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Pocock H, Deakin CD, Lall R, Michelet F, Sun C, Smith D, Hill C, Rai J, Starr K, Brown M, Rodriguez-Bachiller I, Perkins GD. Prehospital optimal shock energy for defibrillation (POSED): A cluster randomised controlled feasibility trial. Resusc Plus 2024; 17:100569. [PMID: 38370312 PMCID: PMC10869912 DOI: 10.1016/j.resplu.2024.100569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/15/2024] [Accepted: 01/25/2024] [Indexed: 02/20/2024] Open
Abstract
Background We explored the feasibility of a large-scale UK ambulance services trial of optimal defibrillation shock energy for out-of-hospital cardiac arrest. The primary objective of this feasibility study was to establish the number of eligible patients and the number recruited. Secondary outcomes were adherence to allocated treatment and data completeness. Methods We conducted a three-arm parallel group cluster randomised controlled feasibility study in a single ambulance service in southern England. Adult patients in out-of-hospital cardiac arrest treated for a shockable rhythm were included. Zoll X series defibrillators (clusters) were randomised to deliver 120-150-200 J, 150-200-200 J, or 200-200-200 J shock strategies. Results Between March 2022 and February 2023, we randomised 38 eligible patients (120-150-200 J (n = 12), 150-200-200 J (n = 10), 200-200-200 J (n = 16)) to the study. The recruitment rate per cluster was 0.07 per month. The median patient age was 71 years (IQR 59-81 years); 79% were male. Twenty-eight cardiac arrests (74%) occurred in a private residence, 29 (76%) were witnessed and 32 (84%) patients received bystander CPR. Treatment adherence was 93% and completeness of clinical and electrical outcomes was 86%. At 30 days, 3/36 (8.3%) patients survived; we were unable to collect survival outcomes for two patients. Defibrillation data collection became difficult when defibrillators became separated from their allocated vehicles. Conclusion We have demonstrated the feasibility of a cluster randomised controlled trial of optimal shock energy for defibrillation in a UK ambulance service. We have identified possible solutions to issues relating to trial design.
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Affiliation(s)
- Helen Pocock
- South Central Ambulance NHS Foundation Trust, Talisman Way, Bicester, Oxfordshire OX26 6HR, UK
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, Warwickshire, UK
| | - Charles D Deakin
- South Central Ambulance NHS Foundation Trust, Talisman Way, Bicester, Oxfordshire OX26 6HR, UK
- University Hospitals Southampton NHS Foundation Trust, Tremona Road, Southampton, Hampshire, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, Warwickshire, UK
| | - Felix Michelet
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, Warwickshire, UK
| | - Chu Sun
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, Warwickshire, UK
| | - Deb Smith
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, Warwickshire, UK
| | - Catherine Hill
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, Warwickshire, UK
| | - Jeskaran Rai
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, Warwickshire, UK
| | - Kath Starr
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, Warwickshire, UK
| | - Martina Brown
- South Central Ambulance NHS Foundation Trust, Talisman Way, Bicester, Oxfordshire OX26 6HR, UK
| | | | - Gavin D. Perkins
- Warwick Clinical Trials Unit, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, Warwickshire, UK
- University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham B15 2GW, Warwickshire, UK
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2
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Couper K, Ji C, Lall R, Deakin CD, Fothergill R, Long J, Mason J, Michelet F, Nolan JP, Nwankwo H, Quinn T, Slowther AM, Smyth MA, Walker A, Chowdhury L, Norman C, Sprauve L, Starr K, Wood S, Bell S, Bradley G, Brown M, Brown S, Charlton K, Coppola A, Evans C, Evans C, Foster T, Jackson M, Kearney J, Lang N, Mellett-Smith A, Osborne R, Pocock H, Rees N, Spaight R, Tibbetts B, Whitley GA, Wiles J, Williams J, Wright A, Perkins GD. Route of drug administration in out-of-hospital cardiac arrest: A protocol for a randomised controlled trial (PARAMEDIC-3). Resusc Plus 2024; 17:100544. [PMID: 38260121 PMCID: PMC10801302 DOI: 10.1016/j.resplu.2023.100544] [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] [Indexed: 01/24/2024] Open
Abstract
Aims The PARAMEDIC-3 trial evaluates the clinical and cost-effectiveness of an intraosseous first strategy, compared with an intravenous first strategy, for drug administration in adults who have sustained an out-of-hospital cardiac arrest. Methods PARAMEDIC-3 is a pragmatic, allocation concealed, open-label, multi-centre, superiority randomised controlled trial. It will recruit 15,000 patients across English and Welsh ambulance services. Adults who have sustained an out-of-hospital cardiac arrest are individually randomised to an intraosseous access first strategy or intravenous access first strategy in a 1:1 ratio through an opaque, sealed envelope system. The randomised allocation determines the route used for the first two attempts at vascular access. Participants are initially enrolled under a deferred consent model.The primary clinical-effectiveness outcome is survival at 30-days. Secondary outcomes include return of spontaneous circulation, neurological functional outcome, and health-related quality of life. Participants are followed-up to six-months following cardiac arrest. The primary health economic outcome is incremental cost per quality-adjusted life year gained. Conclusion The PARAMEDIC-3 trial will provide key information on the clinical and cost-effectiveness of drug route in out-of-hospital cardiac arrest.Trial registration: ISRCTN14223494, registered 16/08/2021, prospectively registered.
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Affiliation(s)
- Keith Couper
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chen Ji
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Charles D Deakin
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- South Central Ambulance NHS Foundation Trust, Otterbourne, UK
| | - Rachael Fothergill
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Clinical Audit and Research Unit, London Ambulance Service, London, UK
| | - John Long
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - James Mason
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Felix Michelet
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Jerry P Nolan
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Department of Anaesthesia, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Henry Nwankwo
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | | | - Anne-Marie Slowther
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael A Smyth
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Alison Walker
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, UK
- Emergency Department, Harrogate and District NHS Foundation Trust, Harrogate, UK
| | | | - Chloe Norman
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | | | - Kath Starr
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Sara Wood
- Warwick Clinical Trials, University of Warwick, Coventry, UK
| | - Steve Bell
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Gemma Bradley
- Research and Development Department, South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
| | - Martina Brown
- South Central Ambulance NHS Foundation Trust, Otterbourne, UK
| | - Shona Brown
- East of England Ambulance Service NHS Trust, Melbourn, UK
| | - Karl Charlton
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Alison Coppola
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | | | - Christine Evans
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, UK
| | - Theresa Foster
- East of England Ambulance Service NHS Trust, Melbourn, UK
| | - Michelle Jackson
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Justin Kearney
- Clinical Audit and Research Unit, London Ambulance Service, London, UK
| | | | - Adam Mellett-Smith
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Clinical Audit and Research Unit, London Ambulance Service, London, UK
| | - Ria Osborne
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Helen Pocock
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- South Central Ambulance NHS Foundation Trust, Otterbourne, UK
| | - Nigel Rees
- Welsh Ambulance Services NHS Trust, Cwmbran, UK
| | - Robert Spaight
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | | | | | - Jason Wiles
- West Midlands Ambulance Service University NHS Foundation Trust, Brierly Hill, UK
| | - Julia Williams
- Research and Development Department, South East Coast Ambulance Service NHS Foundation Trust, Crawley, UK
- Department of Paramedic Science, University of Hertfordshire, Hatfield, UK
| | - Adam Wright
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Gavin D Perkins
- Warwick Clinical Trials, University of Warwick, Coventry, UK
- Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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3
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Michelet F, Smyth M, Lall R, Noordali H, Starr K, Berridge L, Yeung J, Fuller G, Petrou S, Walker A, Mark J, Canaway A, Khan K, Perkins GD. Randomised controlled trial of analgesia for the management of acute severe pain from traumatic injury: study protocol for the paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN). Scand J Trauma Resusc Emerg Med 2023; 31:84. [PMID: 38001541 PMCID: PMC10668487 DOI: 10.1186/s13049-023-01146-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Prehospital analgesia is often required after traumatic injury, currently morphine is the strongest parenteral analgesia routinely available for use by paramedics in the United Kingdom (UK) when treating patients with severe pain. This protocol describes a multi-centre, randomised, double blinded trial comparing the clinical and cost-effectiveness of ketamine and morphine for severe pain following acute traumatic injury. METHODS A two arm pragmatic, phase III trial working with two large NHS ambulance services, with an internal pilot. Participants will be randomised in equal numbers to either (1) morphine or (2) ketamine by IV/IO injection. We aim to recruit 446 participants over the age of 16 years old, with a self-reported pain score of 7 or above out of 10. Randomised participants will receive a maximum of 20 mg of morphine, or a maximum of 30 mg of ketamine, to manage their pain. The primary outcome will be the sum of pain intensity difference. Secondary outcomes measure the effectiveness of pain relief and overall patient experience from randomisation to arrival at hospital as well as monitoring the adverse events, resource use and cost-effectiveness outcomes. DISCUSSION The PACKMAN study is the first UK clinical trial addressing the clinical and cost-effectiveness of ketamine and morphine in treating acute severe pain from traumatic injury treated by NHS paramedics. The findings will inform future clinical practice and provide insights into the effectiveness of ketamine as a prehospital analgesia. TRIAL REGISTRATION ISRCTN, ISRCTN14124474. Registered 22 October 2020, https://www.isrctn.com/ISRCTN14124474.
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Affiliation(s)
- F Michelet
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.
| | - M Smyth
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - R Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - H Noordali
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - K Starr
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - L Berridge
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - J Yeung
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- Critical Care Directorate, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - G Fuller
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - S Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - A Walker
- West Midlands Ambulance Services NHS Trust, Brierley Hill, Dudley, UK
| | - J Mark
- Yorkshire Ambulance Services NHS Trust, Wakefield, UK
| | - A Canaway
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - K Khan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - G D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- Critical Care Directorate, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Watkins S, Chowdhury FJ, Norman C, Brett SJ, Couper K, Goodwin L, Gould DW, AE. Harrison D, Hossain A, Lall R, Mason J, Nolan JP, Nwankwo H, Perkins GD, Samuel K, Schofield B, Soar J, Starr K, Thomas M, Voss S, Benger JR. Randomised trial of the clinical and cost effectiveness of a supraglottic airway device compared with tracheal intubation for in-hospital cardiac arrest (AIRWAYS-3): Protocol, design and implementation. Resusc Plus 2023; 15:100430. [PMID: 37519411 PMCID: PMC10371816 DOI: 10.1016/j.resplu.2023.100430] [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: 05/13/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 08/01/2023] Open
Abstract
Survival from in-hospital cardiac arrest is approximately 18%, but for patients who require advanced airway management survival is lower. Those who do survive are often left with significant disability. Traditionally, resuscitation of cardiac arrest patients has included tracheal intubation, however insertion of a supraglottic airway has gained popularity as an alternative approach to advanced airway management. Evidence from out-of-hospital cardiac arrest suggests no significant differences in mortality or morbidity between these two approaches, but there is no randomised evidence for airway management during in-hospital cardiac arrest. The aim of the AIRWAYS-3 randomised trial, described in this protocol paper, is to determine the clinical and cost effectiveness of a supraglottic airway versus tracheal intubation during in-hospital cardiac arrest. Patients will be allocated randomly to receive either a supraglottic airway or tracheal intubation as the initial advanced airway management. We will also estimate the relative cost-effectiveness of these two approaches. The primary outcome is functional status, measured using the modified Rankin Scale at hospital discharge or 30 days post-randomisation, whichever occurs first. AIRWAYS-3 presents ethical challenges regarding patient consent and data collection. These include the enrolment of unconscious patients without prior consent in a way that avoids methodological bias. Other complexities include the requirement to randomise patients efficiently during a time-critical cardiac arrest. Many of these challenges are encountered in other emergency care research; we discuss our approaches to addressing them. Trial registration: ISRCTN17720457. Prospectively registered on 29/07/2022.
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Affiliation(s)
- Scott Watkins
- Faculty of Health & Applied Sciences, University of the West of England, Bristol, UK
| | | | - Chloe Norman
- Warwick Clinical Trials Unit, University of Warwick, UK
| | | | - Keith Couper
- Warwick Clinical Trials Unit, University of Warwick, UK
| | - Laura Goodwin
- Faculty of Health & Applied Sciences, University of the West of England, Bristol, UK
| | - Doug W. Gould
- Intensive Care National Audit & Research Centre, London, UK
| | | | | | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, UK
| | - James Mason
- Warwick Clinical Trials Unit, University of Warwick, UK
| | - Jerry P. Nolan
- Warwick Clinical Trials Unit, University of Warwick, UK
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Henry Nwankwo
- Warwick Clinical Trials Unit, University of Warwick, UK
| | | | | | - Behnaz Schofield
- Faculty of Health & Applied Sciences, University of the West of England, Bristol, UK
| | | | - Kath Starr
- Warwick Clinical Trials Unit, University of Warwick, UK
| | - Matthew Thomas
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Sarah Voss
- Faculty of Health & Applied Sciences, University of the West of England, Bristol, UK
| | - Jonathan R. Benger
- Faculty of Health & Applied Sciences, University of the West of England, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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5
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Kilonzo MM, Dasgupta R, Thomas R, Aucott L, MacLennan S, Lam TBL, Anson K, Cameron S, Starr K, Burgess N, Keeley FX, Clark CT, N'Dow J, MacLennan G, McClinton S. Cost-utility analysis of shockwave lithotripsy vs ureteroscopic stone treatment in adults. BJU Int 2023; 131:253-261. [PMID: 35974700 PMCID: PMC10087721 DOI: 10.1111/bju.15862] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To assess the cost-effectiveness, resource use implications, quality-adjusted life-years (QALYs) and cost per QALY of care pathways starting with either extracorporeal shockwave lithotripsy (SWL) or with ureteroscopic retrieval (ureteroscopy [URS]) for the management of ureteric stones. PATIENTS AND METHODS Data on quality of life and resource use for 613 patients, collected prospectively in the Therapeutic Interventions for Stones of the Ureter (TISU) randomized controlled trial (ISRCTN 92289221), were used to assess the cost-effectiveness of two care pathways, SWL and URS. A health provider (UK National Health Service) perspective was adopted to estimate the costs of the interventions and subsequent resource use. Quality-of-life data were calculated using a generic instrument, the EuroQol EQ-5D-3L. Results are expressed as incremental cost-effectiveness ratios and cost-effectiveness acceptability curves. RESULTS The mean QALY difference (SWL vs URS) was -0.021 (95% confidence interval [CI] -0.033 to -0.010) and the mean cost difference was -£809 (95% CI -£1061 to -£551). The QALY difference translated into approximately 10 more healthy days over the 6-month period for the patients on the URS care pathway. The probabaility that SWL is cost-effective is 79% at a society's willingness to pay (WTP) threshold for 1 QALY of £30,000 and 98% at a WTP threshold of £20,000. CONCLUSION The SWL pathway results in lower QALYs than URS but costs less. The incremental cost per QALY is £39 118 cost saving per QALY lost, with a 79% probability that SWL would be considered cost-effective at a WTP threshold for 1 QALY of £30 000 and 98% at a WTP threshold of £20 000. Decision-makers need to determine if costs saved justify the loss in QALYs.
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Affiliation(s)
- Mary M Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Ranan Dasgupta
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Ruth Thomas
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sara MacLennan
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Thomas Boon L Lam
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Ken Anson
- Department of Urology, St Georges University Hospitals NHS Foundation Trust, London, UK
| | - Sarah Cameron
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Kath Starr
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Neil Burgess
- Department of Urology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | - Charles T Clark
- BAUS Section of Endourology Consumer/Patient Advisory Group, London, UK
| | - James N'Dow
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Sam McClinton
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
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Day F, Wyatt L, Bhardwaj A, Dubicka B, Ewart C, Gledhill J, James M, Lang A, Marshall T, Montgomery A, Reynolds S, Sprange K, Thomson L, Bradley E, Lathe J, Newman K, Partlett C, Starr K, Sayal K. STAndardised DIagnostic Assessment for children and young people with emotional difficulties (STADIA): protocol for a multicentre randomised controlled trial. BMJ Open 2022; 12:e053043. [PMID: 35545388 PMCID: PMC9096530 DOI: 10.1136/bmjopen-2021-053043] [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: 11/08/2022] Open
Abstract
INTRODUCTION Emotional disorders (such as anxiety and depression) are associated with considerable distress and impairment in day-to-day function for affected children and young people and for their families. Effective evidence-based interventions are available but require appropriate identification of difficulties to enable timely access to services. Standardised diagnostic assessment (SDA) tools may aid in the detection of emotional disorders, but there is limited evidence on the utility of SDA tools in routine care and equipoise among professionals about their clinical value. METHODS AND ANALYSIS A multicentre, two-arm, parallel group randomised controlled trial, with embedded qualitative and health economic components. Participants will be randomised in a 1:1 ratio to either the Development and Well-Being Assessment SDA tool as an adjunct to usual clinical care, or usual care only. A total of 1210 participants (children and young people referred to outpatient, specialist Child and Adolescent Mental Health Services with emotional difficulties and their parent/carers) will be recruited from at least 6 sites in England. The primary outcome is a clinician-made diagnosis about the presence of an emotional disorder within 12 months of randomisation. Secondary outcomes include referral acceptance, diagnosis and treatment of emotional disorders, symptoms of emotional difficulties and comorbid disorders and associated functional impairment. ETHICS AND DISSEMINATION The study received favourable opinion from the South Birmingham Research Ethics Committee (Ref. 19/WM/0133). Results of this trial will be reported to the funder and published in full in the Health Technology Assessment (HTA) Journal series and also submitted for publication in a peer reviewed journal. TRIAL REGISTRATION NUMBER ISRCTN15748675; Pre-results.
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Affiliation(s)
- Florence Day
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Laura Wyatt
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Anupam Bhardwaj
- Cambridgeshire and Peterborough NHS Foundation Trust, Fulbourn, UK
| | - Bernadka Dubicka
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
- Pennine Care NHS Foundation Trust, Ashton-under-Lyne, UK
| | - Colleen Ewart
- STADIA Patient and Public Involvement co-lead, Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Julia Gledhill
- Central and North West London NHS Foundation Trust, London, UK
| | - Marilyn James
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alexandra Lang
- Faculty of Engineering, University of Nottingham, Nottingham, UK
| | | | - Alan Montgomery
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Shirley Reynolds
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Louise Thomson
- Unit of Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Ellen Bradley
- Unit of Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - James Lathe
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kristina Newman
- Institute of Mental Health, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
| | - Chris Partlett
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kath Starr
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kapil Sayal
- Unit of Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Institute of Mental Health, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
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7
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Dasgupta R, Cameron S, Aucott L, MacLennan G, Kilonzo MM, Lam TBL, Thomas R, Norrie J, McDonald A, Anson K, N’Dow J, Burgess N, Clark CT, Keeley FX, MacLennan SJ, Starr K, McClinton S. Shockwave lithotripsy compared with ureteroscopic stone treatment for adults with ureteric stones: the TISU non-inferiority RCT. Health Technol Assess 2022; 26:1-70. [PMID: 35301982 PMCID: PMC8958411 DOI: 10.3310/wuzw9042] [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: 11/22/2022] Open
Abstract
BACKGROUND Urinary stone disease affects 2-3% of the general population. Ureteric stones are associated with severe pain and can have a significant impact on a patient's quality of life. Most ureteric stones are expected to pass spontaneously with supportive care; however, between one-fifth and one-third of patients require an active intervention. The two standard interventions are shockwave lithotripsy and ureteroscopic stone treatment. Both treatments are effective, but they differ in terms of invasiveness, anaesthetic requirement, treatment setting, number of procedures, complications, patient-reported outcomes and cost. There is uncertainty around which is the more clinically effective and cost-effective treatment. OBJECTIVES To determine if shockwave lithotripsy is clinically effective and cost-effective compared with ureteroscopic stone treatment in adults with ureteric stones who are judged to require active intervention. DESIGN A pragmatic, multicentre, non-inferiority, randomised controlled trial of shockwave lithotripsy as a first-line treatment option compared with primary ureteroscopic stone treatment for ureteric stones. SETTING Urology departments in 25 NHS hospitals in the UK. PARTICIPANTS Adults aged ≥ 16 years presenting with a single ureteric stone in any segment of the ureter, confirmed by computerised tomography, who were able to undergo either shockwave lithotripsy or ureteroscopic stone treatment and to complete trial procedures. INTERVENTION Eligible participants were randomised 1 : 1 to shockwave lithotripsy (up to two sessions) or ureteroscopic stone treatment. MAIN OUTCOME MEASURES The primary clinical outcome measure was resolution of the stone episode (stone clearance), which was operationally defined as 'no further intervention required to facilitate stone clearance' up to 6 months from randomisation. This was determined from 8-week and 6-month case report forms and any additional hospital visit case report form that was completed by research staff. The primary economic outcome measure was the incremental cost per quality-adjusted life-year gained at 6 months from randomisation. We estimated costs from NHS resources and calculated quality-adjusted life-years from participant completion of the EuroQol-5 Dimensions, three-level version, at baseline, pre intervention, 1 week post intervention and 8 weeks and 6 months post randomisation. RESULTS In the shockwave lithotripsy arm, 67 out of 302 (22.2%) participants needed further treatment. In the ureteroscopic stone treatment arm, 31 out of 302 (10.3%) participants needed further treatment. The absolute risk difference was 11.4% (95% confidence interval 5.0% to 17.8%); the upper bound of the 95% confidence interval ruled out the prespecified margin of non-inferiority (which was 20%). The mean quality-adjusted life-year difference (shockwave lithotripsy vs. ureteroscopic stone treatment) was -0.021 (95% confidence interval 0.033 to -0.010) and the mean cost difference was -£809 (95% confidence interval -£1061 to -£551). The probability that shockwave lithotripsy is cost-effective is 79% at a threshold of society's willingness to pay for a quality-adjusted life-year of £30,000. The CEAC is derived from the joint distribution of incremental costs and incremental effects. Most of the results fall in the south-west quadrant of the cost effectiveness plane as SWL always costs less but is less effective. LIMITATIONS A limitation of the trial was low return and completion rates of patient questionnaires. The study was initially powered for 500 patients in each arm; however, the total number of patients recruited was only 307 and 306 patients in the ureteroscopic stone treatment and shockwave lithotripsy arms, respectively. CONCLUSIONS Patients receiving shockwave lithotripsy needed more further interventions than those receiving primary ureteroscopic retrieval, although the overall costs for those receiving the shockwave treatment were lower. The absolute risk difference between the two clinical pathways (11.4%) was lower than expected and at a level that is acceptable to clinicians and patients. The shockwave lithotripsy pathway is more cost-effective in an NHS setting, but results in lower quality of life. FUTURE WORK (1) The generic health-related quality-of-life tools used in this study do not fully capture the impact of the various treatment pathways on patients. A condition-specific health-related quality-of-life tool should be developed. (2) Reporting of ureteric stone trials would benefit from agreement on a core outcome set that would ensure that future trials are easier to compare. TRIAL REGISTRATION This trial is registered as ISRCTN92289221. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 19. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ranan Dasgupta
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Sarah Cameron
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Mary M Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Thomas BL Lam
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Ruth Thomas
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Alison McDonald
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Ken Anson
- Department of Urology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - James N’Dow
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Neil Burgess
- Department of Urology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Charles T Clark
- Stone Patient Advisory Group, Section of Endourology, British Association of Urological Surgeons, London, UK
| | - Francis X Keeley
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | | | - Kath Starr
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Samuel McClinton
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
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Dasgupta R, Cameron S, Aucott L, Maclennan G, Thomas R, N’dow J, Norrie J, Anson K, Keeley F, Maclennan S, Starr K, Mcclinton S. TISU (Therepeutic Intervention for Stones in the Ureter): ESWL versus Ureteroscopy, a multicentre RCT. Eur Urol 2021. [DOI: 10.1016/s0302-2838(21)00660-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Dasgupta R, Cameron S, Aucott L, MacLennan G, Thomas RE, Kilonzo MM, Lam TBL, N'Dow J, Norrie J, Anson K, Burgess N, Clark CT, Keeley FX, MacLennan SJ, Starr K, McClinton S. Shockwave Lithotripsy Versus Ureteroscopic Treatment as Therapeutic Interventions for Stones of the Ureter (TISU): A Multicentre Randomised Controlled Non-inferiority Trial. Eur Urol 2021; 80:46-54. [PMID: 33810921 PMCID: PMC8234516 DOI: 10.1016/j.eururo.2021.02.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 02/26/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Renal stone disease is common and can cause emergency presentation with acute pain due to ureteric colic. International guidelines have stated the need for a multicentre randomised controlled trial (RCT) to determine whether a non-invasive outpatient (shockwave lithotripsy [SWL]) or surgical (ureteroscopy [URS]) intervention should be the first-line treatment for those needing active intervention. This has implications for shaping clinical pathways. OBJECTIVE To report a pragmatic multicentre non-inferiority RCT comparing SWL with URS. DESIGN, SETTING, AND PARTICIPANTS This trial tested for non-inferiority of up to two sessions of SWL compared with URS as initial treatment for ureteric stones requiring intervention. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was whether further intervention was required to clear the stone, and secondary outcomes included quality of life assessment, severity of pain, and serious complications; these were based on questionnaires at baseline, 8 wk, and 6 mo. We included patients over 16 yr with a single ureteric stone clinically deemed to require intervention. Intention-to-treat and per-protocol analyses were planned. RESULTS AND LIMITATIONS The study recruited between July 1, 2013 and June 30, 2017. We recruited 613 participants from a total of 1291 eligible patients, randomising 306 to SWL and 307 to URS. Sixty-seven patients (22.1%) in the SWL arm needed further treatment compared with 31 patients (10.3%) in the URS arm. The absolute risk difference was 11.7% (95% confidence interval 5.6%, 17.8%) in favour of URS, which was inside the 20% threshold we set for demonstrating noninferiority of SWL. CONCLUSIONS This RCT was designed to test whether SWL is non-inferior to URS and confirmed this; although SWL is an outpatient noninvasive treatment with potential advantages both for patients and for reducing the use of inpatient health care resources, the trial showed a benefit in overall clinical outcomes with URS compared with SWL, reflecting contemporary practice. The Therapeutic Interventions for Stones of the Ureter (TISU) study provides new evidence to help guide the choice of modality for this common health condition. PATIENT SUMMARY We present the largest trial comparing ureteroscopy versus extracorporeal shockwave lithotripsy for ureteric stones. While ureteroscopy had marginally improved outcome in terms of stone clearance, as expected, shockwave lithotripsy had better results in terms of health care costs. These results should enable patients and health care providers to optimise treatment pathways for this common urological condition.
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Affiliation(s)
- Ranan Dasgupta
- Department of Urology, Imperial College Healthcare NHS Trust, London, W2 1NY, UK.
| | - Sarah Cameron
- Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Ruth E Thomas
- Centre for Healthcare Randomised Trials, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Mary M Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Thomas B L Lam
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK; Academic Urology Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - James N'Dow
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences & Informatics, University of Edinburgh, Edinburgh, UK
| | - Ken Anson
- Department of Urology, St Georges University Hospitals NHS Foundation Trust, London, UK
| | - Neil Burgess
- Department of Urology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Charles T Clark
- Stone Patient Advisory Group, Section of Endourology, British Association of Urological Surgeons, London, UK
| | - Francis X Keeley
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - Sara J MacLennan
- Academic Urology Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Kath Starr
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, UK
| | - Sam McClinton
- NHS Grampian, Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
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Crowley E, Treweek S, Banister K, Breeman S, Constable L, Cotton S, Duncan A, El Feky A, Gardner H, Goodman K, Lanz D, McDonald A, Ogburn E, Starr K, Stevens N, Valente M, Fernie G. Using systematic data categorisation to quantify the types of data collected in clinical trials: the DataCat project. Trials 2020; 21:535. [PMID: 32546192 PMCID: PMC7298750 DOI: 10.1186/s13063-020-04388-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 05/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Data collection consumes a large proportion of clinical trial resources. Each data item requires time and effort for collection, processing and quality control procedures. In general, more data equals a heavier burden for trial staff and participants. It is also likely to increase costs. Knowing the types of data being collected, and in what proportion, will be helpful to ensure that limited trial resources and participant goodwill are used wisely. AIM The aim of this study is to categorise the types of data collected across a broad range of trials and assess what proportion of collected data each category represents. METHODS We developed a standard operating procedure to categorise data into primary outcome, secondary outcome and 15 other categories. We categorised all variables collected on trial data collection forms from 18, mainly publicly funded, randomised superiority trials, including trials of an investigational medicinal product and complex interventions. Categorisation was done independently in pairs: one person having in-depth knowledge of the trial, the other independent of the trial. Disagreement was resolved through reference to the trial protocol and discussion, with the project team being consulted if necessary. KEY RESULTS Primary outcome data accounted for 5.0% (median)/11.2% (mean) of all data items collected. Secondary outcomes accounted for 39.9% (median)/42.5% (mean) of all data items. Non-outcome data such as participant identifiers and demographic data represented 32.4% (median)/36.5% (mean) of all data items collected. CONCLUSION A small proportion of the data collected in our sample of 18 trials was related to the primary outcome. Secondary outcomes accounted for eight times the volume of data as the primary outcome. A substantial amount of data collection is not related to trial outcomes. Trialists should work to make sure that the data they collect are only those essential to support the health and treatment decisions of those whom the trial is designed to inform.
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Affiliation(s)
- Evelyn Crowley
- Health Research Board Clinical Research Facility, University of Cork, Cork, Ireland
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
| | - Katie Banister
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Suzanne Breeman
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Lynda Constable
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Seonaidh Cotton
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Anne Duncan
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Adel El Feky
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Heidi Gardner
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Kirsteen Goodman
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Doris Lanz
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Alison McDonald
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Emma Ogburn
- Primary Care Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Kath Starr
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Natasha Stevens
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Marie Valente
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Gordon Fernie
- Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Breeman S, Constable L, Duncan A, Starr K, McDonald A, Wileman S, Cotton S. Verifying participant-reported clinical outcomes: challenges and implications. Trials 2020; 21:241. [PMID: 32131888 PMCID: PMC7057615 DOI: 10.1186/s13063-020-4169-7] [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: 07/03/2019] [Accepted: 02/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background Researchers often rely on trial participants to self-report clinical outcomes (for example, fractures, re-operations). Little information exists as to the ‘accuracy’ of participant-reported clinical outcomes, particularly in randomised controlled trials (RCTs). To help address this evidence gap, we report four case studies, nested within different RCTs where participant-reported clinical outcome data were compared with those reported by clinicians or extracted from medical notes. Methods Four publicly-funded RCTs with different methods of verifying participant-reported outcomes were identified. In KAT, the participants were asked about hospital admissions for any reason. Where it was thought to be relevant to the trial knee, further information was sought from the lead surgeon at the admitting site to confirm whether or not the admission was relevant to the trial knee. In REFLUX, participants were asked about hospital admissions for any reason. For participants who reported a re-operation, further information was sought from the lead surgeon at the admitting site to confirm this. In RECORD, participants were asked three questions regarding broken bones. Where low-trauma fractures were reported, clinical verification was sought, initially from the research nurse at the site. In CATHETER, participants were asked about urinary tract infections (UTIs), and a prescription of antibiotics was provided for the treatment of UTIs following urethral catheterisation. The GPs of those who reported a UTI were contacted to confirm that an antibiotic prescription had been issued for the suspected UTI. Results In KAT, 397 of 6882 (6%) participant-reported hospital admissions were confirmed as relevant to the trial knee. In REFLUX, 16 of 19 participants (84%) who appeared to have had a re-operation were confirmed as having had one. In RECORD, 473 of 781 (61%) fractures reported by participants were confirmed as being low-trauma fractures. In CATHETER, 429 of 830 participant-reported UTIs (52%) were confirmed as such by the GPs. Conclusions We used different approaches in our verification of participant-reported outcomes in clinical trials, and we believe there is no one optimal solution. Consideration of issues such as what information is sought from participants, the phrasing of questions, whether the medical records are a true ‘gold standard’ and costs and benefits to the RCT may help determine the appropriate approach.
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Affiliation(s)
- Suzanne Breeman
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit (HSRU), University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, Scotland
| | - Lynda Constable
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit (HSRU), University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, Scotland.
| | - Anne Duncan
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit (HSRU), University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, Scotland
| | - Kath Starr
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit (HSRU), University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, Scotland
| | - Alison McDonald
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit (HSRU), University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, Scotland
| | - Samantha Wileman
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit (HSRU), University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, Scotland
| | - Seonaidh Cotton
- Centre for Healthcare Randomised Trials (CHaRT), Health Services Research Unit (HSRU), University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, Scotland
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Starr K, McPherson G, Forrest M, Cotton S. SMS text pre-notification and delivery of reminder e-mails to increase response rates to postal questionnaires: a factorial design, randomised, controlled trial. Trials 2015. [PMCID: PMC4660180 DOI: 10.1186/1745-6215-16-s2-p88] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Pickard R, Lam T, MacLennan G, Starr K, Kilonzo M, McPherson G, Gillies K, McDonald A, Walton K, Buckley B, Glazener C, Boachie C, Burr J, Norrie J, Vale L, Grant A, N'Dow J. Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised controlled trial. Lancet 2012; 380:1927-35. [PMID: 23134837 DOI: 10.1016/s0140-6736(12)61380-4] [Citation(s) in RCA: 152] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Catheter-associated urinary tract infection (CAUTI) is a major preventable cause of harm for patients in hospital. We aimed to establish whether short-term routine use of antimicrobial catheters reduced risk of CAUTI compared with standard polytetrafluoroethylene (PTFE) catheterisation. METHODS In our parallel, three group, multicentre, randomised controlled superiority trial, we enrolled adults (aged ≥16 years) requiring short-term (≤14 days) catheterisation at 24 hospitals in the UK. Participants were randomly allocated 1:1:1 with a remote computer allocation to receive a silver alloy-coated catheter, a nitrofural-impregnated catheter, or a PTFE-coated catheter (control group). Patients undergoing unplanned catheterisation were also included and consent for participation was obtained retrospectively. Participants and trial staff were unmasked to treatment assignment. Data were collected by trial staff and by patient-reported questionnaires for 6 weeks after randomisation. The primary outcome was incidence of symptomatic urinary tract infection for which an antibiotic was prescribed by 6 weeks. We postulated that a 3·3% absolute reduction in CAUTI would represent sufficient benefit to recommend routine use of antimicrobial catheters. This study is registered, number ISRCTN75198618. FINDINGS 708 (10%) of 7102 randomly allocated participants were not catheterised, did not confirm consent, or withdrew, and were not included in the primary analyses. Compared with 271 (12·6%) of 2144 participants in the control group, 263 (12·5%) of 2097 participants allocated a silver alloy catheter had the primary outcome (difference -0·1% [95% CI -2·4 to 2·2]), as did 228 (10·6%) of 2153 participants allocated a nitrofural catheter (-2·1% [-4·2 to 0·1]). Rates of catheter-related discomfort were higher in the nitrofural group than they were in the other groups. INTERPRETATION Silver alloy-coated catheters were not effective for reduction of incidence of symptomatic CAUTI. The reduction we noted in CAUTI associated with nitrofural-impregnated catheters was less than that regarded as clinically important. Routine use of antimicrobial-impregnated catheters is not supported by this trial. FUNDING UK National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Robert Pickard
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
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Pickard R, Lam T, MacLennan G, Starr K, Kilonzo M, McPherson G, Gillies K, McDonald A, Walton K, Buckley B, Glazener C, Boachie C, Burr J, Norrie J, Vale L, Grant A, N’Dow J. Types of urethral catheter for reducing symptomatic urinary tract infections in hospitalised adults requiring short-term catheterisation: multicentre randomised controlled trial and economic evaluation of antimicrobial- and antiseptic-impregnated urethral catheters (the CATHETER trial). Health Technol Assess 2012. [DOI: 10.3310/hta16470] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- R Pickard
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Breeman S, McDonald A, McPherson G, MacLennan G, Campbell M, Starr K, Cotton S. Patient reported clinical outcomes: the challenges and implications for randomised controlled trials. Trials 2011. [PMCID: PMC3287791 DOI: 10.1186/1745-6215-12-s1-a72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Duxon MS, Stretton J, Starr K, Jones DN, Holland V, Riley G, Jerman J, Brough S, Smart D, Johns A, Chan W, Porter RA, Upton N. Evidence that orexin-A-evoked grooming in the rat is mediated by orexin-1 (OX1) receptors, with downstream 5-HT2C receptor involvement. Psychopharmacology (Berl) 2001; 153:203-9. [PMID: 11205420 DOI: 10.1007/s002130000550] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
RATIONALE Orexins A and B have recently been discovered and shown to be derived from preproorexin, primarily expressed in the rat hypothalamus. Orexin-A has been ascribed a number of in vivo functions in the rat after intracerebroventricular (ICV) administration, including hyperphagia, neuroendocrine modulation and, most recently, evidence for a behavioural response characterised by an increase in grooming. OBJECTIVES Here, we have investigated the orexin-receptor subtypes involved in the grooming response to orexin-A (3 microg, ICV) in the rat. METHODS Male rats, habituated to clear Perspex behavioural observation boxes, were pretreated with antagonists with mixed selectivity for OX1, OX2, 5-HT2B and 5-HT2C receptor subtypes prior to the administration of orexin-A and the intense grooming response elicited by this peptide assessed. RESULTS Pretreatment of rats with a mixed OX1/5-HT2B/2C receptor antagonist 1-(4-methylsulfanylphenyl)-3-quinolin-4-ylurea (SB-284422), revealed a significant, but incomplete, blockade of orexin-A-induced grooming. Despite the low potency of orexin-A at 5-HT2B and 5-HT2C receptors in vitro (pKi<5), studies were undertaken to determine whether downstream 5-HT2B or 5-HT2C receptors mediate in the grooming-elicited by orexin-A. Whilst the selective 5-HT2B receptor antagonist, SB-215505 (3 mg/kg, PO, 5-HT2B, pKi=8.58; OX1, pKB < 5.15) failed to effect orexin-A-induced grooming, the selective 5-HT2C receptor antagonist, SB-242084 (1 mg/kg, IP, 5-HT2C, pKi = 8.95; OX1, pKB < 5.1) potently antagonised the grooming response to this peptide. This suggested that the partial blockade of orexin-A-induced grooming obtained with SB-284422 might be attributable to its 5-HT2C and/or OX1 receptor blocking activity. However, complete blockade of orexin-A-induced grooming by the subsequently identified selective OX1 receptor antagonist 1-(2-methylbenzoxazol-6-yl)-3-[1,5]naphthyridin-4-yl urea hydrochloride, SB-334867-A (OX1, pKB = 7.4; OX2, pKB = 5.7), devoid of appreciable affinity for either 5-HT2B (pKi < 5.3) or 5-HT2C (pKi < 5.4) receptors, provides the first definitive evidence that a central behavioural effect of orexin-A (grooming) is mediated by OX1 receptors. CONCLUSIONS This data suggests that orexin-A indirectly activates 5-HT2C receptors downstream from OX1 receptors to elicit grooming in the rat. The use of SB-334867-A in vivo will enable the role of OX,1 receptors within the rat central nervous system to be further characterised.
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Affiliation(s)
- M S Duxon
- Neuroscience Research, SmithKline Beecham Pharmaceuticals, Harlow, Essex, UK.
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Schanberg LE, Sandstrom MJ, Starr K, Gil KM, Lefebvre JC, Keefe FJ, Affleck G, Tennen H. The relationship of daily mood and stressful events to symptoms in juvenile rheumatic disease. Arthritis Care Res 2000; 13:33-41. [PMID: 11094924 DOI: 10.1002/1529-0131(200002)13:1<33::aid-art6>3.0.co;2-s] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES The purpose of this study was 3-fold: 1) to assess the feasibility of a daily diary for use with children with juvenile rheumatic disease (JRD), 2) to describe daily variation in mood, stressful events, and symptoms in children with JRD, and 3) to examine the extent to which daily mood and daily stressful events predict daily symptoms in children with JRD. METHODS Twelve children with JRD completed a daily booklet for 7 days. The daily booklet included measures of daily mood, daily stressful events, daily symptoms, and daily function. The children also completed a visual analog scale for pain and the Children's Depression Inventory. RESULTS Subjects showed good compliance with scheduled completion and return of the daily diaries. Results indicated that children with JRD showed variability in daily mood, frequency of daily stressful events, and daily symptoms across days. Multilevel fixed effects models showed that more negative daily mood and more daily stressful events significantly predicted increased reports of fatigue, stiffness, and cutting back on daily activities. Negative daily mood also correlated with increases in daily reported pain. CONCLUSIONS These results indicate that daily diary research is both feasible and potentially informative in children with JRD. Our data emphasize the need for further investigation into the role of daily mood and daily stressful events on disease course in JRD.
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Affiliation(s)
- L E Schanberg
- Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA
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Lefebvre JC, Keefe FJ, Affleck G, Raezer LB, Starr K, Caldwell DS, Tennen H. The relationship of arthritis self-efficacy to daily pain, daily mood, and daily pain coping in rheumatoid arthritis patients. Pain 1999; 80:425-35. [PMID: 10204758 DOI: 10.1016/s0304-3959(98)00242-5] [Citation(s) in RCA: 117] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There is an increasing awareness in the medical community that psychosocial variables such as beliefs in self-efficacy are important determinants of treatment outcome. However, before measures of self-efficacy are widely incorporated into clinical practice, there needs to be a better understanding of how they relate to daily pain, mood and coping. In the present study 128 rheumatoid arthritis patients completed diaries for 30 days in which they provided daily ratings of joint pain, negative and positive mood, the use of pain coping strategies, and coping efficacy. The patients then participated in an evaluation session during which measures of self-efficacy (the Arthritis Self Efficacy Scale (ASES)), demographic variables, and medical status were collected. A series of hierarchical regression analyses was conducted to determine the degree to which self-efficacy measures collected at the time of the evaluation session were related to daily diary measures collected during the 30 preceding days. The results revealed that self-efficacy was significantly related to daily ratings of pain, mood, coping and coping efficacy. Interestingly, the findings regarding self-efficacy were obtained even after taking into account the effects of important demographic and medical status variables. Taken together, these results suggest that self-efficacy ratings collected from arthritis patients at the time of an evaluation session may well be related to recent experiences of daily pain and mood, as well as the daily use and perceived effectiveness of pain coping strategies.
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Affiliation(s)
- J C Lefebvre
- Department of Psychology, Ohio University, Athens 45701, USA
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Lutgendorf SK, Antoni MH, Ironson G, Starr K, Costello N, Zuckerman M, Klimas N, Fletcher MA, Schneiderman N. Changes in cognitive coping skills and social support during cognitive behavioral stress management intervention and distress outcomes in symptomatic human immunodeficiency virus (HIV)-seropositive gay men. Psychosom Med 1998; 60:204-14. [PMID: 9560871 DOI: 10.1097/00006842-199803000-00017] [Citation(s) in RCA: 182] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We have previously reported decreases in dysphoria, anxiety, and total mood disturbance in symptomatic HIV seropositive gay men after a 10-week cognitive behavioral stress management (CBSM) group intervention. This structured intervention was designed a) to increase cognitive and behavioral coping skills related to managing the distress of symptomatic HIV, and b) to increase social support among group members. Here we examine the relative contribution of changes in coping skills and social support during the intervention period to reductions in dysphoria, anxiety, and distress-related symptoms in this sample. METHODS Participants were randomized to a 10-week CBSM group intervention or to a wait-list control condition. Coping, social supports, and mood were measured before and after the intervention period. RESULTS Members of the CBSM group (N = 22) showed significant improvement in cognitive coping strategies involving positive reframing and acceptance, and in social supports involving attachment, alliances, and guidance at the end of the 10-week CBSM program compared with controls (N = 18) who showed decrements in these coping abilities and no changes in social support. Improved cognitive coping, specifically acceptance of the HIV infection, was strongly related to lower dysphoria, anxiety, and total mood disturbance in both conditions. Changes in social support and in cognitive coping skills seem to mediate the effects of the experimental condition on the changes in distress noted during the intervention. CONCLUSIONS These results suggest that cognitive coping and social support factors can be modified by psychosocial interventions and may be important determinants of the changes in psychological well-being and quality of life during symptomatic HIV infection that can be achieved through this form of intervention.
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Affiliation(s)
- S K Lutgendorf
- Department of Psychology, University of Miami, Coral Gables, Florida 33124-2070, USA
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Abstract
The OX2 membrane glycoprotein contains two immunoglobulin superfamily (IgSF) domains and seems likely to interact with other cell surface proteins. A soluble chimeric protein with the two IgSF domains of OX2 engineered onto domains 3 + 4 of rat CD4 antigen was expressed. To detect possible weak interactions, the chimeric protein was coupled to fluorescent covaspheres to provide a highly avid display of OX2. The OX2 covaspheres bound macrophages but not other cell types. The specificity of the interaction was demonstrated by blocking with Fab fragments of the OX2 monoclonal antibody (mAb). A new mAb, MRC OX88, was raised against macrophages which also blocked the interaction and presumably recognizes the ligand. The epitope for the MRC OX2 mAb and a site for ligand binding were mapped to domain 1 by site-directed mutagenesis. The OX2 antigen is present on thymocytes, some lymphocytes, neurons and endothelial cells; thus, it has the potential to mediate interactions between these cell types and macrophages.
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Affiliation(s)
- S Preston
- MCR Cellular Immunology Unit, Sir William Dunn School of Pathology, Oxford, GB
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Lutgendorf SK, Antoni MH, Ironson G, Klimas N, Kumar M, Starr K, McCabe P, Cleven K, Fletcher MA, Schneiderman N. Cognitive-behavioral stress management decreases dysphoric mood and herpes simplex virus-type 2 antibody titers in symptomatic HIV-seropositive gay men. J Consult Clin Psychol 1997; 65:31-43. [PMID: 9103732 DOI: 10.1037/0022-006x.65.1.31] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study tested the effects of a 10-week group cognitive-behavioral stress management (CBSM) intervention on mood and immunologic parameters in HIV-seropositive gay men whose disease had progressed to a symptomatic stage. Men were randomized to either CBSM or a modified waiting-list control group. The CBSM intervention significantly decreased self-reported dysphoria, anxiety, and total distress. Individuals who practiced relaxation more consistently had significantly greater drops in dysphoria. The intervention also decreased herpes simplex virus-Type 2 (HSV-2) immunoglobulin G antibody titers. The control group showed no significant changes in either mood or antibody titers. Individual difference analyses revealed that decreases in dysphoria significantly predicted lower HSV-2 antibody titers by the end of the 10-week period. Neither group displayed changes in HSV-Type 1 antibody titers or in CD4+ or CD8+ cell numbers.
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Affiliation(s)
- S K Lutgendorf
- Department of Psychology, University of Miami, Coral Gables, Florida 33124-2070, USA
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Abstract
Data from daily diaries were used to analyze pain coping processes in rheumatoid arthritis patients. For 30 consecutive days, 53 individuals described the pain coping strategies they used that day and rated the efficacy of their coping, joint pain, and positive and negative mood. Relations among variables were examined across-persons and within-persons over time. At the across-persons level of analysis, (i) daily coping efficacy was unrelated to pain coping or pain intensity, and (ii) the more frequent daily use of a wide variety of pain coping strategies was correlated with greater pain. Within-person analyses provided unique information about the relations among coping, pain, and mood not apparent in the across-persons results. Specifically, these analyses showed that increases in daily coping efficacy were not only related to decreases in pain, but also to decreases in negative mood and increases in positive mood. Time-lagged effects of coping and coping efficacy were also found. Individuals who reported high levels of coping efficacy on one day had lower levels of pain on the subsequent day. The daily use of pain reduction efforts and relaxation strategies also contributed to an improvement in next-day pain and an enhancement of positive mood. The implications of these findings for the assessment of pain and coping in rheumatoid arthritis patients are discussed.
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Affiliation(s)
- F J Keefe
- Management Program, Duke University Medical Center, Durham, NC 27710, USA
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Hasslen SR, Burns AR, Simon SI, Smith CW, Starr K, Barclay AN, Michie SA, Nelson RD, Erlandsen SL. Preservation of spatial organization and antigenicity of leukocyte surface molecules by aldehyde fixation: flow cytometry and high-resolution FESEM studies of CD62L, CD11b, and Thy-1. J Histochem Cytochem 1996; 44:1115-22. [PMID: 8813076 DOI: 10.1177/44.10.8813076] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
We used transmission and scanning electron microscopy in conjunction with immunogold labeling to study cell surface molecules for evidence of distribution-function relationships. Ascription of functional significance to surface distribution therefore requires preservation of cell morphology and maintenance of molecular expression and distribution through the multiple steps of cell preparation. These requirements prompted us to compare two methods for preparing leukocytes for analysis of surface molecule distribution: one method involved using low temperature to "stabilize" cell morphology and surface molecular organization through immunolabeling; the other involved fixation of the cells with dilute glutaraldehyde before their isolation and labeling. Binding of primary antibodies to several surface molecules, measured by flow cytometry, was comparable for cells prepared by the two methods. Cell morphology and molecular distributions, assessed by high-resolution field emission SEM, were likewise comparable. These results support the conclusion that cell morphologies and CAM distributions previously reported were not affected by exposure of the cells to low temperature through isolation and immunolabeling. Our additional observation that Thy-1 is expressed on both non-projecting and projecting membrane domains of mouse lymph node lymphocytes and rat thymocytes represents a third and new pattern of surface molecule distribution.
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Affiliation(s)
- S R Hasslen
- Department of Laboratory Medicine and Pathology, University of Minnesota School of Medicine, Minneapolis 55455, USA
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Starr K, Renneker M. A cytologic evaluation of sputum in marijuana smokers. J Fam Pract 1994; 39:359-363. [PMID: 7931115] [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] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
BACKGROUND There is growing evidence that smoking marijuana produces pulmonary effects similar to those of smoking tobacco. Cytologic analysis of sputum is readily available to practicing physicians and may be used in evaluating the pulmonary health of marijuana smokers. This study examined the use of sputum cytologic testing in young, athletic, marijuana-only smokers. METHODS Sputum samples were collected from 25 marijuana-smoking members (surfers) who live in rural areas and do not smoke tobacco (mean age 27.5 years). The samples from the study group were compared with the sputum samples of 25 urban tobacco smokers and 25 nonsmokers of similar ages. Components of sputum were analyzed quantitatively and qualitatively. Subjects were educated and counseled as to the results. RESULTS Compared with nonsmokers, marijuana smokers showed significantly higher levels of all pathologic components (P < .05), but lower mean levels of neutrophils (5.4 vs 6.4, P = .005) and pigmented macrophages (4.9 vs 6.1, P < .001) than those of tobacco smokers. Two cases of dysplasia were noted among the tobacco smokers and one among the marijuana smokers. Test-result counseling of a limited data set (6 subjects) at 6 months resulted in a 50% self-reported cessation rate. CONCLUSIONS In this pilot study, results of cytologic evaluations in marijuana smokers closely resembled those observed in tobacco smokers. Further studies are needed to determine longitudinal and dose-related effects of marijuana smoking on cytologic changes. As a noninvasive testing method, sputum cytologic analysis may be a useful tool for evaluating the pulmonary health of marijuana smokers and may present an opportunity to counsel them on the benefits of cessation.
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Affiliation(s)
- K Starr
- Department of Family and Community Medicine, University of California, San Francisco
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Affiliation(s)
- A R Tunkel
- University of Virginia School of Medicine, Charlottesville
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