracey Sach
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Miriam Santer
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Wei Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Jonathan Batchelor
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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50
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Bath PM, Woodhouse LJ, Appleton JP, Beridze M, Christensen H, Dineen RA, Duley L, England TJ, Flaherty K, Havard D, Heptinstall S, James M, Krishnan K, Markus HS, Montgomery AA, Pocock SJ, Randall M, Ranta A, Robinson TG, Scutt P, Venables GS, Sprigg N. Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial. Lancet 2018; 391:850-859. [PMID: 29274727 PMCID: PMC5854459 DOI: 10.1016/s0140-6736(17)32849-0] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 09/23/2017] [Accepted: 11/02/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Intensive antiplatelet therapy with three agents might be more effective than guideline treatment for preventing recurrent events in patients with acute cerebral ischaemia. We aimed to compare the safety and efficacy of intensive antiplatelet therapy (combined aspirin, clopidogrel, and dipyridamole) with that of guideline-based antiplatelet therapy. METHODS We did an international, prospective, randomised, open-label, blinded-endpoint trial in adult participants with ischaemic stroke or transient ischaemic attack (TIA) within 48 h of onset. Participants were assigned in a 1:1 ratio using computer randomisation to receive loading doses and then 30 days of intensive antiplatelet therapy (combined aspirin 75 mg, clopidogrel 75 mg, and dipyridamole 200 mg twice daily) or guideline-based therapy (comprising either clopidogrel alone or combined aspirin and dipyridamole). Randomisation was stratified by country and index event, and minimised with prognostic baseline factors, medication use, time to randomisation, stroke-related factors, and thrombolysis. The ordinal primary outcome was the combined incidence and severity of any recurrent stroke (ischaemic or haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days, as assessed by central telephone follow-up with masking to treatment assignment, and analysed by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN47823388. FINDINGS 3096 participants (1556 in the intensive antiplatelet therapy group, 1540 in the guideline antiplatelet therapy group) were recruited from 106 hospitals in four countries between April 7, 2009, and March 18, 2016. The trial was stopped early on the recommendation of the data monitoring committee. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy (93 [6%] participants vs 105 [7%]; adjusted common odds ratio [cOR] 0·90, 95% CI 0·67-1·20, p=0·47). By contrast, intensive antiplatelet therapy was associated with more, and more severe, bleeding (adjusted cOR 2·54, 95% CI 2·05-3·16, p<0·0001). INTERPRETATION Among patients with recent cerebral ischaemia, intensive antiplatelet therapy did not reduce the incidence and severity of recurrent stroke or TIA, but did significantly increase the risk of major bleeding. Triple antiplatelet therapy should not be used in routine clinical practice. FUNDING National Institutes of Health Research Health Technology Assessment Programme, British Heart Foundation.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK.
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK
| | | | - Hanne Christensen
- Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Department of Neurology, Copenhagen, Denmark
| | - Robert A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences & GEM, University of Nottingham, Nottingham, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Diane Havard
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Stan Heptinstall
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Marilyn James
- Health Economics, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK
| | - Hugh S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Marc Randall
- Department of Neurology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital and University of Otago, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Cardiovascular Research Centre, University of Leicester, Leicester, UK
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Graham S Venables
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK
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