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Eriksson M, Hayat R, Kinsella E, Lewis K, White DCS, Boyd J, Bullen A, Maclean M, Stoddart A, Phair S, Evans H, Noakes J, Alexander D, Keerie C, Linsley C, Milne G, Norrie J, Farrar N, Realpe AX, Donovan JL, Bunch J, Douthwaite K, Temple S, Hogg J, Scott D, Spallone P, Stuart I, Wardlaw JM, Palmer J, Sakka E, Mukerji N, Cirstea E, Davies S, Giannakaki V, Kadhim A, Kennion O, Islam M, Ferguson L, Prasad M, Bacon A, Richards E, Howe J, Kamara C, Gardner J, Roman M, Sikaonga M, Cahill J, Rossdeutsch A, Cahill V, Hamina I, Chaudhari K, Danciut M, Clarkson E, Bjornson A, Bulters D, Digpal R, Ruiz W, Taylor M, Anyog D, Tluchowska K, Nolasco J, Brooks D, Angelopoulou K, Welch B, Broomes N, Fouyas I, MacRaild A, Kaliaperumal C, Teasdale J, Coakley M, Brennan P, Sokol D, Wiggins A, MacDonald M, Risbridger S, Bhatt P, Irvine J, Majeed S, Williams S, Reid J, Walch A, Muir F, van Beijnum J, Leach P, Hughes T, Makwana M, Hamandi K, McAleer D, Gunning B, Walsh D, Wroe Wright O, Patel S, Gurusinghe N, Raza-Knight S, Cromie TL, Brown A, Raj S, Pennington R, Campbell C, Patel S, Colombo F, Teo M, Wildman J, Smith K, Goff E, Stephens D, Borislavova B, Worner R, Buddha S, Clatworthy P, Edwards R, Clayton E, Coy K, Tucker L, Dymond S, Mallick A, Hodnett R, Spickett-Jones F, Grover P, Banaras A, Tshuma S, Muirhead W, Scott Hill C, Shah R, Doke T, Hall R, Coskuner S, Aslett L, Vindlacheruvu R, Ghosh A, Fitzpatrick T, Harris L, Hayton T, Whitehouse A, McDarby A, Hancox R, Auyeung CK, Nair R, Thomas R, McLachlan H, Kountourgioti A, Orjales G, Kruczynski J, Hunter S, Bohnacker N, Marimon R, Parker L, Raha O, Sharma P, Uff C, Boyapati G, Papadopoulos M, Kearney S, Visagan R, Bosetta E, Asif H, Helmy A, Chapas L, Tarantino S, Caldwell K, Guilfoyle M, Agarwal S, Brown D, Holland S, Tajsic T, Fletcher C, Sebyatki A, Ushewokunze S, Ali S, Preston J, Chambers C, Patel M, Holsgrove D, McLaughlan D, Marsden T, Colombo F, Cawley K, Raffalli H, Lee S, Israni A, Dore R, Anderson T, Hennigan D, Mayor S, Glover S, Chavredakis E, Brown D, Sokratous G, Williamson J, Stoneley C, Brodbelt A, Farah JO, Illingworth S, Konteas AB, Davies D, Owen C, Kerr L, Hall P, Al-Shahi Salman R, Forsyth L, Lewis SC, Loan JJM, Neilson AR, Stephen J, Kitchen N, Harkness KA, Hutchinson PJA, Mallucci C, Wade J, White PM. Medical management and surgery versus medical management alone for symptomatic cerebral cavernous malformation (CARE): a feasibility study and randomised, open, pragmatic, pilot phase trial. Lancet Neurol 2024:S1474-4422(24)00096-6. [PMID: 38643777 DOI: 10.1016/s1474-4422(24)00096-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND The highest priority uncertainty for people with symptomatic cerebral cavernous malformation is whether to have medical management and surgery or medical management alone. We conducted a pilot phase randomised controlled trial to assess the feasibility of addressing this uncertainty in a definitive trial. METHODS The CARE pilot trial was a prospective, randomised, open-label, assessor-blinded, parallel-group trial at neuroscience centres in the UK and Ireland. We aimed to recruit 60 people of any age, sex, and ethnicity who had mental capacity, were resident in the UK or Ireland, and had a symptomatic cerebral cavernous malformation. Computerised, web-based randomisation assigned participants (1:1) to medical management and surgery (neurosurgical resection or stereotactic radiosurgery) or medical management alone, stratified by the neurosurgeon's and participant's consensus about the intended type of surgery before randomisation. Assignment was open to investigators, participants, and carers, but not clinical outcome event adjudicators. Feasibility outcomes included site engagement, recruitment, choice of surgical management, retention, adherence, data quality, clinical outcome event rate, and protocol implementation. The primary clinical outcome was symptomatic intracranial haemorrhage or new persistent or progressive non-haemorrhagic focal neurological deficit due to cerebral cavernous malformation or surgery during at least 6 months of follow-up. We analysed data from all randomly assigned participants according to assigned management. This trial is registered with ISRCTN (ISRCTN41647111) and has been completed. FINDINGS Between Sept 27, 2021, and April 28, 2023, 28 (70%) of 40 sites took part, at which investigators screened 511 patients, of whom 322 (63%) were eligible, 202 were approached for recruitment, and 96 had collective uncertainty with their neurosurgeon about whether to have surgery for a symptomatic cerebral cavernous malformation. 72 (22%) of 322 eligible patients were randomly assigned (mean recruitment rate 0·2 [SD 0·25] participants per site per month) at a median of 287 (IQR 67-591) days since the most recent symptomatic presentation. Participants' median age was 50·6 (IQR 38·6-59·2) years, 68 (94%) of 72 participants were adults, 41 (57%) were female, 66 (92%) were White, 56 (78%) had a previous intracranial haemorrhage, and 28 (39%) had a previous epileptic seizure. The intended type of surgery before randomisation was neurosurgical resection for 19 (26%) of 72, stereotactic radiosurgery for 44 (61%), and no preference for nine (13%). Baseline clinical and imaging data were complete for all participants. 36 participants were randomly assigned to medical management and surgery (12 to neurosurgical resection and 24 to stereotactic radiosurgery) and 36 to medical management alone. Three (4%) of 72 participants withdrew, one was lost to follow-up, and one declined face-to-face follow-up, leaving 67 (93%) retained at 6-months' clinical follow-up. 61 (91%) of 67 participants with follow-up adhered to the assigned management strategy. The primary clinical outcome occurred in two (6%) of 33 participants randomly assigned to medical management and surgery (8·0%, 95% CI 2·0-32·1 per year) and in two (6%) of 34 participants randomly assigned to medical management alone (7·5%, 1·9-30·1 per year). Investigators reported no deaths, no serious adverse events, one protocol violation, and 61 protocol deviations. INTERPRETATION This pilot phase trial exceeded its recruitment target, but a definitive trial will require extensive international engagement. FUNDING National Institute for Health and Care Research.
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Norrie J. Health effects of gas fuels: interpreting evidence from a comprehensive meta-analysis. Lancet Respir Med 2024; 12:259-260. [PMID: 38310915 DOI: 10.1016/s2213-2600(24)00005-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 02/06/2024]
Affiliation(s)
- John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh EH16 4UX, UK.
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Simpson AHRW, Clement ND, Simpson SA, Pandit H, Smillie S, Leeds AR, Conaghan PG, Kingsbury SR, Hamilton D, Craig P, Ray D, Keerie C, Kinsella E, Bell-Higgs A, McGarty A, Beadle C, Howie CR, Norrie J. A preoperative package of care for osteoarthritis, consisting of weight loss, orthotics, rehabilitation, and topical and oral analgesia (OPPORTUNITY): a two-centre, open-label, randomised controlled feasibility trial. Lancet Rheumatol 2024; 6:e237-e246. [PMID: 38423028 DOI: 10.1016/s2665-9913(23)00337-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 12/03/2023] [Accepted: 12/13/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND Osteoarthritis of the knee is a major cause of disability worldwide. Non-operative treatments can reduce the morbidity but adherence is poor. We hypothesised that adherence could be optimised if behavioural change was established in the preoperative period. Therefore, we aimed to assess feasibility, acceptability, and recruitment and retention rates of a preoperative package of non-operative care in patients awaiting knee replacement surgery. METHODS We did an open-label, randomised controlled, feasibility trial in two secondary care centres in the UK. Eligible participants were aged 15-85 years, on the waiting list for a knee arthroplasty for osteoarthritis, and met at least one of the thresholds for one of the four components of the preoperative package of non-operative care intervention (ie, weight loss, exercise therapy, use of insoles, and analgesia adjustment). Participants were randomly assigned (2:1) to either the intervention group or the standard of care (ie, control) group. All four aspects of the intervention were delivered weekly over 12 weeks. Participants in the intervention group were reviewed regularly to assess adherence. The primary outcome was acceptability and feasibility of delivering the intervention, as measured by recruitment rate, retention rate at follow-up review after planned surgery, health-related quality of life, joint-specific scores, and adherence (weight change and qualitative interviews). This study is registered with ISRCTN, ISRCTN96684272. FINDINGS Between Sept 3 2018, and Aug 30, 2019, we screened 233 patients, of whom 163 (73%) were excluded and 60 (27%) were randomly assigned to either the intervention group (n=40) or the control group (n=20). 34 (57%) of 60 participants were women, 26 (43%) were men, and the mean age was 66·8 years (SD 8·6). Uptake of the specific intervention components varied: 31 (78%) of 40 had exercise therapy, 28 (70%) weight loss, 22 (55%) analgesia adjustment, and insoles (18 [45%]). Overall median adherence was 94% (IQR 79·5-100). At the final review, the intervention group lost a mean of 11·2 kg (SD 5·6) compared with 1·3 kg (3·8) in the control group (estimated difference -9·8 kg [95% CI -13·4 to -6·3]). A clinically significant improvement in health-related quality o life (mean change 0·078 [SD 0·195]) were reported, and joint-specific scores showed greater improvement in the intervention group than in the control group. No adverse events attributable to the intervention occurred. INTERPRETATION Participants adhered well to the non-operative interventions and their health-related quality of life improved. Participant and health professional feedback were extremely positive. These findings support progression to a full-scale effectiveness trial. FUNDING Versus Arthritis.
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Affiliation(s)
- A Hamish R W Simpson
- Edinburgh Orthopaedics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK.
| | - Nicholas D Clement
- Edinburgh Orthopaedics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Sharon A Simpson
- MRC/SCO Social and Public Health Sciences Unit and School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Hemandt Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, NIHR Biomedical Research Centre-Leeds, University of Leeds, Leeds, UK
| | - Susie Smillie
- School of Social and Political Sciences, University of Glasgow, Glasgow, UK
| | - Anthony R Leeds
- Parker Institute, Frederiksberg Hospital, Copenhagen, Denmark
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, NIHR Biomedical Research Centre-Leeds, University of Leeds, Leeds, UK
| | - Sarah R Kingsbury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, NIHR Biomedical Research Centre-Leeds, University of Leeds, Leeds, UK
| | - David Hamilton
- Research Centre for Health, Glasgow Caledonian University, Glasgow, UK
| | - Peter Craig
- MRC/SCO Social and Public Health Sciences Unit and School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - David Ray
- Anaesthesia and Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Elaine Kinsella
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | | | - Arlene McGarty
- MRC/SCO Social and Public Health Sciences Unit and School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Christine Beadle
- Edinburgh Orthopaedics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Colin R Howie
- Edinburgh Orthopaedics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
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Manoukian S, Mason H, Hagen S, Kearney R, Goodman K, Best C, Elders A, Melone L, Dwyer L, Dembinsky M, Khunda A, Guerrero KL, McClurg D, Norrie J, Thakar R, Bugge C. Cost-effectiveness of 2 Models of Pessary Care for Pelvic Organ Prolapse: Findings From the TOPSY Randomized Controlled Trial. Value Health 2024:S1098-3015(24)00118-9. [PMID: 38492924 DOI: 10.1016/j.jval.2024.03.004] [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] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 02/21/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVES Pelvic organ prolapse is the descent of one or more reproductive organs from their normal position, causing associated negative symptoms. One conservative treatment option is pessary management. This study aimed to to investigate the cost-effectiveness of pessary self-management (SM) when compared with clinic-based care (CBC). A decision analytic model was developed to extend the economic evaluation. METHODS A randomized controlled trial with health economic evaluation. The SM group received a 30-minute SM teaching session, information leaflet, 2-week follow-up call, and a local helpline number. The CBC group received routine outpatient pessary appointments, determined by usual practice. The primary outcome for the cost-effectiveness analysis was incremental cost per quality-adjusted life year (QALY), 18 months post-randomization. Uncertainty was handled using nonparametric bootstrap analysis. In addition, a simple decision analytic model was developed using the trial data to extend the analysis over a 5-year period. RESULTS There was no significant difference in the mean number of QALYs gained between SM and CBC (1.241 vs 1.221), but mean cost was lower for SM (£578 vs £728). The incremental net benefit estimated at a willingness to pay of £20 000 per QALY gained was £564, with an 80.8% probability of cost-effectiveness. The modeling results were consistent with the trial analysis: the incremental net benefit was estimated as £4221, and the probability of SM being cost-effective at 5 years was 69.7%. CONCLUSIONS Results suggest that pessary SM is likely to be cost-effective. The decision analytic model suggests that this result is likely to persist over longer durations.
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Affiliation(s)
- Sarkis Manoukian
- Yunus Centre for Social Business and Health, Glasgow Caledonian University.
| | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University
| | - Suzanne Hagen
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University
| | | | - Kirsteen Goodman
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University
| | - Catherine Best
- Faculty of Health Sciences and Sport, University of Stirling
| | - Andrew Elders
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University
| | - Lynn Melone
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University
| | - Lucy Dwyer
- Manchester University NHS Foundation Trust
| | - Melanie Dembinsky
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University
| | | | | | - Doreen McClurg
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh
| | | | - Carol Bugge
- Department of Nursing and Community Health, Glasgow Caledonian University
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Kilonzo M, Boyers D, Cooper D, Davidson T, Bhal K, N'Dow J, MacLennan G, Norrie J, Abdel‐Fattah M. Three-year cost utility analysis of mini versus standard slings: A trial based economic evaluation. BJUI Compass 2024; 5:230-239. [PMID: 38371196 PMCID: PMC10869650 DOI: 10.1002/bco2.303] [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: 05/24/2023] [Revised: 09/08/2023] [Accepted: 09/26/2023] [Indexed: 02/20/2024] Open
Abstract
Objective To report on the cost-effectiveness of adjustable anchored single-incision mini-slings (mini-slings) compared with tension-free standard mid-urethral slings (standard slings) in the surgical management of female stress urinary incontinence (SUI). Patients and Methods Data on resource use and quality were collected from women aged ≥18 years with predominant SUI undergoing mid-urethral sling procedures in 21 UK hospitals. Resource use and quality of life (QoL) data were prospectively collected alongside the Single-Incision Mini-Slings versus standard synthetic mid-urethral slings Randomised Control Trial (SIMS RCT), for surgical treatment of SUI in women. A health service provider's (National Health Service [NHS]) perspective with 3-year follow-up was adopted to estimate the costs of the intervention and all subsequent resource use. A generic instrument, EuroQol EQ-5D-3L, was used to estimate the QoL. Results are reported as incremental costs, quality adjusted life years (QALYs) and incremental cost per QALY. Results Base case analysis results show that although mini-slings cost less, there was no significant difference in costs: mini-slings versus standard slings: £-6 [95% CI -228-208] or in QALYs: 0.005 [95% CI -0.068-0.073] over the 3-year follow-up. There is substantial uncertainty, with a 56% and 44% probability that mini-slings and standard slings are the most cost-effective treatment, respectively, at a £20 000 willingness-to-pay threshold value for a QALY. Conclusions At 3 years, there is no significant difference between mini-slings and standard slings in costs and QALYs. There is still some uncertainty over the long-term complications and failure rates of the devices used in the treatment of SUI; therefore, it is important to establish the long-term clinical and cost-effectiveness of these procedures.
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Affiliation(s)
- Mary Kilonzo
- Health Economics Research UnitUniversity of AberdeenAberdeenUK
| | - Dwayne Boyers
- Health Economics Research UnitUniversity of AberdeenAberdeenUK
| | - David Cooper
- Health Services Research UnitUniversity of AberdeenAberdeenUK
| | - Tracey Davidson
- Health Services Research UnitUniversity of AberdeenAberdeenUK
| | - Kiron Bhal
- Department of UrogynaecologyUniversity Hospital of WalesCardiffWalesUK
| | - James N'Dow
- Academic Urology UnitUniversity of AberdeenAberdeenUK
| | - Graeme MacLennan
- The Centre for Healthcare Randomised TrialsUniversity of AberdeenAberdeenUK
| | - John Norrie
- Usher Institute Edinburgh Clinical Trials UnitUniversity of EdinburghEdinburghUK
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Machin M, Whittley S, Norrie J, Burgess L, Hunt BJ, Bolton L, Shalhoub J, Everington T, Gohel M, Whiteley MS, Rogers S, Onida S, Turner B, Nandhra S, Lawton R, Stephens-Boal A, Singer C, Dunbar J, Carradice D, Davies AH. Evaluating pharmacological THRomboprophylaxis in Individuals undergoing superficial endoVEnous treatment across NHS and private clinics in the UK: a multi-centre, assessor-blind, randomised controlled trial-THRIVE trial. BMJ Open 2024; 14:e083488. [PMID: 38367965 PMCID: PMC10875503 DOI: 10.1136/bmjopen-2023-083488] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/19/2024] [Indexed: 02/19/2024] Open
Abstract
INTRODUCTION Endovenous therapy is the first choice management for symptomatic varicose veins in NICE guidelines, with 56-70 000 procedures performed annually in the UK. Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a known complication of endovenous therapy, occurring at a rate of up to 3.4%. Despite 73% of UK practitioners administering pharmacological thromboprophylaxis to reduce VTE, no high-quality evidence supporting this practice exists. Pharmacological thromboprophylaxis may have clinical and cost benefit in preventing VTE; however, further evidence is needed. This study aims to establish whether when endovenous therapy is undertaken: a single dose or course of pharmacological thromboprophylaxis alters the risk of VTE; pharmacological thromboprophylaxis is associated with an increased rate of bleeding events; pharmacological prophylaxis is cost effective. METHODS AND ANALYSIS A multi-centre, assessor-blind, randomised controlled trial (RCT) will recruit 6660 participants from 40 NHS and private sites across the UK. Participants will be randomised to intervention (single dose or extended course of pharmacological thromboprophylaxis plus compression) or control (compression alone). Participants will undergo a lower limb venous duplex ultrasound scan at 21-28 days post-procedure to identify asymptomatic DVT. The duplex scan will be conducted locally by blinded assessors. Participants will be contacted remotely for follow-up at 7 days and 90 days post-procedure. The primary outcome is imaging-confirmed lower limb DVT with or without symptoms or PE with symptoms within 90 days of treatment. The main analysis will be according to the intention-to-treat principle and will compare the rates of VTE at 90 days, using a repeated measures analysis of variance, adjusting for any pre-specified strongly prognostic baseline covariates using a mixed effects logistic regression. ETHICS AND DISSEMINATION Ethical approval was granted by Brent Research Ethics Committee (22/LO/0261). Results will be disseminated in a peer-reviewed journal and presented at national and international conferences. TRIAL REGISTRATION NUMBER ISRCTN18501431.
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Affiliation(s)
- Matthew Machin
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Sarah Whittley
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Level 2, NINE Edinburgh BioQuarter, The University of Edinburgh, Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Laura Burgess
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' Foundation Trust, London, UK
| | - Layla Bolton
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Joseph Shalhoub
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Manjit Gohel
- Cambridge Vascular Unit, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Steven Rogers
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Manchester Academic Vascular Research and Innovation Centre (MAVRIC), Manchester University NHS Foundation Trust, Manchester, UK
| | - Sarah Onida
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Benedict Turner
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Sandip Nandhra
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Lawton
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Annya Stephens-Boal
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Carolyn Singer
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Joanne Dunbar
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Daniel Carradice
- Academic Vascular Surgical Unit, Hull York Medical School, Hull, UK
| | - A H Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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Murray S, Thompson J, Townsend RC, Deidda M, Boyd KA, Norman JE, Norrie J, Boardman JP, Luyt K, Khalil A, Bick D, Reed K, Denton J, Fenwick N, Keerie C, Reynolds R, Stock SJ. Randomised placebo-controlled trial of antenatal corticosteroids for planned birth in twins (STOPPIT-3): study protocol. BMJ Open 2024; 14:e078778. [PMID: 38238048 PMCID: PMC10806667 DOI: 10.1136/bmjopen-2023-078778] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/24/2023] [Indexed: 01/23/2024] Open
Abstract
INTRODUCTION The aim of the STOPPIT-3 study is to determine the clinical and cost effectiveness of antenatal corticosteroids (ACS) prior to planned birth of twins in a multicentre placebo-controlled trial with internal pilot. METHODS AND ANALYSIS This study will comprise a multicentre, double-blinded, randomised, placebo-controlled trial in at least 50 UK obstetric units. The target population is 1552 women with a twin pregnancy and a planned birth between 35 and 38+6 weeks' gestation recruited from antenatal clinics. Women will be randomised to Dexamethasone Phosphate (24 mg) or saline administered via two intramuscular injections 24 hours apart, 24-120 hours prior to scheduled birth. OUTCOMES The primary outcome is need for respiratory support within 72 hours of birth. Secondary and safety outcomes will be included. Cognitive and language development at age 2 years will be assessed in a subset of participants using the Parent report of Children's Abilities-Revised questionnaire. We will also determine the cost effectiveness of the treatment with ACS compared with placebo. ETHICS AND DISSEMINATION STOPPIT-3 has been funded and approved by the National Institute of Healthcare Research. It has been approved by the West Midlands Research Ethics Committee (22/WM/0018). The results will be disseminated via publication in peer-reviewed journals and conference presentation and will also be communicated to the public via links with charity partners and social media. TRIAL SPONSOR The University of Edinburgh and Lothian Health Board ACCORD, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, EH16 4TJ. TRIAL REGISTRATION NUMBER ISRCTN59959611.
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Affiliation(s)
- Sarah Murray
- Centre for Reproductive Health, The University of Edinburgh, Edinburgh, UK
| | - Jessica Thompson
- Centre for Reproductive Health, The University of Edinburgh, Edinburgh, UK
| | - Rosie C Townsend
- Centre for Reproductive Health, The University of Edinburgh, Edinburgh, UK
| | - Manuela Deidda
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, UK
| | - Kathleen Anne Boyd
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, UK
| | - Jane E Norman
- University of Nottingham Executive Office, University of Nottingham, Nottingham, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, The University of Edinburgh, Edinburgh, UK
| | - James P Boardman
- Centre for Reproductive Health, The University of Edinburgh, Edinburgh, UK
| | - Karen Luyt
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Asma Khalil
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Debra Bick
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Keith Reed
- CEO, Parent Infant Foundation, London, UK
| | - Jane Denton
- Co lead Elizabeth Bryan Multiple Births Centre, Imperial College London, London, UK
| | | | - Catriona Keerie
- University of Edinburgh College of Medicine and Veterinary Medicine, Edinburgh, UK
| | - Rebecca Reynolds
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, UK
| | - Sarah Jane Stock
- Centre for Medical Informatics, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
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King AJ, Hudson J, Azuara-Blanco A, Burr J, Kernohan A, Homer T, Shabaninejad H, Sparrow JM, Garway-Heath D, Barton K, Norrie J, Davidson T, Vale L, MacLennan G. Evaluating Primary Treatment for People with Advanced Glaucoma: Five-Year Results of the Treatment of Advanced Glaucoma Study. Ophthalmology 2024:S0161-6420(24)00016-2. [PMID: 38199528 DOI: 10.1016/j.ophtha.2024.01.007] [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: 08/23/2023] [Revised: 12/27/2023] [Accepted: 01/02/2024] [Indexed: 01/12/2024] Open
Abstract
PURPOSE To determine whether primary trabeculectomy or medical treatment produces better outcomes in terms of quality of life (QoL), clinical effectiveness, and safety in patients with advanced glaucoma. DESIGN Multicenter randomized controlled trial. PARTICIPANTS Between June 3, 2014, and May 31, 2017, 453 adults with newly diagnosed advanced open-angle glaucoma in at least 1 eye (Hodapp classification) were recruited from 27 secondary care glaucoma departments in the United Kingdom. Two hundred twenty-seven were allocated to trabeculectomy, and 226 were allocated medical management. METHODS Participants were randomized on a 1:1 basis to have either mitomycin C-augmented trabeculectomy or escalating medical management with intraocular pressure (IOP)-reducing drops as the primary intervention and were followed up for 5 years. MAIN OUTCOME MEASURES The primary outcome was vision-specific QoL measured with the 25-item Visual Function Questionnaire (VFQ-25) at 5 years. Secondary outcomes were general health status, glaucoma-related QoL, clinical effectiveness (IOP, visual field, and visual acuity), and safety. RESULTS At 5 years, the mean ± standard deviation VFQ-25 scores in the trabeculectomy and medication arms were 83.3 ± 15.5 and 81.3 ± 17.5, respectively, and the mean difference was 1.01 (95% confidence interval [CI], -1.99 to 4.00; P = 0.51). The mean IOPs were 12.07 ± 5.18 mmHg and 14.76 ± 4.14 mmHg, respectively, and the mean difference was -2.56 (95% CI, -3.80 to -1.32; P < 0.001). Glaucoma severity measured with visual field mean deviation were -14.30 ± 7.14 dB and -16.74 ± 6.78 dB, respectively, with a mean difference of 1.87 (95% CI, 0.87-2.87 dB; P < 0.001). Safety events occurred in 115 (52.2%) of patients in the trabeculectomy arm and 124 (57.9%) of patients in the medication arm (relative risk, 0.92; 95% CI, 0.72-1.19; P = 0.54). Serious adverse events were rare. CONCLUSIONS At 5 years, the Treatment of Advanced Glaucoma Study demonstrated that primary trabeculectomy surgery is more effective in lowering IOP and preventing disease progression than primary medical treatment in patients with advanced disease and has a similar safety profile. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Anthony J King
- Nottingham University Hospital, Nottingham, United Kingdom.
| | - Jemma Hudson
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Augusto Azuara-Blanco
- Centre for Public Health, Queen's University Belfast, Royal Victoria Hospital, Belfast, United Kingdom
| | - Jennifer Burr
- School of Medicine, University of St. Andrews, St. Andrews, United Kingdom
| | - Ashleigh Kernohan
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Tara Homer
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Hosein Shabaninejad
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John M Sparrow
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - David Garway-Heath
- National Institute for Health Research (NIHR) Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Keith Barton
- National Institute for Health Research (NIHR) Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Tracey Davidson
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Luke Vale
- Health Economics Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
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Walsh TS, Aitken LM, McKenzie CA, Boyd J, Macdonald A, Giddings A, Hope D, Norrie J, Weir C, Parker RA, Lone NI, Emerson L, Kydonaki K, Creagh-Brown B, Morris S, McAuley DF, Dark P, Wise MP, Gordon AC, Perkins G, Reade M, Blackwood B, MacLullich A, Glen R, Page VJ. Alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B Trial): protocol for a multicentre phase 3 pragmatic clinical and cost-effectiveness randomised trial in the UK. BMJ Open 2023; 13:e078645. [PMID: 38072483 PMCID: PMC10729141 DOI: 10.1136/bmjopen-2023-078645] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Almost all patients receiving mechanical ventilation (MV) in intensive care units (ICUs) require analgesia and sedation. The most widely used sedative drug is propofol, but there is uncertainty whether alpha2-agonists are superior. The alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B) trial aims to determine whether clonidine or dexmedetomidine (or both) are clinically and cost-effective in MV ICU patients compared with usual care. METHODS AND ANALYSIS Adult ICU patients within 48 hours of starting MV, expected to require at least 24 hours further MV, are randomised in an open-label three arm trial to receive propofol (usual care) or clonidine or dexmedetomidine as primary sedative, plus analgesia according to local practice. Exclusions include patients with primary brain injury; postcardiac arrest; other neurological conditions; or bradycardia. Unless clinically contraindicated, sedation is titrated using weight-based dosing guidance to achieve a Richmond-Agitation-Sedation score of -2 or greater as early as considered safe by clinicians. The primary outcome is time to successful extubation. Secondary ICU outcomes include delirium and coma incidence/duration, sedation quality, predefined adverse events, mortality and ICU length of stay. Post-ICU outcomes include mortality, anxiety and depression, post-traumatic stress, cognitive function and health-related quality of life at 6-month follow-up. A process evaluation and health economic evaluation are embedded in the trial.The analytic framework uses a hierarchical approach to maximise efficiency and control type I error. Stage 1 tests whether each alpha2-agonist is superior to propofol. If either/both interventions are superior, stages 2 and 3 testing explores which alpha2-agonist is more effective. To detect a mean difference of 2 days in MV duration, we aim to recruit 1437 patients (479 per group) in 40-50 UK ICUs. ETHICS AND DISSEMINATION The Scotland A REC approved the trial (18/SS/0085). We use a surrogate decision-maker or deferred consent model consistent with UK law. Dissemination will be via publications, presentations and updated guidelines. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT03653832.
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Affiliation(s)
- Timothy Simon Walsh
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | | | - Julia Boyd
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Alix Macdonald
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Annabel Giddings
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | - John Norrie
- Usher Institute, Edinburgh Clinical Trials Unit, University of Edinburgh No. 9, Bioquarter, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Nazir I Lone
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | | | - Benedict Creagh-Brown
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
- Intensive Care Unit, Royal Surrey County Hospital, Guildford, UK
| | - Stephen Morris
- Primary Care Unit, University of Cambridge, Cambridge, UK
| | | | - Paul Dark
- Intensive Care Unit, University of Manchester, Greater Manchester, UK
| | - Matt P Wise
- Department of Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Gavin Perkins
- Clinical Trials Unit, University of Warwick, Birmingham, UK
| | - Michael Reade
- University of Queensland, Brisbane, Queensland, Australia
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | | | | | - Valerie J Page
- Intensive Care, West Hertfordshire Hospitals NHS Trust, Watford, UK
- Faculty of Medicine, Imperial College London, London, UK
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10
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Chong HY, McNamee P, Bachmair EM, Martin K, Aucott L, Dhaun N, Dures E, Emsley R, Gray SR, Kidd E, Kumar V, Lovell K, MacLennan G, Norrie J, Paul L, Packham J, Ralston SH, Siebert S, Wearden A, Macfarlane G, Basu N. Cost-effectiveness of cognitive behavioural and personalized exercise interventions for reducing fatigue in inflammatory rheumatic diseases. Rheumatology (Oxford) 2023; 62:3819-3827. [PMID: 37018151 PMCID: PMC10691924 DOI: 10.1093/rheumatology/kead157] [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: 09/07/2022] [Revised: 02/09/2023] [Accepted: 02/27/2023] [Indexed: 04/06/2023] Open
Abstract
OBJECTIVES To estimate the cost-effectiveness of a cognitive behavioural approach (CBA) or a personalized exercise programme (PEP), alongside usual care (UC), in patients with inflammatory rheumatic diseases who report chronic, moderate to severe fatigue. METHODS A within-trial cost-utility analysis was conducted using individual patient data collected within a multicentre, three-arm randomized controlled trial over a 56-week period. The primary economic analysis was conducted from the UK National Health Service (NHS) perspective. Uncertainty was explored using cost-effectiveness acceptability curves and sensitivity analysis. RESULTS Complete-case analysis showed that, compared with UC, both PEP and CBA were more expensive [adjusted mean cost difference: PEP £569 (95% CI: £464, £665); CBA £845 (95% CI: £717, £993)] and, in the case of PEP, significantly more effective [adjusted mean quality-adjusted life year (QALY) difference: PEP 0.043 (95% CI: 0.019, 0.068); CBA 0.001 (95% CI: -0.022, 0.022)]. These led to an incremental cost-effectiveness ratio (ICER) of £13 159 for PEP vs UC, and £793 777 for CBA vs UC. Non-parametric bootstrapping showed that, at a threshold value of £20 000 per QALY gained, PEP had a probability of 88% of being cost-effective. In multiple imputation analysis, PEP was associated with significant incremental costs of £428 (95% CI: £324, £511) and a non-significant QALY gain of 0.016 (95% CI: -0.003, 0.035), leading to an ICER of £26 822 vs UC. The estimates from sensitivity analyses were consistent with these results. CONCLUSION The addition of a PEP alongside UC is likely to provide a cost-effective use of health care resources.
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Affiliation(s)
- Huey Yi Chong
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Paul McNamee
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Eva-Maria Bachmair
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen, Aberdeen, UK
| | - Kathryn Martin
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Academic Primary Care Group), University of Aberdeen, Aberdeen, UK
| | - Lorna Aucott
- Centre of Healthcare and Randomised Trials (CHaRT), Health Service Research Unit, University of Aberdeen, Aberdeen, UK
| | - Neeraj Dhaun
- Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh/British Heart Foundation Centre of Research Excellence, Edinburgh, UK
| | - Emma Dures
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Stuart R Gray
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Elizabeth Kidd
- Department of Rheumatology, Freeman’s Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Vinod Kumar
- Department of Rheumatology, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - Karina Lovell
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Graeme MacLennan
- Centre of Healthcare and Randomised Trials (CHaRT), Health Service Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Lorna Paul
- School of Health and Life Science, Glasgow Caledonian University, Glasgow, UK
| | - Jonathan Packham
- Physiotherapy and Paramedicine, Haywood Rheumatology Centre, Stoke-on-Trent, UK
| | - Stuart H Ralston
- Rheumatology and Bone Disease, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Stefan Siebert
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Alison Wearden
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Gary Macfarlane
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen, Aberdeen, UK
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Academic Primary Care Group), University of Aberdeen, Aberdeen, UK
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
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11
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Chisti MJ, Rahman AE, Hasan T, Ahmed T, El Arifeen S, Clemens JD, Rahman ASMMH, Uddin MF, Amin MR, Miah MT, Islam MK, Sharif M, Shahid ASMSB, Ahmed A, Banik G, Rashid M, Ahmed MK, Shahrin L, Afroze F, Sarmin M, Nuzhat S, Sarkar S, Islam J, Islam MS, Norrie J, Campbell H, Nair H, Cunningham S. Evaluation of feasibility phase of adaptive version of locally made bubble continuous positive airway pressure oxygen therapy for the treatment of COVID-19 positive and negative adults with severe pneumonia and hypoxaemia. J Glob Health 2023; 13:06046. [PMID: 37997786 PMCID: PMC10668204 DOI: 10.7189/jogh.13.06046] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
Abstract
Background Bubble continuous positive airway pressure (bCPAP) oxygen therapy has been shown to be safe and effective in treating children with severe pneumonia and hypoxaemia in Bangladesh. Due to lack of adequate non-invasive ventilatory support during coronavirus disease 2019 (COVID-19) crisis, we aimed to evaluate whether bCPAP was safe and feasible when adapted for use in adults with similar indications. Methods Adults (18-64 years) with severe pneumonia and moderate hypoxaemia (80 to <90% oxygen saturation (SpO2) in room air) were provided bCPAP via nasal cannula at a flow rate of 10 litres per minute (l/min) oxygen at 10 centimetres (cm) H2O pressure, in two tertiary hospitals in Dhaka, Bangladesh. Qualitative interviews and focus group discussions, using a descriptive phenomenological approach, were performed with patients and staff (n = 39) prior to and after the introduction (n = 12 and n = 27 respectively) to understand the operational challenges to the introduction of bCPAP. Results We enrolled 30 adults (median age 52, interquartile range (IQR) 40-60 years) with severe pneumonia and hypoxaemia and/or acute respiratory distress syndrome (ARDS) irrespective of coronavirus disease 2019 (COVID-19) test results to receive bCPAP. At baseline mean SpO2 on room air was 87% (±2) which increased to 98% (±2), after initiation of bCPAP. The mean duration of bCPAP oxygen therapy was 14.4 ± 24.8 hours. There were no adverse events of note, and no treatment failure or deaths. Operational challenges to the clinical introduction of bCPAP were lack of functioning pulse oximeters, difficult nasal interface fixation among those wearing nose pin, occasional auto bubbling or lack of bubbling in water-filled plastic bottle, lack of holder for water-filled plastic bottle, rapid turnover of trained clinicians at the hospitals, and limited routine care of patients by hospital clinicians particularly after official hours. Discussion If the tertiary hospitals in Bangladesh are supplied with well-functioning good quality pulse oximeters and enhanced training of the doctors and nurses on proper use of adapted version of bCPAP, in treating adults with severe pneumonia and hypoxaemia with or without ARDS, the bCPAP was found to be safe, well tolerated and not associated with treatment failure across all study participants. These observations increase the confidence level of the investigators to consider a future efficacy trial of adaptive bCPAP oxygen therapy compared to WHO standard low flow oxygen therapy in such patients. Conclusion s Although bCPAP oxygen therapy was found to be safe and feasible in this pilot study, several challenges were identified that need to be taken into account when planning a definitive clinical trial.
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Affiliation(s)
- Mohammod Jobayer Chisti
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ahmed Ehsanur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Taufiq Hasan
- Bangladesh University of Engineering and Technology (BUET), Dhaka, Bangladesh
- Center for Bioengineering Innovation and Design, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | | | - Md. Fakhar Uddin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | | | | | | | | | - Anisuddin Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Goutom Banik
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Meemnur Rashid
- Bangladesh University of Engineering and Technology (BUET), Dhaka, Bangladesh
| | - Md. Kawsar Ahmed
- Bangladesh University of Engineering and Technology (BUET), Dhaka, Bangladesh
| | - Lubaba Shahrin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Farzana Afroze
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Monira Sarmin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sharika Nuzhat
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Supriya Sarkar
- Directorate General of Health Services, Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Jahurul Islam
- Directorate General of Health Services, Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Muhammad Shariful Islam
- Directorate General of Health Services, Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - John Norrie
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Harry Campbell
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Harish Nair
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Steve Cunningham
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, Scotland, UK
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12
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Jansen JO, Hudson J, Cochran C, MacLennan G, Lendrum R, Sadek S, Gillies K, Cotton S, Kennedy C, Boyers D, Ferry G, Lawrie L, Nath M, Wileman S, Forrest M, Brohi K, Harris T, Lecky F, Moran C, Morrison JJ, Norrie J, Paterson A, Tai N, Welch N, Campbell MK. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA 2023; 330:1862-1871. [PMID: 37824132 PMCID: PMC10570916 DOI: 10.1001/jama.2023.20850] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [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: 05/16/2023] [Accepted: 09/23/2023] [Indexed: 10/13/2023]
Abstract
Importance Bleeding is the most common cause of preventable death after trauma. Objective To determine the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) when used in the emergency department along with standard care vs standard care alone on mortality in trauma patients with exsanguinating hemorrhage. Design, Setting, and Participants Pragmatic, bayesian, randomized clinical trial conducted at 16 major trauma centers in the UK. Patients aged 16 years or older with exsanguinating hemorrhage were enrolled between October 2017 and March 2022 and followed up for 90 days. Intervention Patients were randomly assigned (1:1 allocation) to a strategy that included REBOA and standard care (n = 46) or standard care alone (n = 44). Main Outcomes and Measures The primary outcome was all-cause mortality at 90 days. Ten secondary outcomes included mortality at 6 months, while in the hospital, and within 24 hours, 6 hours, or 3 hours; the need for definitive hemorrhage control procedures; time to commencement of definitive hemorrhage control procedures; complications; length of stay; blood product use; and cause of death. Results Of the 90 patients (median age, 41 years [IQR, 31-59 years]; 62 [69%] were male; and the median Injury Severity Score was 41 [IQR, 29-50]) randomized, 89 were included in the primary outcome analysis because 1 patient in the standard care alone group declined to provide consent for continued participation and data collection 4 days after enrollment. At 90 days, 25 of 46 patients (54%) had experienced all-cause mortality in the REBOA and standard care group vs 18 of 43 patients (42%) in the standard care alone group (odds ratio [OR], 1.58 [95% credible interval, 0.72-3.52]; posterior probability of an OR >1 [indicating increased odds of death with REBOA], 86.9%). Among the 10 secondary outcomes, the ORs for mortality and the posterior probabilities of an OR greater than 1 for 6-month, in-hospital, and 24-, 6-, or 3-hour mortality were all increased in the REBOA and standard care group, and the ORs were increased with earlier mortality end points. There were more deaths due to bleeding in the REBOA and standard care group (8 of 25 patients [32%]) than in standard care alone group (3 of 18 patients [17%]), and most occurred within 24 hours. Conclusions and Relevance In trauma patients with exsanguinating hemorrhage, a strategy of REBOA and standard care in the emergency department does not reduce, and may increase, mortality compared with standard care alone. Trial Registration isrctn.org Identifier: ISRCTN16184981.
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Affiliation(s)
- Jan O. Jansen
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
- Center for Injury Science, University of Alabama at Birmingham
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Claire Cochran
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Robbie Lendrum
- Barts Health NHS Trust, Royal London Hospital, St Bartholomew’s Hospital, London, England
| | - Sam Sadek
- Royal London Hospital, London, England
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Seonaidh Cotton
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Charlotte Kennedy
- Health Economics Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Gillian Ferry
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Louisa Lawrie
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Mintu Nath
- Medical Statistics Team, University of Aberdeen, Aberdeen, Scotland
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Mark Forrest
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Karim Brohi
- Queen Mary University of London, London, England
| | - Tim Harris
- Barts Health NHS Trust, Royal London Hospital, St Bartholomew’s Hospital, London, England
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Chris Moran
- Nottingham University Hospital Trust, Nottingham, England
| | - Jonathan J. Morrison
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, Scotland
| | | | - Nigel Tai
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, England
| | - Nick Welch
- Patient and public involvement representative in England
| | - Marion K. Campbell
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
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13
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Needham N, Campbell IH, Grossi H, Kamenska I, Rigby BP, Simpson SA, McIntosh E, Bahuguna P, Meadowcroft B, Creasy F, Mitchell-Grigorjeva M, Norrie J, Thompson G, Gibbs MC, McLellan A, Fisher C, Moses T, Burgess K, Brown R, Thrippleton MJ, Campbell H, Smith DJ. Pilot study of a ketogenic diet in bipolar disorder. BJPsych Open 2023; 9:e176. [PMID: 37814952 PMCID: PMC10594182 DOI: 10.1192/bjo.2023.568] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/11/2023] [Accepted: 08/22/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Recent evidence from case reports suggests that a ketogenic diet may be effective for bipolar disorder. However, no clinical trials have been conducted to date. AIMS To assess the recruitment and feasibility of a ketogenic diet intervention in bipolar disorder. METHOD Euthymic individuals with bipolar disorder were recruited to a 6-8 week trial of a modified ketogenic diet, and a range of clinical, economic and functional outcome measures were assessed. Study registration number: ISRCTN61613198. RESULTS Of 27 recruited participants, 26 commenced and 20 completed the modified ketogenic diet for 6-8 weeks. The outcomes data-set was 95% complete for daily ketone measures, 95% complete for daily glucose measures and 95% complete for daily ecological momentary assessment of symptoms during the intervention period. Mean daily blood ketone readings were 1.3 mmol/L (s.d. = 0.77, median = 1.1) during the intervention period, and 91% of all readings indicated ketosis, suggesting a high degree of adherence to the diet. Over 91% of daily blood glucose readings were within normal range, with 9% indicating mild hypoglycaemia. Eleven minor adverse events were recorded, including fatigue, constipation, drowsiness and hunger. One serious adverse event was reported (euglycemic ketoacidosis in a participant taking SGLT2-inhibitor medication). CONCLUSIONS The recruitment and retention of euthymic individuals with bipolar disorder to a 6-8 week ketogenic diet intervention was feasible, with high completion rates for outcome measures. The majority of participants reached and maintained ketosis, and adverse events were generally mild and modifiable. A future randomised controlled trial is now warranted.
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Affiliation(s)
- Nicole Needham
- Centre for Clinical Brain Sciences, University of Edinburgh, UK
| | | | - Helen Grossi
- Department of Nutrition and Dietetics, Royal Hospital for Children and Young People, NHS Lothian, UK
| | | | | | | | - Emma McIntosh
- Health Economics and Health Technology Assessment, University of Glasgow, UK
| | - Pankaj Bahuguna
- Health Economics and Health Technology Assessment, University of Glasgow, UK
| | | | | | | | - John Norrie
- Usher Institute, University of Edinburgh, UK
| | - Gerard Thompson
- Centre for Clinical Brain Sciences, University of Edinburgh, UK
| | | | - Ailsa McLellan
- Department of Paediatric Neurology, Royal Hospital for Children and Young People, NHS Lothian, UK
| | - Cheryl Fisher
- Department of Nutrition and Dietetics, Royal Hospital for Children and Young People, NHS Lothian, UK
| | - Tessa Moses
- Centre for Engineering Biology, University of Edinburgh, UK
| | - Karl Burgess
- Centre for Engineering Biology, University of Edinburgh, UK
| | | | | | | | - Daniel J. Smith
- Centre for Clinical Brain Sciences, University of Edinburgh, UK
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Simpson AHRW, Makaram NS, Harrison E, Norrie J. Decision-making in surgical study designs: a proposed decision algorithm to aid in the selection of an appropriate research study design for a given surgical intervention: the PERFECT tool. Bone Joint Res 2023; 12:598-600. [PMID: 37732814 PMCID: PMC10512865 DOI: 10.1302/2046-3758.129.bjr-2023-0232] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
Cite this article: Bone Joint Res 2023;12(9):598–600.
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Affiliation(s)
- A. H. R. W. Simpson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
| | - Navnit S. Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
| | - Ewen Harrison
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
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15
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Reynolds-Wright JJ, Norrie J, Cameron ST. Using telemedicine to improve early medical abortion at home (UTAH): a randomised controlled trial to compare telemedicine with in-person consultation for early medical abortion. BMJ Open 2023; 13:e073630. [PMID: 37709327 PMCID: PMC10870195 DOI: 10.1136/bmjopen-2023-073630] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVES To compare telephone consultations with in-person consultations for the provision of medical abortion (using mifepristone 200 mg and misoprostol 800 µg). We hypothesised that telemedicine consultations would be non-inferior to in-person consultations with a non-inferiority limit of 3%. DESIGN Randomised controlled trial with 1:1 allocation. SETTING Community abortion service housed within an integrated sexual and reproductive health service in Edinburgh, UK. PARTICIPANTS The trial began on 13 January 2020, but was stopped early due to COVID-19; recruitment was suspended on 31 March 2020, and was formally closed on 31 August 2021. A total of 125 participants were randomised, approximately 10% of the total planned, with 63 assigned to telemedicine and 62 to in-person consultation. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome: efficacy of medical abortion, defined as complete abortion without surgical intervention. SECONDARY OUTCOMES satisfaction with consultation type, preparedness, unscheduled contact with care, complication rate, time spent in clinical contact and uptake of long-acting contraception. RESULTS Primary outcome was available for 115 participants (lost-to-follow-up telemedicine=2, in-person=8), secondary outcomes were available for 110 participants (n=5 and n=10 in telemedicine and in-person groups did not complete questionnaires). There were no significant differences between groups in treatment efficacy (telemedicine 57/63 (90.5%), in-person 48/62 (77.4%)). However, non-inferiority was not demonstrated (+3.3% in favour of telemedicine, CI -6.6% to +13.3%, lower than non-inferiority margin). There were no significant differences in most secondary outcomes, however, there was more unscheduled contact with care in the telemedicine group (12 (19%) vs 3 (5%), p=0.01). The overall time spent in clinical contact was statistically significantly lower in the telemedicine group (mean 94 (SD 24) vs 111 (24) min, p=0.0005). CONCLUSIONS Telemedicine for medical abortion appeared to be effective, safe and acceptable to women, with less time spent in the clinic. However, due to the small sample size resulting from early cessation, the study was underpowered to confirm this conclusion. These findings warrant further investigation in larger scale studies. TRIAL REGISTRATION NUMBER NCT04139382.
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Affiliation(s)
- John Joseph Reynolds-Wright
- MRC Centre for Reproductive Health, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- Chalmers Centre for Sexual Health, NHS Lothian, Edinburgh, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Bioquarter, Edinburgh, UK
| | - Sharon Tracey Cameron
- MRC Centre for Reproductive Health, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- Chalmers Centre for Sexual Health, NHS Lothian, Edinburgh, UK
- Obstetrics and Gynaecology, University of Edinburgh, Edinburgh, UK
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16
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Boyers D, Kilonzo M, Davidson T, Cooper D, Wardle J, Bhal K, N'Dow J, MacLennan G, Norrie J, Abdel-Fattah M. Patient preferences for stress urinary incontinence treatments: a discrete choice experiment. BMJ Open 2023; 13:e066157. [PMID: 37643846 PMCID: PMC10465896 DOI: 10.1136/bmjopen-2022-066157] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 04/28/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVES To elicit and value patient preferences for the processes and outcomes of surgical management of stress urinary incontinence in women. DESIGN A discrete choice experiment survey to elicit preferences for type of anaesthesia, postoperative recovery time, treatment success, adverse events, impact on daily activities and cost. An experimental design generated 40 choice tasks, and each respondent completed 1 block of 10 and 2 validity tests. Analysis was by multinomial logistical regression. SETTING N=21 UK hospitals. PARTICIPANTS N=325 adult women who were a subsample of those randomised to the single-incision mini-slings clinical trial. OUTCOMES Patient preferences; valuation obtained using willingness to pay. RESULTS N=227 of 325 (70%) returned a questionnaire, and 94% of those completed all choice tasks. Respondents preferred general anaesthesia, shorter recovery times, improved stress urinary incontinence symptoms and avoidance of adverse events. Women were willing to pay (mean (95% CI)) £76 (£33 to £119) per day of reduction in recovery time following surgery. They valued increases in Patient Global Impression of Improvement, ranging from £8173 (£5459 to £10 887) for 'improved' to £11 706 (£8267 to £15 144) for 'very much improved' symptoms, compared with no symptom improvement. This was offset by negative values attached to the avoidance of complications ranging between £-8022 (£-10 661 to £-5383) and £-10 632 (£-14 077 to £-7187) compared to no complications. Women valued treatments that reduced the need to avoid daily activities, with willingness to pay ranging from £-967 (£-2199 to £266) for rarely avoiding activities to £-5338 (£-7258 to £-3417) for frequently avoiding daily activities compared with no avoidance. CONCLUSION This discrete choice experiment demonstrates that patients place considerable value on improvement in stress urinary incontinence symptoms and avoidance of treatment complications. Trade-offs between symptom improvement and adverse event risk should be considered within shared decision-making. The willingness to pay values from this study can be used in future cost-benefit analyses. TRIAL REGISTRATION NUMBER ISRCTN: 93264234; Post-results.
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Affiliation(s)
- Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Tracey Davidson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Kiron Bhal
- University Hospital of Wales, Cardiff, UK
| | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Usher Institute, Edinburgh Clinical Trials Unit, University of Edinburgh No 9 Bioquarter, Edinburgh, UK
| | - Mohamed Abdel-Fattah
- Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
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17
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Mitchell WG, Azuara-Blanco A, Foster PJ, Halawa O, Burr J, Ramsay CR, Cooper D, Cochran C, Norrie J, Friedman D, Chang D. Predictors of long-term intraocular pressure control after lens extraction in primary angle closure glaucoma: results from the EAGLE trial. Br J Ophthalmol 2023; 107:1072-1078. [PMID: 35387778 DOI: 10.1136/bjophthalmol-2021-319765] [Citation(s) in RCA: 1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 03/18/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIMS To assess baseline ocular parameters in the prediction of long-term intraocular pressure (IOP) control after clear lens extraction (CLE) or laser peripheral iridotomy (LPI) in patients with primary angle closure (PAC) disease using data from the Effectiveness of Early Lens Extraction for the treatment of primary angle-closure glaucoma (EAGLE) tria. METHODS This study is a secondary analysis of EAGLE data where we define the primary outcome of 'good responders' as those with IOP<21 mm Hg without requiring additional surgery and 'optimal responders' as those who in addition were medication free, at 36-month follow-up. Primary analysis was conducted using a multivariate logistic regression model to assess how randomised interventions and ocular parameters predict treatment response. RESULTS A total of 369 patients (182 in CLE arm and 187 in LPI arm) completed the 36-month follow-up examination. After CLE, 90% met our predefined 'good response' criterion compared with 67% in the LPI arm, and 66% met 'optimal response' criterion compared with 18% in the LPI arm, with significantly longer drops/surgery-free survival time (p<0.05 for all). Patients randomised to CLE (OR=10.1 (6.1 to 16.8)), Chinese (OR=2.3 (1.3 to 3.9)), and those who had not previously used glaucoma drops (OR=2.8 (1.6 to 4.8)) were more likely to maintain long-term optimal IOP response over 36 months. CONCLUSION Patients with primary angle closure glaucoma/PAC are 10 times more likely to maintain drop-free good IOP control with initial CLE surgery than LPI. Non-Chinese ethnicity, higher baseline IOP and using glaucoma drops prior to randomisation are predictors of worse long-term IOP response.
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Affiliation(s)
- William G Mitchell
- Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Augusto Azuara-Blanco
- Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland, UK
- Queen's University Belfast, Centre for Public Health, Belfast, UK
| | - Paul J Foster
- NIHR Biomedical Research Centre, Moorfields Eye Hospital, Institute of Ophthalmology, University College London, London, UK
| | - Omar Halawa
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Jennifer Burr
- School of Medicine, University of St Andrews, St Andrews, Fife, UK
| | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - David Cooper
- Health Services Research Unit, University of Aberdeen College of Life Sciences and Medicine, Aberdeen, UK
| | - Claire Cochran
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Centre for Health Care Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - David Friedman
- Ophthalmology, Harvard University, Cambridge, Massachusetts, USA
| | - Dolly Chang
- Early Clinical Development, Genentech Inc, South San Francisco, California, USA
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18
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Norrie J. The importance of long-term follow-up in clinical trials. Lancet Glob Health 2023; 11:e995-e996. [PMID: 37349045 DOI: 10.1016/s2214-109x(23)00244-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/16/2023] [Indexed: 06/24/2023]
Affiliation(s)
- John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, Nine BioQuarter, University of Edinburgh, Edinburgh EH16 4UX, UK.
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19
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Date K, Williams B, Cohen J, Chaudhuri N, Bajwah S, Pearson M, Higginson I, Norrie J, Keerie C, Tuck S, Hall P, Currow D, Fallon M, Johnson M. Modified-release morphine or placebo for chronic breathlessness: the MABEL trial protocol. ERJ Open Res 2023; 9:00167-2023. [PMID: 37583966 PMCID: PMC10423982 DOI: 10.1183/23120541.00167-2023] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/13/2023] [Indexed: 08/17/2023] Open
Abstract
Chronic breathlessness, a persistent and disabling symptom despite optimal treatment of underlying causes, is a frightening symptom with serious and widespread impact on patients and their carers. Clinical guidelines support the use of morphine for the relief of chronic breathlessness in common long-term conditions, but questions remain around clinical effectiveness, safety and longer term (>7 days) administration. This trial will evaluate the effectiveness of low-dose oral modified-release morphine in chronic breathlessness. This is a multicentre, parallel group, double-blind, randomised, placebo-controlled trial. Participants (n=158) will be opioid-naïve with chronic breathlessness due to heart or lung disease, cancer or post-coronavirus disease 2019. Participants will be randomised 1:1 to 5 mg oral modified-release morphine/placebo twice daily and docusate/placebo 100 mg twice daily for 56 days. Non-responders at Day 7 will dose escalate to 10 mg morphine/placebo twice daily at Day 15. The primary end-point (Day 28) measure will be worst breathlessness severity (previous 24 h). Secondary outcome measures include worst cough, distress, pain, functional status, physical activity, quality of life, and early identification and management of morphine-related side-effects. At Day 56, participants may opt to take open-label, oral modified-release morphine as part of usual care and complete quarterly breathlessness and toxicity questionnaires. The study is powered to be able to reject the null hypothesis and an embedded normalisation process theory-informed qualitative substudy will explore the adoption of morphine as a first-line pharmacological treatment for chronic breathlessness in clinical practice if effective.
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Affiliation(s)
- Kathryn Date
- Hull Health Trials Unit, Hull York Medical School, University of Hull, Hull, UK
| | - Bronwen Williams
- Hull Health Trials Unit, Hull York Medical School, University of Hull, Hull, UK
| | - Judith Cohen
- Hull Health Trials Unit, Hull York Medical School, University of Hull, Hull, UK
| | | | - Sabrina Bajwah
- Cicely Saunders Institute, King's College London, London, UK
| | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Irene Higginson
- Cicely Saunders Institute, King's College London, London, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Sharon Tuck
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Peter Hall
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - David Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Marie Fallon
- Edinburgh Cancer Research Centre (IGMM), University of Edinburgh, Edinburgh, UK
| | - Miriam Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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20
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Mackenzie SC, Stephen J, Williams L, Daniels J, Norrie J, Becker CM, Byrne D, Cheong Y, Clark TJ, Cooper KG, Cox E, Doust AM, Fernandez P, Hawe J, Holland T, Hummelshoj L, Jackson LJ, King K, Maheshwari A, Martin DC, Sutherland L, Thornton J, Vincent K, Vyas S, Horne AW, Whitaker LHR. Effectiveness of laparoscopic removal of isolated superficial peritoneal endometriosis for the management of chronic pelvic pain in women (ESPriT2): protocol for a multi-centre randomised controlled trial. Trials 2023; 24:425. [PMID: 37349849 PMCID: PMC10286505 DOI: 10.1186/s13063-023-07386-x] [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: 04/21/2023] [Accepted: 05/18/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Endometriosis affects 190 million women and those assigned female at birth worldwide. For some, it is associated with debilitating chronic pelvic pain. Diagnosis of endometriosis is often achieved through diagnostic laparoscopy. However, when isolated superficial peritoneal endometriosis (SPE), the most common endometriosis subtype, is identified during laparoscopy, limited evidence exists to support the common decision to surgically remove it via excision or ablation. Improved understanding of the impact of surgical removal of isolated SPE for the management of chronic pelvic pain in women is required. Here, we describe our protocol for a multi-centre trial to determine the effectiveness of surgical removal of isolated SPE for the management of endometriosis-associated pain. METHODS We plan to undertake a multi-centre participant-blind parallel-group randomised controlled clinical and cost-effectiveness trial with internal pilot. We plan to randomise 400 participants from up to 70 National Health Service Hospitals in the UK. Participants with chronic pelvic pain awaiting diagnostic laparoscopy for suspected endometriosis will be consented by the clinical research team. If isolated SPE is identified at laparoscopy, and deep or ovarian endometriosis is not seen, participants will be randomised intraoperatively (1:1) to surgical removal (by excision or ablation or both, according to surgeons' preference) versus diagnostic laparoscopy alone. Randomisation with block-stratification will be used. Participants will be given a diagnosis but will not be informed of the procedure they received until 12 months post-randomisation, unless required. Post-operative medical treatment will be according to participants' preference. Participants will be asked to complete validated pain and quality of life questionnaires at 3, 6 and 12 months after randomisation. Our primary outcome is the pain domain of the Endometriosis Health Profile-30 (EHP-30), via a between randomised group comparison of adjusted means at 12 months. Assuming a standard deviation of 22 points around the pain score, 90% power, 5% significance and 20% missing data, 400 participants are required to be randomised to detect an 8-point pain score difference. DISCUSSION This trial aims to provide high quality evidence of the clinical and cost-effectiveness of surgical removal of isolated SPE. TRIAL REGISTRATION ISRCTN registry ISRCTN27244948. Registered 6 April 2021.
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Affiliation(s)
- Scott C Mackenzie
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, NINE, Edinburgh BioQuarter, Edinburgh, EH16 4UX, UK
| | - Linda Williams
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, NINE, Edinburgh BioQuarter, Edinburgh, EH16 4UX, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2RD, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, NINE, Edinburgh BioQuarter, Edinburgh, EH16 4UX, UK
| | - Christian M Becker
- Endometriosis CaRe, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, OX3 9DU, UK
| | | | - Ying Cheong
- Faculty of Medicine, Human Development and Health, University of Southampton, Southampton, UK
| | - T Justin Clark
- Birmingham Women's and Children Hospital, Birmingham, B15 2TG, UK
| | - Kevin G Cooper
- NHS Grampian, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN, UK
| | | | - Ann M Doust
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Priscilla Fernandez
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Jeremy Hawe
- Corniche Hospital, Abu Dhabi, United Arab Emirates
| | | | | | | | | | | | - Dan C Martin
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
- Virginia Commonwealth University, Institutional Review Board, Richmond, VA, USA
- EndoFound (Endometriosis Foundation of America), New York, USA
| | - Lauren Sutherland
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | | | - Katy Vincent
- Endometriosis CaRe, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, OX3 9DU, UK
| | - Sanjay Vyas
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Andrew W Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Lucy H R Whitaker
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, EH16 4TJ, UK.
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21
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Lee KK, Lowe D, O'Brien R, Wereski R, Bularga A, Taggart C, Lowry MTH, Ferry AV, Williams MC, Roditi G, Byrne J, Tuck C, Cranley D, Thokala P, Goodacre S, Keerie C, Norrie J, Newby DE, Gray AJ, Mills NL. Troponin in acute chest pain to risk stratify and guide effective use of computed tomography coronary angiography (TARGET-CTCA): a randomised controlled trial. Trials 2023; 24:402. [PMID: 37312104 PMCID: PMC10264092 DOI: 10.1186/s13063-023-07431-9] [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: 03/20/2023] [Accepted: 06/05/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND The majority of patients with suspected acute coronary syndrome presenting to the emergency department will be discharged once myocardial infarction has been ruled out, although a proportion will have unrecognised coronary artery disease. In this setting, high-sensitivity cardiac troponin identifies those at increased risk of future cardiac events. In patients with intermediate cardiac troponin concentrations in whom myocardial infarction has been ruled out, this trial aims to investigate whether outpatient computed tomography coronary angiography (CTCA) reduces subsequent myocardial infarction or cardiac death. METHODS TARGET-CTCA is a multicentre prospective randomised open label with blinded endpoint parallel group event driven trial. After myocardial infarction and clear alternative diagnoses have been ruled out, participants with intermediate cardiac troponin concentrations (5 ng/L to 99th centile upper reference limit) will be randomised 1:1 to outpatient CTCA plus standard of care or standard of care alone. The primary endpoint is myocardial infarction or cardiac death. Secondary endpoints include clinical, patient-centred, process and cost-effectiveness. Recruitment of 2270 patients will give 90% power with a two-sided P value of 0.05 to detect a 40% relative risk reduction in the primary endpoint. Follow-up will continue until 97 primary outcome events have been accrued in the standard care arm with an estimated median follow-up of 36 months. DISCUSSION This randomised controlled trial will determine whether high-sensitivity cardiac troponin-guided CTCA can improve outcomes and reduce subsequent major adverse cardiac events in patients presenting to the emergency department who do not have myocardial infarction. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03952351. Registered on May 16, 2019.
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Affiliation(s)
- Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - David Lowe
- Department of Emergency Medicine, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Rachel O'Brien
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Anda Bularga
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Matthew T H Lowry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Amy V Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Giles Roditi
- Institute of Cardiovascular and Medical Sciences, Glasgow University, Glasgow, UK
| | - John Byrne
- Department of Cardiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Chris Tuck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Denise Cranley
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Alasdair J Gray
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK.
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.
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22
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Chisti MJ, Duke T, Rahman AE, Ahmed T, Arifeen SE, Clemens JD, Uddin MF, Rahman AS, Rahman MM, Sarker TK, Uddin SMN, Shahunja KM, Shahid AS, Faruque A, Sarkar S, Islam MJ, Islam MS, Kabir MF, Cresswell KM, Norrie J, Sheikh A, Campbell H, Nair H, Cunningham S. Feasibility and acceptability of bubble continuous positive airway pressure oxygen therapy for the treatment of childhood severe pneumonia and hypoxaemia in Bangladeshi children. J Glob Health 2023; 13:04040. [PMID: 37224512 DOI: 10.7189/jogh.13.04040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
Background Effective management of hypoxaemia is key to reducing pneumonia deaths in children. In an intensive care setting within a tertiary hospital in Bangladesh, bubble continuous positive airway pressure (bCPAP) oxygen therapy was beneficial in reducing deaths in this population. To inform a future trial, we investigated the feasibility of introducing bCPAP in this population in non-tertiary/district hospitals in Bangladesh. Methods We conducted a qualitative assessment using a descriptive phenomenological approach to understand the structural and functional capacity of the non-tertiary hospitals (Institute of Child and Mother Health and Kushtia General Hospital) for the clinical use of bCPAP. We conducted interviews and focus group discussions (23 nurses, seven physicians, 14 parents). We retrospectively (12 months) and prospectively (three months) measured the prevalence of severe pneumonia and hypoxaemia in children attending the two study sites. For the feasibility phase, we enrolled 20 patients with severe pneumonia (age two to 24 months) to receive bCPAP, putting in place safeguards to identify risk. Results Retrospectively, while 747 of 3012 (24.8%) children had a diagnosis of severe pneumonia, no pulse oxygen saturation information was available. Of 3008 children prospectively assessed with pulse oximetry when attending the two sites, 81 (3.7%) had severe pneumonia and hypoxaemia. The main structural challenges to implementation were the inadequate number of pulse oximeters, lack of power generator backup, high patient load with an inadequate number of hospital staff, and inadequate and non-functioning oxygen flow meters. Functional challenges were the rapid turnover of trained clinicians in the hospitals, limited post-admission routine care for in-patients by hospital clinicians due to their extreme workload (particularly after official hours). The study implemented a minimum of four hourly clinical reviews and provided oxygen concentrators (with backup oxygen cylinders), and automatic power generator backup. Twenty children with a mean age of 6.7 (standard deviation (SD) = 5.0)) months with severe pneumonia and hypoxaemia (median (md) SpO2 = 87% in room air, interquartile range (IQR) = 85-88)) with cough (100%) and severe respiratory difficulties (100%) received bCPAP oxygen therapy for a median of 16 hours (IQR = 6-16). There were no treatment failures or deaths. Conclusions Implementation of low-cost bCPAP oxygen therapy is feasible in non-tertiary/district hospitals when additional training and resources are allocated.
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Affiliation(s)
- Mohammod Jobayer Chisti
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Trevor Duke
- Centre for International Child Health, Royal Children`s Hospital, The University of Melbourne, Melbourne, Australia
| | - Ahmed Ehnasur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shams E Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - John D Clemens
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- International Vaccine Institute, Seoul, Korea
- UCLA Fielding School of Public Health, Los Angeles
| | - Md F Uddin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu Smmh Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md M Rahman
- Institute of Child and Mother Health (ICMH), Matuail Dhaka, Bangladesh
| | | | - S M N Uddin
- 250 bedded General Hospital, Kushtia, Bangladesh
| | | | - Abu Smsb Shahid
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Asg Faruque
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Supriya Sarkar
- Directorate General of Health Services, Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Md Jahurul Islam
- Directorate General of Health Services, Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Muhammad Shariful Islam
- Directorate General of Health Services, Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Md Farhad Kabir
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Kathrin M Cresswell
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - John Norrie
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Harry Campbell
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Harish Nair
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Steve Cunningham
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, The University of Edinburgh, Edinburgh, UK
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23
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Bucci S, Varese F, Quayle E, Cartwright K, Machin M, Whelan P, Chitsabesan P, Richards C, Green V, Norrie J, Schwannauer M. A Digital Intervention to Improve Mental Health and Interpersonal Resilience in Young People Who Have Experienced Technology-Assisted Sexual Abuse: Protocol for a Nonrandomized Feasibility Clinical Trial and Nested Qualitative Study. JMIR Res Protoc 2023; 12:e40539. [PMID: 36943343 PMCID: PMC10131936 DOI: 10.2196/40539] [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: 06/25/2022] [Revised: 10/14/2022] [Accepted: 10/29/2022] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND No evidence-based support has been offered to young people (YP) who have experienced technology-assisted sexual abuse (TASA). Interventions aimed at improving mentalization (the ability to understand the mental states of oneself and others) are increasingly being applied to treat YP with various clinical issues. Digital technology use among YP is now common. A digital intervention aimed at improving mentalization in YP who have experienced TASA may reduce the risk of revictimization and future harm and make YP more resilient and able to manage distress that might result from TASA experiences. OBJECTIVE In this paper, we describe a protocol for determining the feasibility of the i-Minds trial and the acceptability, safety, and usability of the digital intervention (the i-Minds app) and explore how to best integrate i-Minds into existing routine care pathways. METHODS This is a mixed methods nonrandomized study aimed to determine the feasibility, acceptability, safety, and usability of the intervention. Participants aged between 12 and 18 years who report distress associated with TASA exposure will be recruited from the United Kingdom from the National Health Service (NHS) Trust Child and Adolescent Mental Health Services, sexual assault referral centers, and a web-based e-therapy provider. All participants will receive the i-Minds app for 6 weeks. Coproduced with YP and a range of stakeholders, the i-Minds app focuses on 4 main topics: mentalization, TASA and its impact, emotional and mental health, and trauma. A daily prompt will encourage YP to use the app, which is designed to be used in a stand-alone manner alongside routine care. We will follow participants up after the intervention and conduct interviews with stakeholders to explore the acceptability of the app and trial procedures and identify areas for improvement. Informed by the normalization process theory, we will examine barriers and enablers relevant to the future integration of the intervention into existing care pathways, including traditional clinic-based NHS and NHS e-therapy providers. RESULTS This study was approved by the Research Ethics Board of Scotland. We expect data to be collected from up to 60 YP. We expect to conduct approximately 20 qualitative interviews with participants and 20 health care professionals who referred YP to the study. The results of this study have been submitted for publication. CONCLUSIONS This study will provide preliminary evidence on the feasibility of recruiting YP to a trial of this nature and on the acceptability, safety, and usability of the i-Minds app, including how to best integrate it into existing routine care. The findings will inform the decision to proceed with a powered efficacy trial. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number Registry (ISRCTN) ISRCTN43130832; https://www.isrctn.com/ISRCTN43130832. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/40539.
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Affiliation(s)
- Sandra Bucci
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science, The University of Manchester, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Filippo Varese
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science, The University of Manchester, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Ethel Quayle
- School of Health in Social Science, The University of Edinburgh, Edinburgh, United Kingdom
| | - Kim Cartwright
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Matthew Machin
- Division of Informatics, Imaging & Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science, The University of Manchester, Manchester, United Kingdom
| | - Pauline Whelan
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
- Division of Informatics, Imaging & Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science, The University of Manchester, Manchester, United Kingdom
| | - Prathiba Chitsabesan
- Pennine Care NHS Foundation Trust, Greater Manchester, United Kingdom
- University College London, London, United Kingdom
| | | | | | - John Norrie
- Population Health Sciences, Usher Institute, Centre for Population Health Sciences, Edinburgh Clinical Trials Unit, Edinburgh, United Kingdom
| | - Matthias Schwannauer
- School of Health in Social Science, The University of Edinburgh, Edinburgh, United Kingdom
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24
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Sullivan G, Vaher K, Blesa M, Galdi P, Stoye DQ, Quigley AJ, Thrippleton MJ, Norrie J, Bastin ME, Boardman JP. Breast Milk Exposure is Associated With Cortical Maturation in Preterm Infants. Ann Neurol 2023; 93:591-603. [PMID: 36412221 DOI: 10.1002/ana.26559] [Citation(s) in RCA: 1] [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] [Received: 01/10/2022] [Revised: 11/14/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Breast milk exposure is associated with improved neurocognitive outcomes following preterm birth but the neural substrates linking breast milk with outcome are uncertain. We tested the hypothesis that high versus low breast milk exposure in preterm infants results in cortical morphology that more closely resembles that of term-born infants. METHODS We studied 135 preterm (<32 weeks' gestation) and 77 term infants. Feeding data were collected from birth until hospital discharge and brain magnetic resonance imaging (MRI) was performed at term-equivalent age. Cortical indices (volume, thickness, surface area, gyrification index, sulcal depth, and curvature) and diffusion parameters (fractional anisotropy [FA], mean diffusivity [MD], radial diffusivity [RD], axial diffusivity [AD], neurite density index [NDI], and orientation dispersion index [ODI]) were compared between preterm infants who received exclusive breast milk for <75% of inpatient days, preterm infants who received exclusive breast milk for ≥75% of inpatient days and term-born controls. To investigate a dose response effect, we performed linear regression using breast milk exposure quartile weighted by propensity scores. RESULTS In preterm infants, high breast milk exposure was associated with reduced cortical gray matter volume (d = 0.47, 95% confidence interval [CI] = 0.14 to 0.94, p = 0.014), thickness (d = 0.42, 95% CI = 0.08 to 0.84, p = 0.039), and RD (d = 0.38, 95% CI = 0.002 to 0.77, p = 0.039), and increased FA (d = -0.38, 95% CI = -0.74 to -0.01, p = 0.037) after adjustment for age at MRI, which was similar to the cortical phenotype observed in term-born controls. Breast milk exposure quartile was associated with cortical volume (ß = -0.192, 95% CI = -0.342 to -0.042, p = 0.017), FA (ß = 0.223, 95% CI = 0.075 to 0.372, p = 0.007), and RD (ß = -0.225, 95% CI = -0.373 to -0.076, p = 0.007) following adjustment for age at birth, age at MRI, and weighted by propensity scores, suggesting a dose effect. INTERPRETATION High breast milk exposure following preterm birth is associated with a cortical imaging phenotype that more closely resembles the brain morphology of term-born infants and effects appear to be dose-dependent. ANN NEUROL 2023;93:591-603.
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Affiliation(s)
- Gemma Sullivan
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Kadi Vaher
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Manuel Blesa
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Paola Galdi
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - David Q Stoye
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Alan J Quigley
- Department of Radiology, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Michael J Thrippleton
- Edinburgh Imaging, University of Edinburgh, Edinburgh, UK.,Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Usher Institute, Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Mark E Bastin
- Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, UK
| | - James P Boardman
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.,Centre for Clinical Brain Sciences, Chancellor's Building, University of Edinburgh, Edinburgh, UK
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25
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Cafferkey J, Ferguson A, Grahamslaw J, Oatey K, Norrie J, Lone N, Walsh T, Horner D, Appelboam A, Hall P, Skipworth R, Bell D, Rooney K, Shankar-Hari M, Corfield A, Gray A. Albumin versus balanced crystalloid for resuscitation in the treatment of sepsis: A protocol for a randomised controlled feasibility study, "ABC-Sepsis". J Intensive Care Soc 2023; 24:78-84. [PMID: 36860553 PMCID: PMC9157259 DOI: 10.1177/17511437221103692] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 11/17/2022] Open
Abstract
Background Patients presenting with suspected sepsis to secondary care often require fluid resuscitation to correct hypovolaemia and/or septic shock. Existing evidence signals, but does not demonstrate, a benefit for regimes including albumin over balanced crystalloid alone. However, interventions may be started too late, missing a critical resuscitation window. Methods ABC Sepsis is a currently recruiting randomised controlled feasibility trial comparing 5% human albumin solution (HAS) with balanced crystalloid for fluid resuscitation in patients with suspected sepsis. This multicentre trial is recruiting adult patients within 12 hours of presentation to secondary care with suspected community acquired sepsis, with a National Early Warning Score ≥5, who require intravenous fluid resuscitation. Participants are randomised to 5% HAS or balanced crystalloid as the sole resuscitation fluid for the first 6 hours. Objectives Primary objectives are feasibility of recruitment to the study and 30-day mortality between groups. Secondary objectives include in-hospital and 90-day mortality, adherence to trial protocol, quality of life measurement and secondary care costs. Discussion This trial aims to determine the feasibility of conducting a trial to address the current uncertainty around optimal fluid resuscitation of patients with suspected sepsis. Understanding the feasibility of delivering a definitive study will be dependent on how the study team are able to negotiate clinician choice, Emergency Department pressures and participant acceptability, as well as whether any clinical signal of benefit is detected.
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Affiliation(s)
- John Cafferkey
- Emergency Medicine Research Group
Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of
Edinburgh, Edinburgh, UK
| | - Andrew Ferguson
- Emergency Medicine Research Group
Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of
Edinburgh, Edinburgh, UK
| | - Julia Grahamslaw
- Emergency Medicine Research Group
Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of
Edinburgh, Edinburgh, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit,
Usher Institute, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Department of Critical Care, Royal
Infirmary of Edinburgh, Usher Institute, University of
Edinburgh, Edinburgh, UK
| | - Nazir Lone
- Department of Critical Care, Royal
Infirmary of Edinburgh, Usher Institute, University of
Edinburgh, Edinburgh, UK
| | - Timothy Walsh
- Department of Critical Care, Royal
Infirmary of Edinburgh, Usher Institute, University of
Edinburgh, Edinburgh, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation
Trust, Salford, UK,Division of Infection, Immunity and
Respiratory Medicine, University of
Manchester, Manchester, UK
| | - Andy Appelboam
- Academic Department of Emergency
Medicine Exeter (ACADEMEx), Royal Devon and Exeter Hospital NHS
Foundation Trust, Exeter Devon
| | - Peter Hall
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | | | - Derek Bell
- Department of Acute Medicine, Chelsea and Westminster
Campus, Imperial College London, London
| | | | - Manu Shankar-Hari
- The Queen’s Medical Research
Institute, Edinburgh BioQuarter, Centre for
Inflammation Research, University of Edinburgh, UK
| | - Alasdair Corfield
- Emergency Department, Royal Alexandra
Hospital, NHS Greater Glasgow and Clyde, UK
| | - Alasdair Gray
- Emergency Medicine Research Group
Edinburgh (EMERGE), Department of Emergency Medicine, Royal Infirmary of
Edinburgh, Edinburgh, UK,Acute Care Edinburgh, Centre for
Population and Health Sciences, Usher Institute, University of
Edinburgh, Edinburgh UK,Professor Alasdair Gray, Emergency Medicine
Research Group Edinburgh (EMERGE), Department of Emergency Medicine, Royal
Infirmary of Edinburgh, Edinburgh EH16 4SA, UK.
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26
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Mpaata CN, Matovu B, Takuwa M, Kiwanuka N, Lewis S, Norrie J, Ononge S, Tuck S, Wolters M, Demulliez M, Ssekitoleko RT. Systems and processes for regulation of investigational medical devices in Uganda. Front Med Technol 2023; 4:1054120. [PMID: 36756148 PMCID: PMC9899893 DOI: 10.3389/fmedt.2022.1054120] [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: 09/26/2022] [Accepted: 12/19/2022] [Indexed: 01/24/2023] Open
Abstract
Background In many parts of the world, medical devices and the processes of their development are tightly regulated. However, the current regulatory landscape in Uganda like other developing countries is weak and poorly defined, which creates significant barriers to innovation, clinical evaluation, and translation of medical devices. Aim To evaluate current knowledge, systems and infrastructure for medical devices regulation and innovation in Uganda. Methods A mixed methods study design using the methods triangulation strategy was employed in this study. Data of equal weight were collected sequentially. First, a digital structured questionnaire was sent out to innovators to establish individual knowledge and experience with medical device innovation and regulation. Then, a single focus group discussion involving both medical device innovators and regulators to collect data about the current regulatory practices for medical devices in Uganda. Univariate and bivariate analysis was done for the quantitative data to summarize results in graphs and tables. Qualitative data was analyzed using thematic analysis. Ethical review and approval were obtained from the Makerere University School of Biomedical Sciences, Research and Ethics Committee, and the Uganda National Council for Science and Technology. Results A total of 47 innovators responded to the questionnaire. 14 respondents were excluded since they were not medical device innovators. Majority (76%) of individuals had been innovators for more than a year, held a bachelor's degree with a background in Engineering and applied sciences, and worked in an academic research institute. 22 of the 33 medical device innovators had stopped working on their innovations and had stalled at the proof-of-concept stage. Insufficient funding, inadequate technical expertise and confusing regulatory landscape were major challenges to innovation. The two themes that emerged from the discussion were "developing standards for medical devices regulation" and "implementation of regulations in practical processes". Legal limitations, lengthy processes, and low demand were identified as challenges to developing medical device regulations. Conclusions Efforts have been taken by government to create a pathway for medical device innovations to be translated to the market. More work needs to be done to coordinate efforts among stakeholders to build effective medical device regulations in Uganda.
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Affiliation(s)
- Charles Norman Mpaata
- Biomedical Engineering Unit, Department of Physiology, School of Biomedical Sciences College of Health Sciences, Makerere University, Kampala, Uganda
| | - Brian Matovu
- Biomedical Engineering Unit, Department of Physiology, School of Biomedical Sciences College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mercy Takuwa
- Biomedical Engineering Unit, Department of Physiology, School of Biomedical Sciences College of Health Sciences, Makerere University, Kampala, Uganda
| | - Noah Kiwanuka
- Clinical Trials Unit, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Steff Lewis
- Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, United Kingdom
| | - John Norrie
- Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, United Kingdom
| | - Sam Ononge
- Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sharon Tuck
- Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, United Kingdom
| | - Maria Wolters
- Informatics Forum, School of Informatics, College of Science and Engineering, University of Edinburgh, Edinburgh, United Kingdom
| | - Marc Demulliez
- School of Engineering & Physical Sciences, Heriot-Watt University, Edinburgh, United Kingdom
| | - Robert T. Ssekitoleko
- Biomedical Engineering Unit, Department of Physiology, School of Biomedical Sciences College of Health Sciences, Makerere University, Kampala, Uganda,Correspondence: Robert T. Ssekitoleko
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27
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Machin M, Peerbux S, Whittley S, Hunt BJ, Everington T, Gohel M, Norrie J, Epstein D, Warwick DJ, Baker C, Hamady Z, Smith S, Bolton L, Stephens-Boal A, Gray B, Shalhoub J, Davies AH. Examining the benefit of graduated compression stockings in the prevention of hospital-associated venous thromboembolism in low-risk surgical patients: a multicentre cluster randomised controlled trial (PETS trial). BMJ Open 2023; 13:e069802. [PMID: 36653057 PMCID: PMC9853211 DOI: 10.1136/bmjopen-2022-069802] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Hospital-acquired thrombosis (HAT) is defined as any venous thromboembolism (VTE)-related event during a hospital admission or occurring up to 90 days post discharge, and is associated with significant morbidity, mortality and healthcare-associated costs. Although surgery is an established risk factor for VTE, operations with a short hospital stay (<48 hours) and that permit early ambulation are associated with a low risk of VTE. Many patients undergoing short-stay surgical procedures and who are at low risk of VTE are treated with graduated compression stockings (GCS). However, evidence for the use of GCS in VTE prevention for this cohort is poor. METHODS AND ANALYSIS A multicentre, cluster randomised controlled trial which aims to determine whether GCS are superior in comparison to no GCS in the prevention of VTE for surgical patients undergoing short-stay procedures assessed to be at low risk of VTE. A total of 50 sites (21 472 participants) will be randomised to either intervention (GCS) or control (no GCS). Adult participants (18-59 years) who undergo short-stay surgical procedures and are assessed as low risk of VTE will be included in the study. Participants will provide consent to be contacted for follow-up at 7-days and 90-days postsurgical procedure. The primary outcome is the rate of symptomatic VTE, that is, deep vein thrombosis or pulmonary embolism during admission or within 90 days. Secondary outcomes include healthcare costs and changes in quality of life. The main analysis will be according to the intention-to-treat principle and will compare the rates of VTE at 90 days, measured at an individual level, using hierarchical (multilevel) logistic regression. ETHICS AND DISSEMINATION Ethical approval was granted by the Camden and Kings Cross Research Ethics Committee (22/LO/0390). Findings will be published in a peer-reviewed journal and presented at national and international conferences. TRIAL REGISTRATION NUMBER ISRCTN13908683.
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Affiliation(s)
- Matthew Machin
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Sarrah Peerbux
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Sarah Whittley
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Manjit Gohel
- Department of Vascular Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - John Norrie
- Usher Institute of Population Health Sciences and Informatics, Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - David Epstein
- Faculty of Economic and Business Sciences, University of Granada, Granada, Spain
| | - David J Warwick
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Christopher Baker
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Zaed Hamady
- General Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sasha Smith
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Layla Bolton
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Annya Stephens-Boal
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Beverley Gray
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Joseph Shalhoub
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Alun Huw Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
- Imperial Vascular Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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28
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Gaughan EE, Quinn TM, Mills A, Bruce AM, Antonelli J, MacKinnon AC, Aslanis V, Li F, O’Connor R, Boz C, Mills R, Emanuel P, Burgess M, Rinaldi G, Valanciute A, Mills B, Scholefield E, Hardisty G, Findlay EG, Parker RA, Norrie J, Dear JW, Akram AR, Koch O, Templeton K, Dockrell DH, Walsh TS, Partridge S, Humphries D, Wang-Jairaj J, Slack RJ, Schambye H, Phung D, Gravelle L, Lindmark B, Shankar-Hari M, Hirani N, Sethi T, Dhaliwal K. An Inhaled Galectin-3 Inhibitor in COVID-19 Pneumonitis: A Phase Ib/IIa Randomized Controlled Clinical Trial (DEFINE). Am J Respir Crit Care Med 2023; 207:138-149. [PMID: 35972987 PMCID: PMC9893334 DOI: 10.1164/rccm.202203-0477oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [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: 03/07/2022] [Accepted: 08/16/2022] [Indexed: 02/02/2023] Open
Abstract
Rationale: High circulating galectin-3 is associated with poor outcomes in patients with coronavirus disease (COVID-19). We hypothesized that GB0139, a potent inhaled thiodigalactoside galectin-3 inhibitor with antiinflammatory and antifibrotic actions, would be safely and effectively delivered in COVID-19 pneumonitis. Objectives: Primary outcomes were safety and tolerability of inhaled GB0139 as an add-on therapy for patients hospitalized with COVID-19 pneumonitis. Methods: We present the findings of two arms of a phase Ib/IIa randomized controlled platform trial in hospitalized patients with confirmed COVID-19 pneumonitis. Patients received standard of care (SoC) or SoC plus 10 mg inhaled GB0139 twice daily for 48 hours, then once daily for up to 14 days or discharge. Measurements and Main Results: Data are reported from 41 patients, 20 of which were assigned randomly to receive GB0139. Primary outcomes: the GB0139 group experienced no treatment-related serious adverse events. Incidences of adverse events were similar between treatment arms (40 with GB0139 + SoC vs. 35 with SoC). Secondary outcomes: plasma GB0139 was measurable in all patients after inhaled exposure and demonstrated target engagement with decreased circulating galectin (overall treatment effect post-hoc analysis of covariance [ANCOVA] over days 2-7; P = 0.0099 vs. SoC). Plasma biomarkers associated with inflammation, fibrosis, coagulopathy, and major organ function were evaluated. Conclusions: In COVID-19 pneumonitis, inhaled GB0139 was well-tolerated and achieved clinically relevant plasma concentrations with target engagement. The data support larger clinical trials to determine clinical efficacy. Clinical trial registered with ClinicalTrials.gov (NCT04473053) and EudraCT (2020-002230-32).
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Affiliation(s)
- Erin E. Gaughan
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Respiratory Medicine
| | - Tom M. Quinn
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Respiratory Medicine
| | | | | | | | | | | | - Feng Li
- Centre for Inflammation Research, Edinburgh BioQuarter
| | | | - Cecilia Boz
- Centre for Inflammation Research, Edinburgh BioQuarter
| | - Ross Mills
- Centre for Inflammation Research, Edinburgh BioQuarter
| | | | | | | | | | - Bethany Mills
- Centre for Inflammation Research, Edinburgh BioQuarter
| | | | | | | | | | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, and
| | - James W. Dear
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Ahsan R. Akram
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Respiratory Medicine
| | - Oliver Koch
- Centre for Inflammation Research, Edinburgh BioQuarter
- Infectious Diseases Department, Western General Hospital, Edinburgh, United Kingdom
| | | | - David H. Dockrell
- Centre for Inflammation Research, Edinburgh BioQuarter
- Infectious Diseases Department, Western General Hospital, Edinburgh, United Kingdom
| | - Timothy S. Walsh
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Critical Care, New Royal Infirmary of Edinburgh, Edinburgh BioQuarter, Edinburgh, United Kingdom
| | | | | | | | | | | | - De Phung
- Galecto Inc., Copenhagen, Denmark; and
| | | | | | - Manu Shankar-Hari
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Critical Care, New Royal Infirmary of Edinburgh, Edinburgh BioQuarter, Edinburgh, United Kingdom
| | - Nikhil Hirani
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Respiratory Medicine
| | | | - Kevin Dhaliwal
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Respiratory Medicine
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Reid FM, Aucott L, Glazener CMA, Elders A, Hemming C, Cooper KG, Freeman RM, Smith ARB, Hagen S, Kilonzo M, Boyers D, MacLennan G, Norrie J, Breeman S. PROSPECT: 4- and 6-year follow-up of a randomised trial of surgery for vaginal prolapse. Int Urogynecol J 2023; 34:67-78. [PMID: 36018353 PMCID: PMC9834125 DOI: 10.1007/s00192-022-05308-0] [Citation(s) in RCA: 1] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/24/2022] [Indexed: 01/16/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Our aim was to compare the mid-term results of native tissue, biological xenograft and polypropylene mesh surgery for women with vaginal wall prolapse. METHODS A total of 1348 women undergoing primary transvaginal repair of an anterior and/or posterior prolapse were recruited between January 2010 and August 2013 from 35 UK centres. They were randomised by remote allocation to native tissue surgery, biological xenograft or polypropylene mesh. We performed both 4- and 6-year follow-up using validated patient-reported outcome measures. RESULTS At 4 and 6 years post-operation, there was no clinically important difference in Pelvic Organ Prolapse Symptom Score for any of the treatments. Using a strict composite outcome to assess functional cure at 6 years, we found no difference in cure among the three types of surgery. Half the women were cured at 6 years but only 10.3 to 12% of women had undergone further surgery for prolapse. However, 8.4% of women in the mesh group had undergone further surgery for mesh complications. There was no difference in the incidence of chronic pain or dyspareunia between groups. CONCLUSIONS At the mid-term outcome of 6 years, there is no benefit from augmenting primary prolapse repairs with polypropylene mesh inlays or biological xenografts. There was no evidence that polypropylene mesh inlays caused greater pain or dyspareunia than native tissue repairs.
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Affiliation(s)
- Fiona M Reid
- Warrell Unit, St Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Oxford Road Campus, Manchester, M13 0JH, UK.
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Andrew Elders
- NMAHP Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Christine Hemming
- Department of Obstetrics and Gynaecology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Kevin G Cooper
- Department of Obstetrics and Gynaecology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Robert M Freeman
- Department of Obstetrics and Gynaecology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Anthony R B Smith
- Warrell Unit, St Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Oxford Road Campus, Manchester, M13 0JH, UK
| | - Suzanne Hagen
- NMAHP Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher institute, University of Edinburgh, Edinburgh, UK
| | - Suzanne Breeman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Abdel-Fattah M, Cooper D, Davidson T, Kilonzo M, Boyers D, Bhal K, McDonald A, Wardle J, N'Dow J, MacLennan G, Norrie J. Single-incision mini-slings versus standard synthetic mid-urethral slings for surgical treatment of stress urinary incontinence in women: The SIMS RCT. Health Technol Assess 2022; 26:1-190. [PMID: 36520097 PMCID: PMC9761550 DOI: 10.3310/btsa6148] [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] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Stress urinary incontinence is the most common type of urinary incontinence in premenopausal women. Until recently, synthetic mid-urethral slings (mesh/tape) were the standard surgical treatment, if conservative management failed. Adjustable anchored single-incision mini-slings are newer, use less mesh and may reduce perioperative morbidity, but it is unclear how their success rates and safety compare with those of standard tension-free mid-urethral slings. OBJECTIVE The objective was to compare tension-free standard mid-urethral slings with adjustable anchored single-incision mini-slings among women with stress urinary incontinence requiring surgical intervention, in terms of patient-reported effectiveness, health-related quality of life, safety and cost-effectiveness. DESIGN This was a pragmatic non-inferiority randomised controlled trial. Allocation was by remote web-based randomisation (1 : 1 ratio). SETTING The trial was set in 21 UK hospitals. PARTICIPANTS Participants were women aged ≥ 18 years with predominant stress urinary incontinence, undergoing a mid-urethral sling procedure. INTERVENTIONS Single-incision mini-slings, compared with standard mid-urethral slings. MAIN OUTCOME MEASURES The primary outcome was patient-reported success rates on the Patient Global Impression of Improvement scale at 15 months post randomisation (≈ 1 year post surgery), with success defined as outcomes of 'very much improved' or 'much improved'. The primary economic outcome was incremental cost per quality-adjusted life-year gained. Secondary outcomes were adverse events, impact on other urinary symptoms, quality of life and sexual function. RESULTS A total of 600 participants were randomised. At 15 months post randomisation, adjustable anchored single-incision mini-slings were non-inferior to tension-free standard mid-urethral slings at the 10% margin for the primary outcome [single-incision mini-sling 79% (212/268) vs. standard mid-urethral sling 76% (189/250), risk difference 4.6, 95% confidence interval -2.7 to 11.8; p non-inferiority < 0.001]. Similarly, at 3 years' follow-up, patient-reported success rates in the single-incision mini-sling group were non-inferior to those of the standard mid-urethral sling group at the 10% margin [single-incision mini-sling 72% (177/246) vs. standard mid-urethral sling 67% (157/235), risk difference 5.7, 95% confidence interval -1.3 to 12.8; p non-inferiority < 0.001]. Tape/mesh exposure rates were higher for single-incision mini-sling participants, with 3.3% (9/276) [compared with 1.9% (5/261) in the standard mid-urethral sling group] reporting tape exposure over the 3 years of follow-up. The rate of groin/thigh pain was slightly higher in the single-incision mini-sling group at 15 months [single-incision mini-sling 15% (41/276) vs. standard mid-urethral sling 12% (31/261), risk difference 3.0%, 95% confidence interval -1.1% to 7.1%]; however, by 3 years, the rate of pain was slightly higher among the standard mid-urethral sling participants [single-incision mini-sling 14% (39/276) vs. standard mid-urethral sling 15% (39/261), risk difference -0.8, 95% confidence interval -4.1 to 2.5]. At the 3-year follow-up, quality of life and sexual function outcomes were similar in both groups: for the International Consultation on Incontinence Questionnaire Lower Urinary Tract Symptoms Quality of Life, the mean difference in scores was -1.1 (95% confidence interval -3.1 to 0.8; p = 0.24), and for the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, International Urogynecological Association-Revised, it was 0 (95% confidence interval -0.1, 0.1; p = 0.92). However, more women in the single-incision mini-sling group reported dyspareunia [12% (17/145), compared with 4.8% (7/145) in the standard mid-urethral sling group, risk difference 7.0%, 95% confidence interval 1.9% to 12.1%]. The base-case economics results showed no difference in costs (-£6, 95% confidence interval -£228 to £208) or quality-adjusted life-years (0.005, 95% confidence interval -0.068 to 0.073) between the groups. There is a 56% probability that single-incision mini-slings will be considered cost-effective at the £20,000 willingness-to-pay threshold value for a quality-adjusted life-year. LIMITATIONS Follow-up data beyond 3 years post randomisation are not available to inform longer-term safety and cost-effectiveness. CONCLUSIONS Single-incision mini-slings were non-inferior to standard mid-urethral slings in patient-reported success rates at up to 3 years' follow-up. FUTURE WORK Success rates, adverse events, retreatment rates, symptoms, and quality-of-life scores at 10 years' follow-up will help inform long-term effectiveness. TRIAL REGISTRATION This trial was registered as ISRCTN93264234. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 47. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Mohamed Abdel-Fattah
- Aberdeen Centre For Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Tracey Davidson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Kiron Bhal
- Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Alison McDonald
- Aberdeen Centre For Women's Health Research, University of Aberdeen, Aberdeen, UK
| | | | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Aberdeen Centre For Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
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Stallard S, Savioli F, McConnachie A, Norrie J, Dudman K, Morrow ES, Romics L. Antibiotic prophylaxis in breast cancer surgery (PAUS trial): randomised clinical double-blind parallel-group multicentre superiority trial. Br J Surg 2022; 109:1224-1231. [PMID: 35932230 PMCID: PMC10364710 DOI: 10.1093/bjs/znac280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/08/2022] [Accepted: 07/19/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Participants were patients with invasive breast cancer undergoing primary surgery. The aim was to test whether a single dose of amoxicillin-clavulanic acid would reduce wound infection at 30 days postoperatively, and to identify risk factors for infection. METHODS Participants were randomised to either a single bolus of 1.2 g intravenous amoxicillin-clavulanic acid after the induction of anaesthesia (intervention) or no antibiotic (control). The primary outcome was the incidence of wound infection at 30 days postoperatively. RESULTS There were 871 evaluable patients. Of these, 438 received prophylactic antibiotic and 433 served as controls. Seventy-one (16.2 per cent) patients in the intervention group developed a wound infection by 30 days, while there were 83 (19.2 per cent) infections in the control group. This was not statistically significant (odds ratio (OR) 0.82, 95 per cent c.i. 0.58 to 1.15; P = 0.250). The risk of infection increased for every 5 kg/m2 of BMI (OR 1.29, 95 per cent c.i. 1.10 to 1.52; P = 0.003). Patients who were preoperative carriers of Staphylococcus aureus had an increased risk of postoperative wound infection; however, there was no benefit of preoperative antibiotics for patients with either a high BMI or who were carriers of S. aureus. CONCLUSION There was no statistically significant or clinically meaningful reduction in wound infection at 30 days following breast cancer surgery in patients who received a single dose of amoxicillin-clavulanic acid preoperatively. REGISTRATION NUMBER N0399145605 (National Research Register).
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Affiliation(s)
- Sheila Stallard
- Gartnavel General Hospital, Gartnavel General Hospital, Glasgow, UK
| | - Francesca Savioli
- Academic Unit of Surgery, School of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | | | - John Norrie
- Usher Institute, College of Medicine and Veterinary Medicine, Edinburgh, UK
| | | | - Elizabeth S Morrow
- Academic Unit of Surgery, School of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Laszlo Romics
- Academic Unit of Surgery, School of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK.,New Victoria Hospital, Glasgow, UK
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Normahani P, Burgess L, Norrie J, Epstein DM, Kandiyil N, Saratzis A, Smith S, Khunti K, Edmonds M, Ahluwalia R, Coward T, Hartshorne T, Ashwell S, Shalhoub J, Pigott E, Davies AH, Jaffer U. Study protocol for a multicentre comparative diagnostic accuracy study of tools to establish the presence and severity of peripheral arterial disease in people with diabetes mellitus: the DM PAD study. BMJ Open 2022; 12:e066950. [PMID: 36328388 PMCID: PMC9639108 DOI: 10.1136/bmjopen-2022-066950] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Peripheral arterial disease (PAD) is a key risk factor for cardiovascular disease, foot ulceration and lower limb amputation in people with diabetes. Early diagnosis of PAD can enable optimisation of therapies to manage these risks. Its diagnosis is fundamental, though challenging in the context of diabetes. Although a variety of diagnostic bedside tests are available, there is no agreement as to which is the most accurate in routine clinical practice.The aim of this study is to determine the diagnostic performance of a variety of tests (audible waveform assessment, visual waveform assessment, ankle brachial pressure index (ABPI), exercise ABPI and toe brachial pressure index (TBPI)) for the diagnosis of PAD in people with diabetes as determined by a reference test (CT angiography (CTA) or magnetic resonance angiography (MRA)). In selected centres, we also aim to evaluate the performance of a new point-of-care duplex ultrasound scan (PAD-scan). METHODS AND ANALYSIS A prospective multicentre diagnostic accuracy study (ClinicalTrials.gov Identifier NCT05009602). We aim to recruit 730 people with diabetes from 18 centres across the UK, covering primary and secondary healthcare. Consenting participants will undergo the tests under investigation. Reference tests (CTA or MRA) will be performed within 6 weeks of the index tests. Imaging will be reported by blinded consultant radiologists at a core imaging lab, using a validated scoring system, which will also be used to categorise PAD severity. The presence of one or more arterial lesions of ≥50% stenosis, or tandem lesions with a combined value of ≥50%, will be used as the threshold for the diagnosis of PAD. The primary outcome measure of diagnostic performance will be test sensitivity. ETHICS AND DISSEMINATION The study has received approval from the National Research Ethics Service (NRES) (REC reference 21/PR/1221). Results will be disseminated through research presentations and papers. TRIAL REGISTRATION NUMBER NCT05009602.
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Affiliation(s)
- Pasha Normahani
- Department of Surgery and Cancer, Imperial College London, London, UK
- Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Laura Burgess
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - John Norrie
- Usher Institute, Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
- Edinburgh Clinical Trials Unit, Edinburgh, UK
| | - David Mark Epstein
- Faculty of Economics and Business Sciences, University of Granada, Granada, Spain
| | - Neghal Kandiyil
- Department of Radiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Sasha Smith
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - M Edmonds
- King's Diabetes Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Raju Ahluwalia
- King's Diabetes Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Trusha Coward
- Podiatry Services, Central London Community Healthcare Trust, London, UK
| | - Tim Hartshorne
- Vascular Studies Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Simon Ashwell
- Diabetes Care Centre, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Joseph Shalhoub
- Department of Surgery and Cancer, Imperial College London, London, UK
- Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | | | - Alun H Davies
- Department of Surgery and Cancer, Imperial College London, London, UK
- Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Usman Jaffer
- Department of Surgery and Cancer, Imperial College London, London, UK
- Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
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Jones D, Knight SR, Sremanakova J, Lapitan MCM, Qureshi AU, Drake TM, Tabiri S, Ghosh D, Thomas M, Kingsley PA, Sundar S, Maimbo M, Yenli E, Shaw C, Valparaiso AP, Bhangu A, Magill L, Norrie J, Roberts TE, Theodoratou E, Weiser TG, Harrison EM, Burden ST. Malnutrition and nutritional screening in patients undergoing surgery in low and middle income countries: A systematic review. JCSM Clinical Reports 2022. [DOI: 10.1002/crt2.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Debra Jones
- School of Health Sciences University of Manchester Manchester UK
| | - Stephen R. Knight
- Centre for Medical Informatics, Usher Institute University of Edinburgh Edinburgh UK
| | - Jana Sremanakova
- School of Health Sciences University of Manchester Manchester UK
| | - Marie Carmela M. Lapitan
- Department of Surgery, Institute of Clinical Epidemiology, National Institutes of Health University of the Philippines Manila Philippines
| | - Ahmad U. Qureshi
- Department of General Surgery Services Institute of Medical Sciences Lahore Pakistan
| | - Thomas M. Drake
- Centre for Medical Informatics, Usher Institute University of Edinburgh Edinburgh UK
| | - Stephen Tabiri
- Department of Surgery, School of Medicine University for Development Studies Tamale Ghana
| | - Dhruva Ghosh
- Department of Paediatric Surgery Christian Medical College Ludhiana India
| | - Maria Thomas
- Department of Paediatric Surgery Christian Medical College Ludhiana India
| | - Pamela A. Kingsley
- Department of Radiation Oncology Christian Medical College Ludhiana India
| | - Sudha Sundar
- Institute of Cancer and Genomic Sciences University of Birmingham Birmingham UK
| | - Mayaba Maimbo
- Department of General Surgery Kitwe Teaching Hospital Kitwe Zambia
| | - Edwin Yenli
- Department of Surgery, School of Medicine University for Development Studies Tamale Ghana
| | - Catherine Shaw
- Centre for Medical Informatics, Usher Institute University of Edinburgh Edinburgh UK
| | - Apple P. Valparaiso
- Department of Surgery, Institute of Clinical Epidemiology, National Institutes of Health University of the Philippines Manila Philippines
| | - Aneel Bhangu
- Institute of Cancer and Genomic Sciences University of Birmingham Birmingham UK
| | - Laura Magill
- Institute of Applied Health Research University of Birmingham Birmingham UK
| | - John Norrie
- Centre for Global Health, Usher Institute University of Edinburgh Edinburgh UK
| | - Tracey E. Roberts
- Institute of Applied Health Research University of Birmingham Birmingham UK
| | - Evropi Theodoratou
- Centre for Global Health, Usher Institute University of Edinburgh Edinburgh UK
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer University of Edinburgh Edinburgh UK
| | - Thomas G. Weiser
- Department of Surgery Stanford University Stanford CA USA
- Department of Clinical Surgery University of Edinburgh Edinburgh UK
| | - Ewen M. Harrison
- Centre for Medical Informatics, Usher Institute University of Edinburgh Edinburgh UK
| | - Sorrel T. Burden
- School of Health Sciences University of Manchester Manchester UK
- Intestinal Failure Unit Salford Royal NHS Foundation Trust Manchester UK
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Heer R, Lewis R, Duncan A, Penegar S, Vadiveloo T, Clark E, Yu G, Mariappan P, Cresswell J, McGrath J, N'Dow J, Nabi G, Mostafid H, Kelly J, Ramsay C, Lazarowicz H, Allan A, Breckons M, Campbell K, Campbell L, Feber A, McDonald A, Norrie J, Orozco-Leal G, Rice S, Tandogdu Z, Taylor E, Wilson L, Vale L, MacLennan G, Hall E. Photodynamic versus white-light-guided resection of first-diagnosis non-muscle-invasive bladder cancer: PHOTO RCT. Health Technol Assess 2022; 26:1-144. [PMID: 36300825 PMCID: PMC9639219 DOI: 10.3310/plpu1526] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 11/04/2022] Open
Abstract
BACKGROUND Around 7500 people are diagnosed with non-muscle-invasive bladder cancer in the UK annually. Recurrence following transurethral resection of bladder tumour is common, and the intensive monitoring schedule required after initial treatment has associated costs for patients and the NHS. In photodynamic diagnosis, before transurethral resection of bladder tumour, a photosensitiser that is preferentially absorbed by tumour cells is instilled intravesically. Transurethral resection of bladder tumour is then conducted under blue light, causing the photosensitiser to fluoresce. Photodynamic diagnosis-guided transurethral resection of bladder tumour offers better diagnostic accuracy than standard white-light-guided transurethral resection of bladder tumour, potentially reducing the chance of subsequent recurrence. OBJECTIVE The objective was to assess the clinical effectiveness and cost-effectiveness of photodynamic diagnosis-guided transurethral resection of bladder tumour. DESIGN This was a multicentre, pragmatic, open-label, parallel-group, non-masked, superiority randomised controlled trial. Allocation was by remote web-based service, using a 1 : 1 ratio and a minimisation algorithm balanced by centre and sex. SETTING The setting was 22 NHS hospitals. PARTICIPANTS Patients aged ≥ 16 years with a suspected first diagnosis of high-risk non-muscle-invasive bladder cancer, no contraindications to photodynamic diagnosis and written informed consent were eligible. INTERVENTIONS Photodynamic diagnosis-guided transurethral resection of bladder tumour and standard white-light cystoscopy transurethral resection of bladder tumour. MAIN OUTCOME MEASURES The primary clinical outcome measure was the time to recurrence from the date of randomisation to the date of pathologically proven first recurrence (or intercurrent bladder cancer death). The primary health economic outcome was the incremental cost per quality-adjusted life-year gained at 3 years. RESULTS We enrolled 538 participants from 22 UK hospitals between 11 November 2014 and 6 February 2018. Of these, 269 were allocated to photodynamic diagnosis and 269 were allocated to white light. A total of 112 participants were excluded from the analysis because of ineligibility (n = 5), lack of non-muscle-invasive bladder cancer diagnosis following transurethral resection of bladder tumour (n = 89) or early cystectomy (n = 18). In total, 209 photodynamic diagnosis and 217 white-light participants were included in the clinical end-point analysis population. All randomised participants were included in the cost-effectiveness analysis. Over a median follow-up period of 21 months for the photodynamic diagnosis group and 22 months for the white-light group, there were 86 recurrences (3-year recurrence-free survival rate 57.8%, 95% confidence interval 50.7% to 64.2%) in the photodynamic diagnosis group and 84 recurrences (3-year recurrence-free survival rate 61.6%, 95% confidence interval 54.7% to 67.8%) in the white-light group (hazard ratio 0.94, 95% confidence interval 0.69 to 1.28; p = 0.70). Adverse event frequency was low and similar in both groups [12 (5.7%) in the photodynamic diagnosis group vs. 12 (5.5%) in the white-light group]. At 3 years, the total cost was £12,881 for photodynamic diagnosis-guided transurethral resection of bladder tumour and £12,005 for white light. There was no evidence of differences in the use of health services or total cost at 3 years. At 3 years, the quality-adjusted life-years gain was 2.094 in the photodynamic diagnosis transurethral resection of bladder tumour group and 2.087 in the white light group. The probability that photodynamic diagnosis-guided transurethral resection of bladder tumour was cost-effective was never > 30% over the range of society's cost-effectiveness thresholds. LIMITATIONS Fewer patients than anticipated were correctly diagnosed with intermediate- to high-risk non-muscle-invasive bladder cancer before transurethral resection of bladder tumour and the ratio of intermediate- to high-risk non-muscle-invasive bladder cancer was higher than expected, reducing the number of observed recurrences and the statistical power. CONCLUSIONS Photodynamic diagnosis-guided transurethral resection of bladder tumour did not reduce recurrences, nor was it likely to be cost-effective compared with white light at 3 years. Photodynamic diagnosis-guided transurethral resection of bladder tumour is not supported in the management of primary intermediate- to high-risk non-muscle-invasive bladder cancer. FUTURE WORK Further work should include the modelling of appropriate surveillance schedules and exploring predictive and prognostic biomarkers. TRIAL REGISTRATION This trial is registered as ISRCTN84013636. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 40. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rakesh Heer
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Lewis
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Anne Duncan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Steven Penegar
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Thenmalar Vadiveloo
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Emma Clark
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Ge Yu
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | | | - Joanne Cresswell
- Department of Urology, South Tees Hospitals NHS Trust, Middlesbrough, UK
| | - John McGrath
- Department of Urology, Royal Devon and Exeter Hospital NHS Trust, Exeter, UK
| | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Ghulam Nabi
- School of Medicine, University of Dundee, Dundee, UK
| | - Hugh Mostafid
- Department of Urology, Basingstoke and North Hampshire NHS Foundation Trust, Basingstoke, UK
| | - John Kelly
- University College London Cancer Institute, University College London Hospitals NHS Foundation Trust, London, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Henry Lazarowicz
- Department of Urology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Angela Allan
- Department of Urology, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Matthew Breckons
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Karen Campbell
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Louise Campbell
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Andy Feber
- University College London Cancer Institute, University College London Hospitals NHS Foundation Trust, London, UK
| | - Alison McDonald
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Giovany Orozco-Leal
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen Rice
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Zafer Tandogdu
- University College London Cancer Institute, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Laura Wilson
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
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35
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Heer R, Lewis R, Vadiveloo T, Yu G, Mariappan P, Cresswell J, McGrath J, Nabi G, Mostafid H, Lazarowicz H, Kelly J, Duncan A, Penegar S, Breckons M, Wilson L, Clark E, Feber A, Orozco-Leal G, Tandogdu Z, Taylor E, N'Dow J, Norrie J, Ramsay C, Rice S, Vale L, MacLennan G, Hall E. A Randomized Trial of PHOTOdynamic Surgery in Non-Muscle-Invasive Bladder Cancer. NEJM Evid 2022; 1:EVIDoa2200092. [PMID: 38319866 DOI: 10.1056/evidoa2200092] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
PDD or WL Resection of Tumors in NMIBCIn this open-label trial, patients with intermediate- or high-risk non-muscle-invasive bladder cancer at diagnosis were randomly assigned to photodynamic diagnosis or white light-guided transurethral resection of bladder tumor. Three-year recurrence-free rates were 57.8% and 61.6% in the PDD and WL groups, respectively, with no difference in quality-adjusted life years between the treatment groups at 3 years.
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Affiliation(s)
- Rakesh Heer
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Thenmalar Vadiveloo
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, United Kingdom
| | - Ge Yu
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Paramananthan Mariappan
- Edinburgh Bladder Cancer Surgery, Department of Urology, Western General Hospital, Edinburgh
| | | | - John McGrath
- Royal Devon and Exeter Hospital NHS Trust, Exeter, United Kingdom
| | - Ghulam Nabi
- University of Dundee, Dundee, United Kingdom
| | - Hugh Mostafid
- Basingstoke and North Hampshire NHS Foundation Trust, Basingstoke, United Kingdom
| | - Henry Lazarowicz
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - John Kelly
- University College London Hospitals NHS Foundation Trust, London
| | - Anne Duncan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, United Kingdom
| | | | - Matt Breckons
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Laura Wilson
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Emma Clark
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andy Feber
- University College London Hospitals NHS Foundation Trust, London
| | | | - Zafer Tandogdu
- University College London Hospitals NHS Foundation Trust, London
| | | | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - John Norrie
- Edinburgh Clinical Trials Unit, Edinburgh University, Edinburgh
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Stephen Rice
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Luke Vale
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, United Kingdom
| | - Emma Hall
- The Institute of Cancer Research, London
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Jolliffe DA, Holt H, Greenig M, Talaei M, Perdek N, Pfeffer P, Vivaldi G, Maltby S, Symons J, Barlow NL, Normandale A, Garcha R, Richter AG, Faustini SE, Orton C, Ford D, Lyons RA, Davies GA, Kee F, Griffiths CJ, Norrie J, Sheikh A, Shaheen SO, Relton C, Martineau AR. Effect of a test-and-treat approach to vitamin D supplementation on risk of all cause acute respiratory tract infection and covid-19: phase 3 randomised controlled trial (CORONAVIT). BMJ 2022; 378:e071230. [PMID: 36215226 PMCID: PMC9449358 DOI: 10.1136/bmj-2022-071230] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine the effect of population level implementation of a test-and-treat approach to correction of suboptimal vitamin D status (25-hydroxyvitamin D (25(OH)D) <75 nmol/L) on risk of all cause acute respiratory tract infection and covid 19. DESIGN Phase 3 open label randomised controlled trial. SETTING United Kingdom. PARTICIPANTS 6200 people aged ≥16 years who were not taking vitamin D supplements at baseline. INTERVENTIONS Offer of a postal finger prick test of blood 25(OH)D concentration with provision of a six month supply of lower dose vitamin D (800 IU/day, n=1550) or higher dose vitamin D (3200 IU/day, n=1550) to those with blood 25(OH)D concentration <75 nmol/L, compared with no offer of testing or supplementation (n=3100). Follow-up was for six months. MAIN OUTCOME MEASURES The primary outcome was the proportion of participants with at least one swab test or doctor confirmed acute respiratory tract infection of any cause. A secondary outcome was the proportion of participants with swab test confirmed covid-19. Logistic regression was used to calculate odds ratios and associated 95% confidence intervals. The primary analysis was conducted by intention to treat. RESULTS Of 3100 participants offered a vitamin D test, 2958 (95.4%) accepted and 2674 (86.3%) had 25(OH)D concentrations <75 nmol/L and received vitamin D supplements (n=1328 lower dose, n=1346 higher dose). Compared with 136/2949 (4.6%) participants in the no offer group, at least one acute respiratory tract infection of any cause occurred in 87/1515 (5.7%) in the lower dose group (odds ratio 1.26, 95% confidence interval 0.96 to 1.66) and 76/1515 (5.0%) in the higher dose group (1.09, 0.82 to 1.46). Compared with 78/2949 (2.6%) participants in the no offer group, 55/1515 (3.6%) developed covid-19 in the lower dose group (1.39, 0.98 to 1.97) and 45/1515 (3.0%) in the higher dose group (1.13, 0.78 to 1.63). CONCLUSIONS Among people aged 16 years and older with a high baseline prevalence of suboptimal vitamin D status, implementation of a population level test-and-treat approach to vitamin D supplementation was not associated with a reduction in risk of all cause acute respiratory tract infection or covid-19. TRIAL REGISTRATION ClinicalTrials.gov NCT04579640.
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Affiliation(s)
- David A Jolliffe
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK
| | - Hayley Holt
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK
- Asthma UK Centre for Applied Research, Queen Mary University of London, London, UK
| | - Matthew Greenig
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK
| | - Mohammad Talaei
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK
| | - Natalia Perdek
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK
| | - Paul Pfeffer
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK
| | - Giulia Vivaldi
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK
| | - Sheena Maltby
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK
| | | | - Nicola L Barlow
- Clinical Biochemistry Department, Black Country Pathology Services, City Hospital, Birmingham, UK
| | - Alexa Normandale
- Clinical Biochemistry Department, Black Country Pathology Services, City Hospital, Birmingham, UK
| | - Rajvinder Garcha
- Clinical Biochemistry Department, Black Country Pathology Services, City Hospital, Birmingham, UK
| | - Alex G Richter
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sian E Faustini
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Christopher Orton
- Population Data Science, Swansea University Medical School, Swansea, UK
- Health Data Research UK BREATHE Hub, Swansea University, Swansea, UK
| | - David Ford
- Population Data Science, Swansea University Medical School, Swansea, UK
- Health Data Research UK BREATHE Hub, Swansea University, Swansea, UK
| | - Ronan A Lyons
- Population Data Science, Swansea University Medical School, Swansea, UK
- Health Data Research UK BREATHE Hub, Swansea University, Swansea, UK
| | - Gwyneth A Davies
- Population Data Science, Swansea University Medical School, Swansea, UK
- Health Data Research UK BREATHE Hub, Swansea University, Swansea, UK
- Asthma UK Centre for Applied Research, University of Edinburgh, Edinburgh, UK
| | - Frank Kee
- Centre for Public Health (NI), Queen's University Belfast, Belfast, UK
| | - Christopher J Griffiths
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK
- Asthma UK Centre for Applied Research, Queen Mary University of London, London, UK
- Health Data Research UK BREATHE Hub, Queen Mary University of London, London, UK
| | - John Norrie
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Health Data Research UK BREATHE Hub, University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, University of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Health Data Research UK BREATHE Hub, University of Edinburgh, Edinburgh, UK
| | - Seif O Shaheen
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK
| | - Clare Relton
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK
| | - Adrian R Martineau
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK
- Asthma UK Centre for Applied Research, Queen Mary University of London, London, UK
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Lawton R, Hunt BJ, Norrie J, Shalhoub J, Thapar A, Davies AH. Compression Hosiery to Avoid Post-Thrombotic Syndrome (CHAPS) Trial. Eur J Vasc Endovasc Surg 2022; 64:431-432. [PMID: 35961624 DOI: 10.1016/j.ejvs.2022.07.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 07/11/2022] [Accepted: 07/22/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Rebecca Lawton
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - Beverley J Hunt
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Joseph Shalhoub
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - Ankur Thapar
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, United Kingdom
| | - Alun H Davies
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, United Kingdom.
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Abdel-fattah M, Johnson D, Constable L, Thomas R, Cotton S, Tripathee S, Cooper D, Boran S, Dimitropoulos K, Evans S, Granitsiotis P, Hashim H, Kilonzo M, Larcombe J, Little P, MacLennan S, Murchie P, Myint PK, N’Dow J, Norrie J, Omar MI, Paterson C, Scotland G, Thiruchelvam N, MacLennan G. Randomised controlled trial comparing the clinical and cost-effectiveness of various washout policies versus no washout policy in preventing catheter associated complications in adults living with long-term catheters: study protocol for the CATHETER II study. Trials 2022; 23:630. [PMID: 35927733 PMCID: PMC9351274 DOI: 10.1186/s13063-022-06577-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Various washout policies are widely used in adults living with long-term catheters (LTC). There is currently insufficient evidence on the benefits and potential harms of prophylactic LTC washout policies in the prevention of blockages and other LTC-related adverse events, such as urinary tract infections. CATHETER II tests the hypothesis that weekly prophylactic LTC washouts (normal saline or citric acid) in addition to standard LTC care reduce the incidence of catheter blockage requiring intervention compared to standard LTC care only in adults living with LTC. METHODS CATHETER II is a pragmatic three-arm open multi-centre superiority randomised controlled trial with an internal pilot, economic analysis, and embedded qualitative study. Eligible participants are adults aged ≥ 18 years, who have had a LTC in use for ≥ 28 days, have no plans to discontinue the use of the catheter, are able to undertake the catheter washouts, and complete trial documentation or have a carer able to help them. Participants are identified from general practitioner practices, secondary/tertiary care, community healthcare, care homes, and via public advertising strategies. Participants are randomised 1:1:1 to receive a weekly saline (0.9%) washout in addition to standard LTC care, a weekly citric acid (3.23%) washout in addition to standard LTC care or standard LTC care only. Participants and/or carers will receive training to administer the washouts. Patient-reported outcomes are collected at baseline and for 24 months post-randomisation. The primary clinical outcome is catheter blockage requiring intervention up to 24 months post-randomisation expressed per 1000 catheter days. Secondary outcomes include symptomatic catheter-associated urinary tract infection requiring antibiotics, catheter change, adverse events, NHS/ healthcare use, and impact on quality of life. DISCUSSION This study will guide treatment decision-making and clinical practice guidelines regarding the effectiveness of various prophylactic catheter washout policies in men and women living with LTC. This research has received ethical approval from Wales Research Ethics Committee 6 (19/WA/0015). TRIAL REGISTRATION ISRCTN ISRCTN17116445 . Registered prospectively on 06 November 2019.
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Affiliation(s)
- Mohamed Abdel-fattah
- grid.7107.10000 0004 1936 7291Aberdeen Centre for Women’s Health Research, University of Aberdeen, Aberdeen, UK
| | - Diana Johnson
- grid.7107.10000 0004 1936 7291Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Lynda Constable
- grid.7107.10000 0004 1936 7291Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Ruth Thomas
- grid.7107.10000 0004 1936 7291Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Seonaidh Cotton
- grid.7107.10000 0004 1936 7291Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Sheela Tripathee
- grid.7107.10000 0004 1936 7291Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - David Cooper
- grid.7107.10000 0004 1936 7291Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sue Boran
- The Queen’s Nursing Institute, London, UK
| | | | | | | | - Hashim Hashim
- grid.418484.50000 0004 0380 7221North Bristol NHS Trust, Bristol, UK
| | - Mary Kilonzo
- grid.7107.10000 0004 1936 7291Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Paul Little
- grid.5491.90000 0004 1936 9297Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Sara MacLennan
- grid.7107.10000 0004 1936 7291Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Peter Murchie
- grid.7107.10000 0004 1936 7291Academic Primary Care Research Group, University of Aberdeen, Aberdeen, UK
| | - Phyo Kyaw Myint
- grid.7107.10000 0004 1936 7291Ageing Clinical & Experimental Research Team, University of Aberdeen, Aberdeen, UK
| | - James N’Dow
- grid.7107.10000 0004 1936 7291Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- grid.4305.20000 0004 1936 7988Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Muhammad Imran Omar
- grid.7107.10000 0004 1936 7291Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Catherine Paterson
- grid.1039.b0000 0004 0385 7472School of Nursing, Midwifery and Public Health, University of Canberra, Canberra, Australia
| | - Graham Scotland
- grid.7107.10000 0004 1936 7291Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Nikesh Thiruchelvam
- grid.24029.3d0000 0004 0383 8386Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Graeme MacLennan
- grid.7107.10000 0004 1936 7291Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
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Constable L, Abrams P, Cooper D, Kilonzo M, Cotterill N, Harding C, Drake MJ, Pardoe MN, McDonald A, Smith R, Norrie J, McCormack K, Ramsay C, Uren A, Mundy T, Glazener C, MacLennan G. Synthetic sling or artificial urinary sphincter for men with urodynamic stress incontinence after prostate surgery: the MASTER non-inferiority RCT. Health Technol Assess 2022; 26:1-152. [PMID: 35972773 PMCID: PMC9421661 DOI: 10.3310/tbfz0277] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Stress urinary incontinence is common in men after prostate surgery and can be difficult to improve. Implantation of an artificial urinary sphincter is the most common surgical procedure for persistent stress urinary incontinence, but it requires specialist surgical skills, and revisions may be necessary. In addition, the sphincter is relatively expensive and its operation requires adequate patient dexterity. New surgical approaches include the male synthetic sling, which is emerging as a possible alternative. However, robust comparable data, derived from randomised controlled trials, on the relative safety and efficacy of the male synthetic sling and the artificial urinary sphincter are lacking. OBJECTIVE We aimed to compare the clinical effectiveness and cost-effectiveness of the male synthetic sling with those of the artificial urinary sphincter surgery in men with persistent stress urinary incontinence after prostate surgery. DESIGN This was a multicentre, non-inferiority randomised controlled trial, with a parallel non-randomised cohort and embedded qualitative component. Randomised controlled trial allocation was carried out by remote web-based randomisation (1 : 1), minimised on previous prostate surgery (radical prostatectomy or transurethral resection of the prostate), radiotherapy (or not, in relation to prostate surgery) and centre. Surgeons and participants were not blind to the treatment received. Non-randomised cohort allocation was participant and/or surgeon preference. SETTING The trial was set in 28 UK urological centres in the NHS. PARTICIPANTS Participants were men with urodynamic stress incontinence after prostate surgery for whom surgery was deemed appropriate. Exclusion criteria included previous sling or artificial urinary sphincter surgery, unresolved bladder neck contracture or urethral stricture after prostate surgery, and an inability to give informed consent or complete trial documentation. INTERVENTIONS We compared male synthetic sling with artificial urinary sphincter. MAIN OUTCOME MEASURES The clinical primary outcome measure was men's reports of continence (assessed from questions 3 and 4 of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form) at 12 months post randomisation (with a non-inferiority margin of 15%). The primary economic outcome was cost-effectiveness (assessed as the incremental cost per quality-adjusted life-year at 24 months post randomisation). RESULTS In total, 380 men were included in the randomised controlled trial (n = 190 in each group), and 99 out of 100 men were included in the non-randomised cohort. In terms of continence, the male sling was non-inferior to the artificial urinary sphincter (intention-to-treat estimated absolute risk difference -0.034, 95% confidence interval -0.117 to 0.048; non-inferiority p = 0.003), indicating a lower success rate in those randomised to receive a sling, but with a confidence interval excluding the non-inferiority margin of -15%. In both groups, treatment resulted in a reduction in incontinence symptoms (as measured by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form). Between baseline and 12 months' follow-up, the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score fell from 16.1 to 8.7 in the male sling group and from 16.4 to 7.5 in the artificial urinary sphincter group (mean difference for the time point at 12 months 1.30, 95% confidence interval 0.11 to 2.49; p = 0.032). The number of serious adverse events was small (male sling group, n = 8; artificial urinary sphincter group, n = 15; one man in the artificial urinary sphincter group experienced three serious adverse events). Quality-of-life scores improved and satisfaction was high in both groups. Secondary outcomes that showed statistically significant differences favoured the artificial urinary sphincter over the male sling. Outcomes of the non-randomised cohort were similar. The male sling cost less than the artificial sphincter but was associated with a smaller quality-adjusted life-year gain. The incremental cost-effectiveness ratio for male slings compared with an artificial urinary sphincter suggests that there is a cost saving of £425,870 for each quality-adjusted life-year lost. The probability that slings would be cost-effective at a £30,000 willingness-to-pay threshold for a quality-adjusted life-year was 99%. LIMITATIONS Follow-up beyond 24 months is not available. More specific surgical/device-related pain outcomes were not included. CONCLUSIONS Continence rates improved from baseline, with the male sling non-inferior to the artificial urinary sphincter. Symptoms and quality of life significantly improved in both groups. Men were generally satisfied with both procedures. Overall, secondary and post hoc analyses favoured the artificial urinary sphincter over the male sling. FUTURE WORK Participant reports of any further surgery, satisfaction and quality of life at 5-year follow-up will inform longer-term outcomes. Administration of an additional pain questionnaire would provide further information on pain levels after both surgeries. TRIAL REGISTRATION This trial is registered as ISRCTN49212975. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 36. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Lynda Constable
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Nikki Cotterill
- Faculty of Health and Applied Sciences (HAS), University of the West of England, Bristol, UK
| | - Chris Harding
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marcus J Drake
- Bristol Urological Institute, University of Bristol, Bristol, UK
| | - Megan N Pardoe
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Alison McDonald
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rebecca Smith
- Research and Innovation, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - John Norrie
- Usher Institute, Centre of Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Kirsty McCormack
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Alan Uren
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Tony Mundy
- Urology, University College Hospital, London, UK
| | - Cathryn Glazener
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Roche AD, McConnell AC, Donaldson K, Lawson A, Tan S, Toft K, Cairns G, Colle A, Coleman AA, Stewart K, Digard P, Norrie J, Stokes AA. Personalised 3D printed respirators for healthcare workers during the COVID-19 pandemic. Front Med Technol 2022; 4:963541. [PMID: 35982716 PMCID: PMC9380470 DOI: 10.3389/fmedt.2022.963541] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/05/2022] [Indexed: 11/22/2022] Open
Abstract
Widespread issues in respirator availability and fit have been rendered acutely apparent by the COVID-19 pandemic. This study sought to determine whether personalized 3D printed respirators provide adequate filtration and function for healthcare workers through a Randomized Controlled Trial (RCT). Fifty healthcare workers recruited within NHS Lothian, Scotland, underwent 3D facial scanning or 3D photographic reconstruction to produce 3D printed personalized respirators. The primary outcome measure was quantitative fit-testing to FFP3 standard. Secondary measures included respirator comfort, wearing experience, and function instrument (R-COMFI) for tolerability, Modified Rhyme Test (MRT) for intelligibility, and viral decontamination on respirator material. Of the 50 participants, 44 passed the fit test with the customized respirator, not significantly different from the 38 with the control (p = 0.21). The customized respirator had significantly improved comfort over the control respirator in both simulated clinical conditions (p < 0.0001) and during longer wear (p < 0.0001). For speech intelligibility, both respirators performed equally. Standard NHS decontamination agents were able to eradicate 99.9% of viral infectivity from the 3D printed plastics tested. Personalized 3D printed respirators performed to the same level as control disposable FFP3 respirators, with clear communication and with increased comfort, wearing experience, and function. The materials used were easily decontaminated of viral infectivity and would be applicable for sustainable and reusable respirators.
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Affiliation(s)
- Aidan D. Roche
- Deanery of Clinical Sciences, Queens Medical Research Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Alistair C. McConnell
- School of Engineering, Institute for Integrated Micro and Nano Systems, The University of Edinburgh, Edinburgh, United Kingdom
| | - Karen Donaldson
- School of Engineering, Institute for Integrated Micro and Nano Systems, The University of Edinburgh, Edinburgh, United Kingdom
- *Correspondence: Karen Donaldson
| | - Angus Lawson
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, United Kingdom
| | - Spring Tan
- Roslin Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Kate Toft
- Department of Speech and Language Therapy, St John's Hospital, Livingston, United Kingdom
| | - Gillian Cairns
- Department of Speech and Language Therapy, Royal Hospital for Sick Children, Edinburgh, United Kingdom
| | - Alexandre Colle
- School of Engineering, Institute for Integrated Micro and Nano Systems, The University of Edinburgh, Edinburgh, United Kingdom
| | | | - Ken Stewart
- Deanery of Clinical Sciences, Queens Medical Research Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Paul Digard
- Roslin Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - John Norrie
- Edinburgh Clinical Trials Unit, The University of Edinburgh, Edinburgh, United Kingdom
| | - Adam A. Stokes
- School of Engineering, Institute for Integrated Micro and Nano Systems, The University of Edinburgh, Edinburgh, United Kingdom
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Matovu B, Takuwa M, Mpaata CN, Denison F, Kiwanuka N, Lewis S, Norrie J, Ononge S, Muhimbise O, Tuck S, Etuket MD, Ssekitoleko RT. Review of investigational medical devices' clinical trials and regulations in Africa as a benchmark for new innovations. Front Med Technol 2022; 4:952767. [PMID: 35968546 PMCID: PMC9368574 DOI: 10.3389/fmedt.2022.952767] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/05/2022] [Indexed: 01/05/2023] Open
Abstract
Medical technologies present a huge potential in improving global health playing a key role toward achieving Sustainable Development Goal 3 by 2030. A number of clinicians, innovators, business entities and biomedical engineers among others have developed a number of innovative medical devices and technologies to address the healthcare challenges especially in Africa. Globally, medical devices clinical trials present the most acceptable method for determining the risks and benefits of medical device innovations with the aim of ascertaining their effectiveness and safety as compared with established medical practice. However, there are very few medical device clinical trials reported in Africa compared to other regions like USA, UK and Europe. Most of the medical device clinical trials reported in Africa are addressing challenges around HIV/AIDS, maternal health and NCDs. In this mini review, we report about some of the published medical device clinical trials in Africa PubMed and Google Scholar and their associated challenges.
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Affiliation(s)
- Brian Matovu
- Biomedical Engineering Unit, Department of Physiology, School of Biomedical Sciences College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mercy Takuwa
- Biomedical Engineering Unit, Department of Physiology, School of Biomedical Sciences College of Health Sciences, Makerere University, Kampala, Uganda
| | - Charles Norman Mpaata
- Biomedical Engineering Unit, Department of Physiology, School of Biomedical Sciences College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fiona Denison
- Department of Epidemiology and Biostatistics, The Queen's Medical Research Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Noah Kiwanuka
- Edinburgh Medical School, Clinical Trials Unit, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Steff Lewis
- Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, United Kingdom
| | - John Norrie
- Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, United Kingdom
| | - Sam Ononge
- Department of Obstetrics and Gynaecology, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Owen Muhimbise
- Biomedical Engineering Unit, Department of Physiology, School of Biomedical Sciences College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sharon Tuck
- Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, United Kingdom
| | - Maureen Dimitri Etuket
- Biomedical Engineering Unit, Department of Physiology, School of Biomedical Sciences College of Health Sciences, Makerere University, Kampala, Uganda
| | - Robert T. Ssekitoleko
- Biomedical Engineering Unit, Department of Physiology, School of Biomedical Sciences College of Health Sciences, Makerere University, Kampala, Uganda,*Correspondence: Robert T. Ssekitoleko
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Kernohan A, Homer T, Shabaninejad H, King AJ, Hudson J, Fernie G, Azuara-Blanco A, Burr J, Sparrow JM, Garway-Heath D, Barton K, Norrie J, Maclennan G, Vale L. Cost-effectiveness of primary surgical versus primary medical management in the treatment of patients presenting with advanced glaucoma. Br J Ophthalmol 2022; 107:bjophthalmol-2021-320887. [PMID: 35882513 PMCID: PMC10579172 DOI: 10.1136/bjo-2021-320887] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 06/29/2022] [Indexed: 11/04/2022]
Abstract
SYNOPSIS Advanced glaucoma is associated with sight loss. This within-trial economic evaluation compares medical and surgical management strategies. At 2 years, medication appears more cost-effective though longitudinal outcomes are an important subject in future research. BACKGROUND/AIMS Open angle glaucoma (OAG) is a progressive optic neuropathy. Approximately 25% of newly diagnosed patients with OAG present with advanced disease in at least one eye. The vision loss associated with OAG can lead to significant impacts on vision, quality of life and health care resources. The Treatment of Advanced Glaucoma Study is a randomised controlled trial comparing the effectiveness of primary surgical and medical management for newly diagnosed advanced patients with OAG. An economic evaluation was carried out to understand the costs and benefits of each strategy. METHODS A cost utility analysis was carried out from a National Health Service perspective over a 2-year time horizon inclusive of patient costs. The primary outcome was patient health-related quality of life measured by the EQ-5D-5L, Health Utilities Index 3 (HUI3) and Glaucoma Utility Index (GUI). Results were expressed as incremental cost per QALY gained. RESULTS Trabeculectomy was associated with higher costs and greater effect, the EQ-5D-5L results have an incremental cost per QALY of £45,456. The likelihood of surgery being cost-effective at a £20, 000, £30,000 and £50,000 QALY threshold is 0%, 12% and 56%, respectively. The results for the HUI3, GUI and inclusion of patient costs do not change the conclusions of the study. CONCLUSION This is the first study to evaluate management strategies for those presenting with advanced glaucoma. At a 2-year time horizon, medication is the more cost-effective approach for managing glaucoma. Future research can focus on the costs and benefits of the treatments over a longer time horizon.
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Affiliation(s)
- Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tara Homer
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hosein Shabaninejad
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Anthony J King
- Department of Ophthalmology, Nottingham University Hospital, Nottingham, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Gordon Fernie
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Jennifer Burr
- School of Medicine, University of St Andrews, St Andrews, UK
| | - John M Sparrow
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - David Garway-Heath
- National Institute for Health Research (NIHR) Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Keith Barton
- National Institute for Health Research (NIHR) Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Graeme Maclennan
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- NIHR Applied Research Collaboration North East and North Cumbria, NIHR, Newcastle, UK
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43
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Knight SR, Qureshi AU, Drake TM, Lapitan MCM, Maimbo M, Yenli E, Tabiri S, Ghosh D, Kingsley PA, Sundar S, Shaw C, Valparaiso AP, Bhangu A, Brocklehurst P, Magill L, Morton DG, Norrie J, Roberts TE, Theodoratou E, Weiser TG, Burden S, Harrison EM. The impact of preoperative oral nutrition supplementation on outcomes in patients undergoing gastrointestinal surgery for cancer in low- and middle-income countries: a systematic review and meta-analysis. Sci Rep 2022; 12:12456. [PMID: 35864290 PMCID: PMC9304351 DOI: 10.1038/s41598-022-16460-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 03/23/2022] [Accepted: 07/11/2022] [Indexed: 12/24/2022] Open
Abstract
Malnutrition is an independent predictor for postoperative complications in low- and middle-income countries (LMICs). We systematically reviewed evidence on the impact of preoperative oral nutrition supplementation (ONS) on patients undergoing gastrointestinal cancer surgery in LMICs. We searched EMBASE, Cochrane Library, Web of Science, Scopus, WHO Global Index Medicus, SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) databases from inception to March 21, 2022 for randomised controlled trials evaluating preoperative ONS in gastrointestinal cancer within LMICs. We evaluated the impact of ONS on all postoperative outcomes using random-effects meta-analysis. Seven studies reported on 891 patients (446 ONS group, 445 control group) undergoing surgery for gastrointestinal cancer. Preoperative ONS reduced all cause postoperative surgical complications (risk ratio (RR) 0.53, 95% CI 0.46-0.60, P < 0.001, I2 = 0%, n = 891), infection (0.52, 0.40-0.67, P = 0.008, I2 = 0%, n = 570) and all-cause mortality (0.35, 0.26-0.47, P = 0.014, I2 = 0%, n = 588). Despite heterogeneous populations and baseline rates, absolute risk ratio (ARR) was reduced for all cause (pooled effect -0.14, -0.22 to -0.06, P = 0.006; number needed to treat (NNT) 7) and infectious complications (-0.13, -0.22 to -0.06, P < 0.001; NNT 8). Preoperative nutrition in patients undergoing gastrointestinal cancer surgery in LMICs demonstrated consistently strong and robust treatment effects across measured outcomes. However additional higher quality research, with particular focus within African populations, are urgently required.
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Affiliation(s)
- Stephen R. Knight
- grid.4305.20000 0004 1936 7988Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX UK
| | - Ahmad U. Qureshi
- grid.415544.50000 0004 0411 1373Department of Surgery, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Thomas M. Drake
- grid.4305.20000 0004 1936 7988Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX UK
| | - Marie Carmela M. Lapitan
- grid.443239.b0000 0000 9950 521XDepartment of Surgery, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - Mayaba Maimbo
- Department of General Surgery, Kitwe Teaching Hospital, Kitwe, Zambia
| | - Edwin Yenli
- grid.442305.40000 0004 0441 5393Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana
| | - Stephen Tabiri
- grid.442305.40000 0004 0441 5393Department of Surgery, School of Medicine, University for Development Studies, Tamale, Ghana ,grid.442305.40000 0004 0441 5393Dean of School of Medicine, University for Development Studies, Tamale, Ghana
| | - Dhruva Ghosh
- grid.414306.40000 0004 1777 6366Department of Paediatric Surgery, Christian Medical College, Ludhiana, India
| | - Pamela A. Kingsley
- grid.414306.40000 0004 1777 6366Department of Radiation Oncology Department, Christian Medical College, Ludhiana, India
| | - Sudha Sundar
- grid.6572.60000 0004 1936 7486Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Catherine Shaw
- grid.4305.20000 0004 1936 7988Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX UK
| | - Apple P. Valparaiso
- grid.443239.b0000 0000 9950 521XDepartment of Surgery, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - Aneel Bhangu
- grid.6572.60000 0004 1936 7486Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Peter Brocklehurst
- grid.6572.60000 0004 1936 7486Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Laura Magill
- grid.6572.60000 0004 1936 7486Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Dion G. Morton
- grid.6572.60000 0004 1936 7486Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - John Norrie
- grid.4305.20000 0004 1936 7988Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Tracey E. Roberts
- grid.6572.60000 0004 1936 7486Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Evropi Theodoratou
- grid.4305.20000 0004 1936 7988Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, UK ,grid.4305.20000 0004 1936 7988Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Thomas G. Weiser
- grid.168010.e0000000419368956Department of Surgery, Stanford University, Stanford, USA ,grid.4305.20000 0004 1936 7988Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Sorrel Burden
- grid.5379.80000000121662407School of Health Sciences, University of Manchester, Manchester, UK
| | - Ewen M. Harrison
- grid.4305.20000 0004 1936 7988Centre for Medical Informatics, Usher Institute, Nine Bioquarter, University of Edinburgh, Edinburgh, EH16 4UX UK
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44
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Woodfield J, Edlmann E, Black PL, Boyd J, Copley PC, Cranswick G, Eborall H, Keerie C, Khan S, Lawton J, Lowe DJ, Norrie J, Niven A, Reed MJ, Shenkin SD, Statham P, Stoddart A, Tomlinson J, Brennan PM. Duration of External Neck Stabilisation (DENS) following odontoid fracture in older or frail adults: protocol for a randomised controlled trial of collar versus no collar. BMJ Open 2022; 12:e057753. [PMID: 35840308 PMCID: PMC9295672 DOI: 10.1136/bmjopen-2021-057753] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Fractures of the odontoid process frequently result from low impact falls in frail or older adults. These are increasing in incidence and importance as the population ages. In the UK, odontoid fractures in older adults are usually managed in hard collars to immobilise the fracture and promote bony healing. However, bony healing does not always occur in older adults, and bony healing is not associated with quality of life, functional, or pain outcomes. Further, hard collars can cause complications such as skin pressure ulcers, swallowing difficulties and difficulties with personal care. We hypothesise that management with no immobilisation may be superior to management in a hard collar for older or frail adults with odontoid fractures. METHODS AND ANALYSES This is the protocol for the Duration of External Neck Stabilisation (DENS) trial-a non-blinded randomised controlled trial comparing management in a hard collar with management without a collar for older (≥65 years) or frail (Rockwood Clinical Frailty Scale ≥5) adults with a new odontoid fracture. 887 neurologically intact participants with any odontoid process fracture type will be randomised to continuing with a hard collar (standard care) or removal of the collar (intervention). The primary outcome is quality of life measured using the EQ-5D-5L at 12 weeks. Secondary outcomes include pain scores, neck disability index, health and social care use and costs, and mortality. ETHICS AND DISSEMINATION Informed consent for participation will be sought from those able to provide it. We will also include those who lack capacity to ensure representativeness of frail and acutely unwell older adults. Results will be disseminated via scientific publication, lay summary, and visual abstract. The DENS trial received a favourable ethical opinion from the Scotland A Research Ethics Committee (21/SS/0036) and the Leeds West Research Ethics Committee (21/YH/0141). TRIAL REGISTRATION NUMBER NCT04895644.
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Affiliation(s)
- Julie Woodfield
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Translational Neurosurgery, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
| | - Ellie Edlmann
- Southwest Neurosurgical Centre, Derriford Hospital, Plymouth, UK
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Polly L Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | | | - Gina Cranswick
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Helen Eborall
- University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Sadaquate Khan
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - Julia Lawton
- University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - David J Lowe
- Department of Emergency, Queen Elizabeth University Hospital Campus, Glasgow, UK
- University of Glasgow Institute of Health and Wellbeing, Glasgow, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Angela Niven
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Matthew J Reed
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
- University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Susan Deborah Shenkin
- University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
- Advanced Care Research Centre, University of Edinburgh College of Medicine and Veterinary Medicine, Edinburgh, UK
| | - Patrick Statham
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - Andrew Stoddart
- Edinburgh Health Services Research Unit, The University Of Edinburgh, Edinburgh, UK
| | - James Tomlinson
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul M Brennan
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
- Translational Neurosurgery, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
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45
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Gumley AI, Bradstreet S, Ainsworth J, Allan S, Alvarez-Jimenez M, Birchwood M, Briggs A, Bucci S, Cotton S, Engel L, French P, Lederman R, Lewis S, Machin M, MacLennan G, McLeod H, McMeekin N, Mihalopoulos C, Morton E, Norrie J, Reilly F, Schwannauer M, Singh SP, Sundram S, Thompson A, Williams C, Yung A, Aucott L, Farhall J, Gleeson J. Digital smartphone intervention to recognise and manage early warning signs in schizophrenia to prevent relapse: the EMPOWER feasibility cluster RCT. Health Technol Assess 2022; 26:1-174. [PMID: 35639493 DOI: 10.3310/hlze0479] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 01/01/2023] Open
Abstract
BACKGROUND Relapse is a major determinant of outcome for people with a diagnosis of schizophrenia. Early warning signs frequently precede relapse. A recent Cochrane Review found low-quality evidence to suggest a positive effect of early warning signs interventions on hospitalisation and relapse. OBJECTIVE How feasible is a study to investigate the clinical effectiveness and cost-effectiveness of a digital intervention to recognise and promptly manage early warning signs of relapse in schizophrenia with the aim of preventing relapse? DESIGN A multicentre, two-arm, parallel-group cluster randomised controlled trial involving eight community mental health services, with 12-month follow-up. SETTINGS Glasgow, UK, and Melbourne, Australia. PARTICIPANTS Service users were aged > 16 years and had a schizophrenia spectrum disorder with evidence of a relapse within the previous 2 years. Carers were eligible for inclusion if they were nominated by an eligible service user. INTERVENTIONS The Early signs Monitoring to Prevent relapse in psychosis and prOmote Wellbeing, Engagement, and Recovery (EMPOWER) intervention was designed to enable participants to monitor changes in their well-being daily using a mobile phone, blended with peer support. Clinical triage of changes in well-being that were suggestive of early signs of relapse was enabled through an algorithm that triggered a check-in prompt that informed a relapse prevention pathway, if warranted. MAIN OUTCOME MEASURES The main outcomes were feasibility of the trial and feasibility, acceptability and usability of the intervention, as well as safety and performance. Candidate co-primary outcomes were relapse and fear of relapse. RESULTS We recruited 86 service users, of whom 73 were randomised (42 to EMPOWER and 31 to treatment as usual). Primary outcome data were collected for 84% of participants at 12 months. Feasibility data for people using the smartphone application (app) suggested that the app was easy to use and had a positive impact on motivations and intentions in relation to mental health. Actual app usage was high, with 91% of users who completed the baseline period meeting our a priori criterion of acceptable engagement (> 33%). The median time to discontinuation of > 33% app usage was 32 weeks (95% confidence interval 14 weeks to ∞). There were 8 out of 33 (24%) relapses in the EMPOWER arm and 13 out of 28 (46%) in the treatment-as-usual arm. Fewer participants in the EMPOWER arm had a relapse (relative risk 0.50, 95% confidence interval 0.26 to 0.98), and time to first relapse (hazard ratio 0.32, 95% confidence interval 0.14 to 0.74) was longer in the EMPOWER arm than in the treatment-as-usual group. At 12 months, EMPOWER participants were less fearful of having a relapse than those in the treatment-as-usual arm (mean difference -4.29, 95% confidence interval -7.29 to -1.28). EMPOWER was more costly and more effective, resulting in an incremental cost-effectiveness ratio of £3041. This incremental cost-effectiveness ratio would be considered cost-effective when using the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year gained. LIMITATIONS This was a feasibility study and the outcomes detected cannot be taken as evidence of efficacy or effectiveness. CONCLUSIONS A trial of digital technology to monitor early warning signs that blended with peer support and clinical triage to detect and prevent relapse is feasible. FUTURE WORK A main trial with a sample size of 500 (assuming 90% power and 20% dropout) would detect a clinically meaningful reduction in relapse (relative risk 0.7) and improvement in other variables (effect sizes 0.3-0.4). TRIAL REGISTRATION This trial is registered as ISRCTN99559262. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 27. See the NIHR Journals Library website for further project information. Funding in Australia was provided by the National Health and Medical Research Council (APP1095879).
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Affiliation(s)
- Andrew I Gumley
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Simon Bradstreet
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - John Ainsworth
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Stephanie Allan
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Mario Alvarez-Jimenez
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Maximillian Birchwood
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Andrew Briggs
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Sandra Bucci
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Sue Cotton
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia
| | - Lidia Engel
- School of Health and Social Development, Deakin University, Melbourne, VIC, Australia
| | - Paul French
- Department of Nursing, Manchester Metropolitan University, Manchester, UK
| | - Reeva Lederman
- School of Computing and Information Systems, Melbourne School of Engineering, University of Melbourne, Melbourne, VIC, Australia
| | - Shôn Lewis
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Matthew Machin
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Hamish McLeod
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Nicola McMeekin
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Cathy Mihalopoulos
- School of Health and Social Development, Deakin University, Melbourne, VIC, Australia
| | - Emma Morton
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - John Norrie
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | | | - Swaran P Singh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Suresh Sundram
- Department of Psychiatry, Monash University, Melbourne, VIC, Australia
| | - Andrew Thompson
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia.,Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Chris Williams
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Alison Yung
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Farhall
- Department of Psychology and Counselling, La Trobe University, Melbourne, VIC, Australia.,NorthWestern Mental Health, Melbourne, VIC, Australia
| | - John Gleeson
- Healthy Brain and Mind Research Centre, Australian Catholic University, Melbourne, VIC, Australia
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46
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Gumley AI, Bradstreet S, Ainsworth J, Allan S, Alvarez-Jimenez M, Aucott L, Birchwood M, Briggs A, Bucci S, Cotton SM, Engel L, French P, Lederman R, Lewis S, Machin M, MacLennan G, McLeod H, McMeekin N, Mihalopoulos C, Morton E, Norrie J, Schwannauer M, Singh SP, Sundram S, Thompson A, Williams C, Yung AR, Farhall J, Gleeson J. The EMPOWER blended digital intervention for relapse prevention in schizophrenia: a feasibility cluster randomised controlled trial in Scotland and Australia. Lancet Psychiatry 2022; 9:477-486. [PMID: 35569503 DOI: 10.1016/s2215-0366(22)00103-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Early warning signs monitoring by service users with schizophrenia has shown promise in preventing relapse but the quality of evidence is low. We aimed to establish the feasibility of undertaking a definitive randomised controlled trial to determine the effectiveness of a blended digital intervention for relapse prevention in schizophrenia. METHODS This multicentre, feasibility, cluster randomised controlled trial aimed to compare Early signs Monitoring to Prevent relapse in psychosis and prOmote Well-being, Engagement, and Recovery (EMPOWER) with treatment as usual in community mental health services (CMHS) in Glasgow and Melbourne. CMHS were the unit of randomisation, selected on the basis of those that probably had five or more care coordinators willing to participate. Participants were eligible if they were older than 16 years, had a schizophrenia or related diagnosis confirmed via case records, were able to provide informed consent, had contact with CMHS, and had had a relapse within the previous 2 years. Participants were randomised within stratified clusters to EMPOWER or to continue their usual approach to care. EMPOWER blended a smartphone for active monitoring of early warning signs with peer support to promote self-management and clinical triage to promote access to relapse prevention. Main outcomes were feasibility, acceptability, usability, and safety, which was assessed through face-to-face interviews. App usage was assessed via the smartphone and self-report. Primary end point was 12 months. Participants, research assistants and other team members involved in delivering the intervention were not masked to treatment conditions. Assessment of relapse was done by an independent adjudication panel masked to randomisation group. The study is registered at ISRCTN (99559262). FINDINGS We identified and randomised eight CMHS (six in Glasgow and two in Melbourne) comprising 47 care coordinators. We recruited 86 service users between Jan 19 and Aug 8, 2018; 73 were randomised (42 [58%] to EMPOWER and 31 [42%] to treatment as usual). There were 37 (51%) men and 36 (49%) women. At 12 months, main outcomes were collected for 32 (76%) of service users in the EMPOWER group and 30 (97%) of service users in the treatment as usual group. Of those randomised to EMPOWER, 30 (71%) met our a priori criterion of more than 33% adherence to daily monitoring that assumed feasibility. Median time to discontinuation of these participants was 31·5 weeks (SD 14·5). There were 29 adverse events in the EMPOWER group and 25 adverse events in the treatment as usual group. There were 13 app-related adverse events, affecting 11 people, one of which was serious. Fear of relapse was lower in the EMPOWER group than in the treatment as usual group at 12 months (mean difference -7·53 (95% CI -14·45 to 0·60; Cohen's d -0·53). INTERPRETATION A trial of digital technology to monitor early warning signs blended with peer support and clinical triage to detect and prevent relapse appears to be feasible, safe, and acceptable. A further main trial is merited. FUNDING UK National Institute for Health Research Health Technology Assessment programme and the Australian National Health and Medical Research Council.
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Affiliation(s)
- Andrew I Gumley
- Glasgow Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
| | - Simon Bradstreet
- Glasgow Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - John Ainsworth
- Division of Informatics Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Stephanie Allan
- Glasgow Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Mario Alvarez-Jimenez
- Orygen Melbourne, Melbourne, VIC, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Lorna Aucott
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Maximillian Birchwood
- Centre for Mental Health and Wellbeing Research, Warwick Medical School, University of Warwick, Warwick, UK
| | - Andrew Briggs
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Sandra Bucci
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Sue M Cotton
- Orygen Melbourne, Melbourne, VIC, Australia; Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Lidia Engel
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paul French
- Department of Psychiatry, Manchester Metropolitan University, Manchester, UK
| | - Reeva Lederman
- School of Computing and Information Systems, Faculty of Engineering and Information Technology, University of Melbourne, Melbourne, VIC, Australia
| | - Shôn Lewis
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Matthew Machin
- Division of Informatics Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, UK
| | - Hamish McLeod
- Glasgow Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Nicola McMeekin
- Glasgow Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Cathy Mihalopoulos
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Emma Morton
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - John Norrie
- The Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Swaran P Singh
- Centre for Mental Health and Wellbeing Research, Warwick Medical School, University of Warwick, Warwick, UK
| | - Suresh Sundram
- Department of Psychiatry, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia; Mental Health Program, Monash Health, Melbourne, VIC, Australia
| | - Andrew Thompson
- Orygen Melbourne, Melbourne, VIC, Australia; Centre for Mental Health and Wellbeing Research, Warwick Medical School, University of Warwick, Warwick, UK
| | - Chris Williams
- Glasgow Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Alison R Yung
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; School of Medicine, Deakin University, Melbourne, VIC, Australia
| | - John Farhall
- Department of Psychology and Counselling, La Trobe University, Melbourne, VIC, Australia; NorthWestern Mental Health, The Royal Melbourne Hospital, Epping, VIC, Australia
| | - John Gleeson
- Healthy Brain and Mind Research Centre, School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, VIC, Australia
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47
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Turner S, Cotton S, Wood J, Bell V, Raja EA, Scott NW, Morgan H, Lawrie L, Emele D, Kennedy C, Scotland G, Fielding S, MacLennan G, Norrie J, Forrest M, Gaillard EA, de Jongste J, Pijnenburg M, Thomas M, Price D. Reducing asthma attacks in children using exhaled nitric oxide (RAACENO) as a biomarker to inform treatment strategy: a multicentre, parallel, randomised, controlled, phase 3 trial. Lancet Respir Med 2022; 10:584-592. [PMID: 35101183 DOI: 10.1016/s2213-2600(21)00486-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/09/2021] [Accepted: 10/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The benefit of fractional exhaled nitric oxide (FeNO) in guiding asthma treatment is uncertain. We evaluated the efficacy of adding FeNO to symptom-guided treatment in children with asthma versus only symptom-guided treatment. METHODS RAACENO was a multicentre, parallel, randomised, controlled, phase 3 trial done in 35 secondary care centres and 17 primary care recruitment sites (only seven primary care sites managed to recruit patients) in the UK. Patients with a confirmed asthma diagnosis, aged 6-15 years, prescribed inhaled corticosteroids, and who received a course of oral corticosteroids for at least one asthma exacerbation during the 12 months before recruitment were included. Participants were randomly assigned to either FeNO plus symptom-guided treatment (intervention) or symptom-guided treatment alone (standard care) using a 24 h in-house, web-based randomisation system. Participants and the clinical and research teams were not masked to the group allocation. A web-based algorithm gave treatment recommendations based on the Asthma Control Test (ACT) or Childhood ACT (CACT) score; current asthma treatment; adherence to study treatment in the past 3 months; and use of FeNO (in the intervention group). Follow-up occurred at 3-month intervals for 12 months. The primary outcome was any asthma exacerbation treated with oral corticosteroids in the 12 months after randomisation, assessed in the intention-to-treat population. This study is registered with the International Standard Randomised Controlled Trial Registry, ISRCTN67875351. FINDINGS Between June 22, 2017, and Aug 8, 2019, 535 children were assessed for eligibility, 20 were ineligible and six were excluded post-randomisation. 509 children were recruited and at baseline, the mean age of participants was 10·1 years (SD 2·6), and 308 (60·5%) were male. The median FeNO was 21 ppb (IQR 10-48), mean predicted FEV1 was 89·6% (SD 18·0), and median daily dose of inhaled corticosteroids was 400 μg budesonide equivalent (IQR 400-1000). Asthma was partly or fully controlled in 256 (50·3%) of 509 participants. The primary outcome, which was available for 506 (99%) of 509 participants, occurred in 123 (48·2%) of 255 participants in the intervention group and 129 (51·4%) of 251 in the standard care group, the intention-to-treat adjusted odds ratio (OR) was 0·88 (95% CI 0·61 to 1·27; p=0·49). The adjusted difference in the percentage of participants who received the intervention in whom the primary outcome occurred compared with those who received standard care was -3·1% (-11·9% to 5·6%). In 377 (21·3%) of 1771 assessments, the algorithm recommendation was not followed. Adverse events were reported by 27 (5·3%) of 509 participants (15 in the standard care group and 12 in the intervention group). The most common adverse event was itch after skin prick testing (reported by eight participants in each group). INTERPRETATION We found that the addition of FeNO to symptom-guided asthma treatment did not lead to reduced exacerbations among children prone to asthma exacerbation. Asthma symptoms remain the only tool for guiding treatment decisions. FUNDING National Institute for Health Research.
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Affiliation(s)
- Steve Turner
- Royal Aberdeen Children's Hospital, University of Aberdeen, Aberdeen, UK.
| | - Seonaidh Cotton
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jessica Wood
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Victoria Bell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Neil W Scott
- Department of Medical Statistics, University of Aberdeen, Aberdeen, UK
| | - Heather Morgan
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Louisa Lawrie
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - David Emele
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Charlotte Kennedy
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Shona Fielding
- Department of Medical Statistics, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Mark Forrest
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Erol A Gaillard
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | | | | | - Mike Thomas
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - David Price
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK; Observational and Pragmatic Research Institute, Singapore
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48
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Bennett SE, Almeida C, Bachmair EM, Gray SR, Lovell K, Paul L, Wearden A, Macfarlane GJ, Basu N, Dures E, Aucott L, Martin K, Dhaun N, Emsley R, Kidd E, Kumar V, MacLennan G, Paul M, Norrie J, Packham J, Ralston SH, Siebert S, Nicol A, Norris K, Mann S, Van Lierop L, Gomez E, McCurdy F, Findlay V, Hastie N, Morgan E, Emmanuel R, Whibley D, Urquart A, MacPerson L, Rowland J, Kiddie G, Pankhurst D, Paul J, Nicholson H, Dunsmore A, Knight A, Ellis J, Maclean C, Crighton L, Shearer C, Coyle J, Begg S, Ackerman L, Carnevale J, Arbuthnot S, Watters H, Dockrell D, Hamilton D, Salutous D, Cathcart S, Rimmer D, Hughes E, Harvey J, Gillies M, Webster S, Milne L, Semple G, Duffy K, Turner L, Alexander J, Innes J, Clark C, Meek C, McKenna E, Routledge C, Hinchcliffe-Hume H, Traianos E, Dibnah B, Storey D, O'Callaghan G, Baron JY, Hunt S, Wheat N, Smith P, Barcroft EA, Thompson A, Tomlinson J, Barber J, MacPerson G, White P, Hewlett S. Remotely delivered cognitive-behavioural and personalized exercise interventions to lessen the impact of fatigue: a qualitative evaluation. Rheumatol Adv Pract 2022; 6:rkac051. [PMID: 35795008 PMCID: PMC9252174 DOI: 10.1093/rap/rkac051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/13/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
Fatigue can be a disabling symptom of inflammatory rheumatic diseases. LIFT (Lessening the Impact of Fatigue in inflammatory rheumatic diseases: a randomized Trial) is a randomized trial of remotely delivered cognitive-behavioural approach or personalized exercise programme interventions, compared with usual care. The aim of this nested qualitative study was to evaluate participants’ experiences of taking part in the intervention, including their ideas about future service delivery.
Methods
Semi-structured telephone interviews were conducted with a subgroup of LIFT participants to discuss their views and experiences of the interventions.
Results
Forty-three participants (30 women) from six sites who had participated in the cognitive-behavioural approach (n = 22) or personalized exercise programme (n = 21) interventions took part. Five themes were identified in the thematic analysis. In the theme ‘not a miracle cure, but a way to better manage fatigue’, LIFT could not cure fatigue; however, most felt better able to manage after participating. Participants valued ‘building a therapeutic relationship’ with the same therapist throughout the intervention. In ‘structure, self-monitoring and being accountable’, participants liked the inclusion of goal-setting techniques and were motivated by reporting back to the therapist.
After taking part in the interventions, participants felt ‘better equipped to cope with fatigue’; more confident and empowered. Lastly, participants shared ideas for ‘a tailored programme delivered remotely’, including follow-up sessions, video calling, and group-based sessions for social support.
Conclusion
Many participants engaged with the LIFT interventions and reported benefits of taking part. This suggests an important future role for the remote delivery of fatigue self-management.
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Affiliation(s)
- Sarah E Bennett
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol
| | - Celia Almeida
- School of Health and Social Wellbeing, University of the West of England
- Academic Rheumatology, Bristol Royal Infirmary , Bristol
| | - Eva-Maria Bachmair
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen , Aberdeen
| | - Stuart R Gray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow , Glasgow
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, University of Manchester , Manchester
| | - Lorna Paul
- School of Health and Life Science, Glasgow Caledonian University , Glasgow
| | - Alison Wearden
- Division of Psychology and Mental Health, University of Manchester , Manchester
| | - Gary J Macfarlane
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen , Aberdeen
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow , Glasgow, UK
| | - Emma Dures
- School of Health and Social Wellbeing, University of the West of England
- Academic Rheumatology, Bristol Royal Infirmary , Bristol
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49
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Halford S, Wan S, Dragoni I, Silvester J, Nazarov B, Anthony D, Anthony S, Ladds E, Norrie J, Dhaliwal K. Correction to: SPIKE-1: A Randomised Phase II/III trial in a community setting, assessing use of camostat in reducing the clinical progression of COVID-19 by blocking SARS-CoV-2 Spike protein-initiated membrane fusion. Trials 2022; 23:336. [PMID: 35449061 PMCID: PMC9022056 DOI: 10.1186/s13063-022-06266-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sarah Halford
- Cancer Research UK Centre for Drug Development, London, UK.
| | - Susan Wan
- Cancer Research UK Centre for Drug Development, London, UK
| | - Ilaria Dragoni
- Cancer Research UK Centre for Drug Development, London, UK
| | | | | | | | - Suzie Anthony
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Emma Ladds
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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50
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Cotton S, Devereux G, Abbas H, Briggs A, Campbell K, Chaudhuri R, Choudhury G, Dawson D, De Soyza A, Fielding S, Gompertz S, Haughney J, Lang CC, Lee AJ, MacLennan G, MacNee W, McCormack K, McMeekin N, Mills NL, Morice A, Norrie J, Petrie MC, Price D, Short P, Vestbo J, Walker P, Wedzicha J, Wilson A, Lipworth BJ. Use of the oral beta blocker bisoprolol to reduce the rate of exacerbation in people with chronic obstructive pulmonary disease (COPD): a randomised controlled trial (BICS). Trials 2022; 23:307. [PMID: 35422024 PMCID: PMC9009490 DOI: 10.1186/s13063-022-06226-8] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/26/2022] [Indexed: 12/13/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is associated with significant morbidity, mortality and healthcare costs. Beta blockers are well-established drugs widely used to treat cardiovascular conditions. Observational studies consistently report that beta blocker use in people with COPD is associated with a reduced risk of COPD exacerbations. The bisoprolol in COPD study (BICS) investigates whether adding bisoprolol to routine COPD treatment has clinical and cost-effective benefits. A sub-study will risk stratify participants for heart failure to investigate whether any beneficial effect of bisoprolol is restricted to those with unrecognised heart disease. Methods BICS is a pragmatic randomised parallel group double-blind placebo-controlled trial conducted in UK primary and secondary care sites. The major inclusion criteria are an established predominant respiratory diagnosis of COPD (post-bronchodilator FEV1 < 80% predicted, FEV1/FVC < 0.7), a self-reported history of ≥ 2 exacerbations requiring treatment with antibiotics and/or oral corticosteroids in a 12-month period since March 2019, age ≥ 40 years and a smoking history ≥ 10 pack years. A computerised randomisation system will allocate 1574 participants with equal probability to intervention or control groups, stratified by centre and recruitment in primary/secondary care. The intervention is bisoprolol (1.25 mg tablets) or identical placebo. The dose of bisoprolol/placebo is titrated up to a maximum of 4 tablets a day (5 mg bisoprolol) over 4–7 weeks depending on tolerance to up-dosing of bisoprolol/placebo—these titration assessments are completed by telephone or video call. Participants complete the remainder of the 52-week treatment period on the final titrated dose (1, 2, 3, 4 tablets) and during that time are followed up at 26 and 52 weeks by telephone or video call. The primary outcome is the total number of participant reported COPD exacerbations requiring oral corticosteroids and/or antibiotics during the 52-week treatment period. A sub-study will risk stratify participants for heart failure by echocardiography and measurement of blood biomarkers. Discussion The demonstration that bisoprolol reduces the incidence of exacerbations would be relevant not only to patients and clinicians but also to healthcare providers, in the UK and globally. Trial registration Current controlled trials ISRCTN10497306. Registered on 16 August 2018 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06226-8.
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Affiliation(s)
- Seonaidh Cotton
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Graham Devereux
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK. .,Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.
| | - Hassan Abbas
- Division of Applied Medicine, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Andrew Briggs
- Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Karen Campbell
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Rekha Chaudhuri
- Gartnavel General Hospital, University of Glasgow, Glasgow, G12 0YN, UK
| | | | - Dana Dawson
- Division of Applied Medicine, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Anthony De Soyza
- University of Newcastle, Medical School, Newcastle Upon Tyne, NE2 4HH, UK
| | - Shona Fielding
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Simon Gompertz
- Queen Elizabeth Hospital Birmingham, Birmingham, B15 2WB, UK
| | - John Haughney
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Chim C Lang
- Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK
| | - Amanda J Lee
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - William MacNee
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, EH16 4TJ, UK
| | - Kirsty McCormack
- Centre for Healthcare Randomised Trials (CHaRT), University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Nicola McMeekin
- Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Alyn Morice
- Cardiovascular and Respiratory Studies, Castle Hill Hospital, Hull, HU16 5JQ, UK
| | - John Norrie
- NINE Edinburgh BioQuarter, University of Edinburgh, 9 Little France Road, Edinburgh, EH16 4UX, UK
| | - Mark C Petrie
- Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, G12 8TD, UK
| | - David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | | | - Jorgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, M23 9LT, UK
| | - Paul Walker
- Liverpool University Hospitals Foundation NHS Trust, University Hospital Aintree, Lower Lane, Liverpool, L9 7AL, UK
| | - Jadwiga Wedzicha
- National Heart and Lung Institute, Imperial College, London, SW3 6LY, UK
| | - Andrew Wilson
- Department of Medicine, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Brian J Lipworth
- Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, UK
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