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Akhtar K, Alkhaffaf B, Ariyarathenam A, Avery K, Barham P, Bateman A, Beard C, Berrisford R, Blazeby JM, Blencowe N, Boddy A, Bowrey D, Bracey T, Brierley RC, Briton K, Byrne J, Catton J, Chaparala R, Clark SK, Clarke T, Cooke J, Couper G, Culliford L, Dawson H, Deans C, Donovan JL, Ekblad C, Elliott J, Exon D, Falk S, Farooq N, Garfield K, Gaunt DM, Gill F, Goldin R, Gravani A, Hanna G, Hayes S, Heys R, Hindmarsh C, Hollinghurst S, Hollingworth W, Hollowood A, Houlihan R, Howes B, Howie L, Humphreys L, Hutton D, Jarvis R, Jepson M, Kandiyali R, Kaur S, Kaye P, Kelly J, King A, Kirwin J, Krysztopik R, Lamb P, Lang A, Lee V, Maitland S, Mapstone N, Melia G, Metcalfe C, Melhado R, Moure-Fernandez A, Nair B, Nicklin J, Noble F, Noble SM, O’Connell A, Palmer S, Parsons S, Pursnani K, Rea N, Reed F, Rice C, Richards C, Rogers C, Sanders G, Save V, Shaw C, Schiller M, Schranz R, Shetty V, Shirkey B, Singleton J, Skipworth R, Smith J, Streets C, Titcomb D, Turner P, Ubhi S, Underwood T, Vinod C, Vohra R, Ward EM, Warman R, Welch N, Wheatley T, White K, Wickens RA, Wilkerson P, Williams A, Williams R, Wilmshurst N, Wong NACS. Laparoscopic or open abdominal surgery with thoracotomy for patients with oesophageal cancer: ROMIO randomized clinical trial. Br J Surg 2024; 111:znae023. [PMID: 38525931 PMCID: PMC10961947 DOI: 10.1093/bjs/znae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 11/16/2023] [Accepted: 01/10/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVE This study investigated if hybrid oesophagectomy with minimally invasive gastric mobilization and thoracotomy enabled faster recovery than open surgery. METHODS In eight UK centres, this pragmatic RCT recruited patients for oesophagectomy to treat localized cancer. Participants were randomly allocated to hybrid or open surgery, stratified by centre and receipt of neoadjuvant treatment. Large dressings aimed to mask patients to their allocation for six days post-surgery. The authors present the intention-to-treat analysis of outcome measures from the first 3 months post-randomization, including the primary outcome, the patient-reported physical function scale of the EORTC QLQ-C30, and cost-effectiveness. Current Controlled Trials registration: ISRCTN 59036820 (feasibility study), 10386621 (definitive study). FINDINGS There was no evidence of a difference between hybrid (n = 267) and open (n = 266) surgery in average physical function over 3 months post-randomization: difference in means 2.1, 95% c.i. -2.0 to 6.2, P = 0.3. Complication rates were similar; for example, 88 (34%) participants in the open and 82 (32%) participants in the hybrid surgery groups experienced a pulmonary infection within 30 days. There was no evidence that hybrid surgery was more cost-effective than open surgery at 3 months. CONCLUSIONS Patient-reported physical function in the 3 months post-randomization provided no evidence of a difference in recovery time between hybrid and open surgery, or a difference in cost-effectiveness. Both approaches to surgery were completed safely, with a similar risk of key complications, suggesting that surgeons who have a preference for one of the two approaches need not change their practice.
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Matheson L, Greaves C, Duda JL, Wells M, Secher D, Rhodes P, Lorenc A, Jepson M, Ozakinci G, Watson E, Fulton-Lieuw T, Mittal S, Main B, Nankivell P, Mehanna H, Brett J. Development of the 'ACT now & check-it-out' intervention to support patient-initiated follow up for Head and Neck cancer patients. Patient Educ Couns 2024; 119:108033. [PMID: 37988772 DOI: 10.1016/j.pec.2023.108033] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVE Current Head and Neck cancer (HNC) follow-up models are considered sub-optimal at detecting recurrences. We describe the development of a patient-initiated follow up (PIFU) trial intervention support package, to support HNC patients to engage in PIFU self-care behaviors. METHODS An intervention mapping approach, informed by evidence synthesis, theory and stakeholder consultation, guided intervention development. Data sources included a patient survey (n = 144), patient interviews (n = 30), 7 workshops with patients (n = 25) and caregivers (n = 3) and 5 workshops with health professionals (n = 21). RESULTS The intervention ('ACT now & check-it-out') comprises an education and support session with a health professional and an app and/or a booklet for patients. The main targets for change in patient self-care behaviors were: assessing what is normal for them; regularly checking for symptom changes; prompt help-seeking for persistent/new symptoms; self-management of fear of recurrence; engaging with the intervention over time. CONCLUSIONS We have developed an evidence, person and theory-based intervention to support PIFU self-care behaviors in HNC patients. PRACTICE IMPLICATIONS A trial is underway to assess the effectiveness and cost-effectiveness of the intervention. If successful, this intervention could be adapted for patients with other cancers or diseases, which is important given the recent shift towards PIFU pathways.
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Affiliation(s)
- Lauren Matheson
- Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, OX3 0FL Oxford, UK.
| | - Colin Greaves
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham B15 2TT, UK.
| | - Joan L Duda
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham B15 2TT, UK.
| | - Mary Wells
- Nursing Directorate, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK.
| | | | | | - Ava Lorenc
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK.
| | - Marcus Jepson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK.
| | - Gozde Ozakinci
- Division of Psychology, University of Stirling, Stirling FK9 4LA, UK.
| | - Eila Watson
- Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, OX3 0FL Oxford, UK.
| | - Tessa Fulton-Lieuw
- Institute of Head and Neck Studies and Education (InHANSE), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK.
| | - Saloni Mittal
- Institute of Head and Neck Studies and Education (InHANSE), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK.
| | - Barry Main
- Bristol Dental School, University of Bristol, BS1 2LY, UK.
| | - Paul Nankivell
- Institute of Head and Neck Studies and Education (InHANSE), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK.
| | - Hisham Mehanna
- Institute of Head and Neck Studies and Education (InHANSE), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK.
| | - Jo Brett
- Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, OX3 0FL Oxford, UK.
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Shelley B, Goebel A, Grant S, Jackson L, Jarrett H, Jepson M, Kerr A, Marczin N, Mehta R, Melody T, Middleton L, Naidu B, Szentgyorgyi L, Tearne S, Watkins B, Wilson M, Worrall A, Yeung J, Smith FG. Study protocol for a randomised controlled trial to investigate the effectiveness of thoracic epidural and paravertebral blockade in reducing chronic post-thoracotomy pain: 2 (TOPIC 2). Trials 2023; 24:748. [PMID: 37996898 PMCID: PMC10666334 DOI: 10.1186/s13063-023-07463-1] [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: 05/17/2023] [Accepted: 06/15/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Thoracotomy is considered one of the most painful surgical procedures and can cause debilitating chronic post-surgical pain lasting months or years postoperatively. Aggressive management of acute pain resulting from thoracotomy may reduce the likelihood of developing chronic pain. This trial compares the two most commonly used modes of acute analgesia provision at the time of thoracotomy (thoracic epidural blockade (TEB) and paravertebral blockade (PVB)) in terms of their clinical and cost-effectiveness in preventing chronic post-thoracotomy pain. METHODS TOPIC 2 is a multi-centre, open-label, parallel group, superiority, randomised controlled trial, with an internal pilot investigating the use of TEB and PVB in 1026 adult (≥ 18 years old) patients undergoing thoracotomy in up to 20 thoracic centres throughout the UK. Patients (N = 1026) will be randomised in a 1:1 ratio to receive either TEB or PVB. During the first year, the trial will include an integrated QuinteT (Qualitative Research Integrated into Trials) Recruitment Intervention (QRI) with the aim of optimising recruitment and informed consent. The primary outcome is the incidence of chronic post-surgical pain at 6 months post-randomisation defined as 'worst chest pain over the last week' equating to a visual analogue score greater than or equal to 40 mm indicating at least a moderate level of pain. Secondary outcomes include acute pain, complications of regional analgesia and surgery, health-related quality of life, mortality and a health economic analysis. DISCUSSION Both TEB and PVB have been demonstrated to be effective in the prevention of acute pain following thoracotomy and nationally practice is divided. Identification of which mode of analgesia is both clinically and cost-effective in preventing chronic post-thoracotomy pain could ameliorate the debilitating effects of chronic pain, improving health-related quality of life, facilitating return to work and caring responsibilities and resulting in a cost saving to the NHS. TRIAL REGISTRATION NCT03677856 [ClinicalTrials.gov] registered September 19, 2018. https://clinicaltrials.gov/ct2/show/NCT03677856 . First patient recruited 8 January 2019.
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Affiliation(s)
- Ben Shelley
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Andreas Goebel
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Stephen Grant
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Louise Jackson
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - Marcus Jepson
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Amy Kerr
- University Hospitals Birmingham Thoracic Surgical Research Centre, Bristol, UK
| | - Nandor Marczin
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | | | | | - Babu Naidu
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | | | | | - Ben Watkins
- Birmingham Clinical Trial Unit, Birmingham, UK
| | - Matthew Wilson
- School of Health & Related Research, University of Sheffield, Sheffield, UK
| | | | - Joyce Yeung
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Fang Gao Smith
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.
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Khalid T, Ben-Shlomo Y, Bertram W, Culliford L, England C, Henderson E, Jameson C, Jepson M, Palmer S, Whitehouse MR, Wylde V. Prehabilitation for frail patients undergoing total hip or knee replacement: protocol for the Joint PREP feasibility randomised controlled trial. Pilot Feasibility Stud 2023; 9:138. [PMID: 37550774 PMCID: PMC10405490 DOI: 10.1186/s40814-023-01363-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 07/15/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Approximately, 8% of community-based adults aged ≥ 50 years in England are frail. Frailty has been found to be associated with poorer outcomes after joint replacement. Targeting frailty preoperatively via exercise and protein supplementation has the potential to improve outcomes for people undergoing joint replacement. Prior to proceeding with a randomised controlled trial (RCT), a feasibility study is necessary to address key uncertainties and explore how to optimise trial design and delivery. METHODS The Joint PRehabilitation with Exercise and Protein (Joint PREP) study is a feasibility study for a multicentre, two-arm, parallel group, pragmatic, RCT to evaluate the clinical and cost-effectiveness of prehabilitation for frail patients undergoing total hip or knee replacement. Sixty people who are ≥ 65 years of age, frail according to the self-reported Groningen Frailty Indicator, and scheduled to undergo total hip or knee replacement at 2-3 hospitals in England and Wales will be recruited and randomly allocated on a 1:1 ratio to the intervention or usual care group. The usual care group will receive the standard care at their hospital. The intervention group will be given a daily protein supplement and will be asked to follow a home-based, tailored daily exercise programme for 12 weeks before their operation, in addition to usual care. Participants will be supported through six follow-up calls from a physiotherapist during the 12-week intervention period. Study questionnaires will be administered at baseline and 12 weeks after randomisation. Embedded qualitative research with patients will explore their experiences of participating, reasons for nonparticipation, and/or reasons for withdrawal or treatment discontinuation. Primary feasibility outcomes will be eligibility and recruitment rates, adherence to the intervention, and acceptability of the trial and the intervention. DISCUSSION This study will generate important data regarding the feasibility of a RCT to evaluate a prehabilitation intervention for frail patients undergoing total hip and knee replacement. A future phase-3 RCT will determine if preoperative exercise and protein supplementation improve the recovery of frail patients after primary joint replacement. TRIAL REGISTRATION ISRCTN11121506, registered 29 September 2022.
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Affiliation(s)
| | - Yoav Ben-Shlomo
- Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Applied Research Collaboration West at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Wendy Bertram
- Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Lucy Culliford
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Clare England
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Catherine Jameson
- Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Marcus Jepson
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Shea Palmer
- Centre for Care Excellence, Coventry University and University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Michael R Whitehouse
- Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Vikki Wylde
- Bristol Medical School, University of Bristol, Bristol, UK.
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK.
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Lorenc A, Rooshenas L, Conefrey C, Wade J, Farrar N, Mills N, Paramasivan S, Realpe A, Jepson M. Non-COVID-19 UK clinical trials and the COVID-19 pandemic: impact, challenges and possible solutions. Trials 2023; 24:424. [PMID: 37349850 PMCID: PMC10286467 DOI: 10.1186/s13063-023-07414-w] [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: 11/09/2022] [Accepted: 05/25/2023] [Indexed: 06/24/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic impacted the operationalisation of non-COVID-19 clinical trials globally, particularly site and participant recruitment and trial success/stoppage. Trials which anticipate recruitment challenges may embed methods such as the QuinteT Recruitment Intervention (QRI) to help identify and understand the sources of challenges. Such interventions can help shed light on pandemic-related challenges. This paper reports our experience of the impact of the COVID-19 pandemic on conducting clinical trials with an embedded QRI, highlighting how the QRI aided in identifying challenges and potential solutions, particularly related to the site set-up and participant recruitment. MAIN BODY We report on 13 UK clinical trials which included a QRI. Information is from QRI data and researchers' experience and reflections. In most trials, recruitment was lower than even the lowest anticipated rates. The flexibility of the QRI facilitated rapid data collection to understand and document, and in some instances respond to, operational challenges. Challenges were mostly logistical, pandemic-related and beyond the control of the site or central trial teams. Specifically: disrupted and variable site opening timelines -often due to local research and development (R&D) delays- shortages of staff to recruit patients; fewer eligible patients or limited access to patients; and intervention-related factors. Almost all trials were affected by pandemic-related staffing issues including redeployment, prioritisation of COVID-19 care and research, and COVID-19-related staff illness and absence. Trials of elective procedures were particularly impacted by the pandemic, which caused changes to care/recruitment pathways, deprioritisation of services, reduced clinical and surgical capacity and longer waiting lists. Attempted solutions included extra engagement with staff and R&D departments, trial protocol changes (primarily moving online) and seeking additional resourcing. CONCLUSION We have highlighted wide-ranging, extensive and consistent pandemic-related challenges faced by UK clinical trials, which the QRI helped to identify and, in some cases, address. Many challenges were insurmountable at individual trials or trials unit level. This overview highlights the need to streamline trial regulatory processes, address staffing crises, improve recognition of NHS research staff and for clearer, more nuanced central guidance on the prioritisation of studies and how to deal with the backlog. Pre-emptively embedding qualitative work and stakeholder consultation into trials with anticipated difficulties, moving some processes online, and flexible trial protocols may improve the resilience of trials in the current challenging context.
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Affiliation(s)
- Ava Lorenc
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Leila Rooshenas
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Carmel Conefrey
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Julia Wade
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Nicola Farrar
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Nicola Mills
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Sangeetha Paramasivan
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Alba Realpe
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Marcus Jepson
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
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Lorenc A, Greaves C, Duda J, Brett J, Matheson L, Fulton‐Lieuw T, Secher D, Rhodes P, Ozakinci G, Nankivell P, Mehanna H, Jepson M. Exploring the views of patients' and their family about patient-initiated follow-up in head and neck cancer: A mixed methods study. Eur J Cancer Care (Engl) 2022; 31:e13641. [PMID: 35789510 PMCID: PMC9787693 DOI: 10.1111/ecc.13641] [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: 12/07/2021] [Revised: 03/21/2022] [Accepted: 06/06/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The objective of this work was to explore head and neck cancer (HNC) patients' and their family members' views on acceptability and feasibility of patient-initiated follow-up (PIFU), including concerns and anticipated benefits. METHODS Patients were recruited from UK HNC clinics, support groups and advocacy groups. They completed a survey (n = 144) and/or qualitative interview (n = 30), three with a family member. Qualitative data were analysed thematically, quantitative data using descriptive statistics. RESULTS Preference for follow-up care in HNC was complex and individual. Many patients thought PIFU could beneficially reallocate health care resources and encourage self-management. Patients' main concerns with PIFU were losing the reassurance of regular clinic appointments and addressing mental well-being needs within PIFU, possibly using peer support. Patients were concerned about their ability to detect recurrence due to lack of expertise and information. They emphasised the importance of a reliable, direct and easy urgent appointment service and of feeling supported and heard by clinicians. Patients believed family and friends need support. CONCLUSION PIFU may be feasible and acceptable for certain HNC patients, providing it addresses support for mental well-being, provides quick, reliable and direct clinician access and information on "red flag" symptoms, and ensures patients and their caregivers feel supported.
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Affiliation(s)
- Ava Lorenc
- QuinteT Research Group, Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Colin Greaves
- School of Sport, Exercise and Rehabilitation SciencesUniversity of BirminghamBirminghamUK
| | - Joan Duda
- School of Sport, Exercise and Rehabilitation SciencesUniversity of BirminghamBirminghamUK
| | - Jo Brett
- Supportive Cancer Care Research Group, Faculty of Health and Life SciencesOxford Brookes UniversityOxfordUK
| | - Lauren Matheson
- Supportive Cancer Care Research Group, Faculty of Health and Life SciencesOxford Brookes UniversityOxfordUK
| | - Tessa Fulton‐Lieuw
- Institute of Head and Neck Studies and Education (InHANSE), Institute of Cancer and Genomic SciencesUniversity of BirminghamBirminghamUK
| | | | | | - Gozde Ozakinci
- Division of Psychology, Faculty of Natural SciencesUniversity of StirlingStirlingUK
| | - Paul Nankivell
- Institute of Head and Neck Studies and Education (InHANSE), Institute of Cancer and Genomic SciencesUniversity of BirminghamBirminghamUK,University Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Hisham Mehanna
- Institute of Head and Neck Studies and Education (InHANSE), Institute of Cancer and Genomic SciencesUniversity of BirminghamBirminghamUK,University Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Marcus Jepson
- QuinteT Research Group, Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
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Farrar N, Elliott D, Houghton C, Jepson M, Mills N, Paramasivan S, Plumb L, Wade J, Young B, Donovan JL, Rooshenas L. Understanding the perspectives of recruiters is key to improving randomised controlled trial enrolment: a qualitative evidence synthesis. Trials 2022; 23:883. [PMID: 36266700 PMCID: PMC9585862 DOI: 10.1186/s13063-022-06818-4] [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: 05/17/2022] [Accepted: 10/05/2022] [Indexed: 11/10/2022] Open
Abstract
Background Recruiting patients to randomised controlled trials (RCTs) is often reported to be challenging, and the evidence base for effective interventions that could be used by staff (recruiters) undertaking recruitment is lacking. Although the experiences and perspectives of recruiters have been widely reported, an evidence synthesis is required in order to inform the development of future interventions. This paper aims to address this by systematically searching and synthesising the evidence on recruiters’ perspectives and experiences of recruiting patients into RCTs. Methods A qualitative evidence synthesis (QES) following Thomas and Harden’s approach to thematic synthesis was conducted. The Ovid MEDLINE, CINAHL, EMBASE, PsycInfo, Cochrane Central Register of Controlled Trials, ORRCA and Web of Science electronic databases were searched. Studies were sampled to ensure that the focus of the research was aligned with the phenomena of interest of the QES, their methodological relevance to the QES question, and to include variation across the clinical areas of the studies. The GRADE CERQual framework was used to assess confidence in the review findings. Results In total, 9316 studies were identified for screening, which resulted in 128 eligible papers. The application of the QES sampling strategy resulted in 30 papers being included in the final analysis. Five overlapping themes were identified which highlighted the complex manner in which recruiters experience RCT recruitment: (1) recruiting to RCTs in a clinical environment, (2) enthusiasm for the RCT, (3) making judgements about whether to approach a patient, (4) communication challenges, (5) interplay between recruiter and professional roles. Conclusions This QES identified factors which contribute to the complexities that recruiters can face in day-to-day clinical settings, and the influence recruiters and non-recruiting healthcare professionals have on opportunities afforded to patients for RCT participation. It has reinforced the importance of considering the clinical setting in its entirety when planning future RCTs and indicated the need to better normalise and support research if it is to become part of day-to-day practice. Trial registration PROSPERO CRD42020141297 (registered 11/02/2020). Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06818-4.
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Affiliation(s)
- Nicola Farrar
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Daisy Elliott
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Catherine Houghton
- School of Nursing and Midwifery, Áras Moyola, National University of Ireland Galway, Galway, Ireland
| | - Marcus Jepson
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Nicola Mills
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Sangeetha Paramasivan
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Lucy Plumb
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,UK Kidney Association, UK Renal Registry, Bristol, UK
| | - Julia Wade
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Bridget Young
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, L69 3GB, UK
| | - Jenny L Donovan
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Leila Rooshenas
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
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Donovan JL, Jepson M, Rooshenas L, Paramasivan S, Mills N, Elliott D, Wade J, Reda D, Blazeby JM, Moghanaki D, Hwang ES, Davies L. Development of a new adapted QuinteT Recruitment Intervention (QRI-Two) for rapid application to RCTs underway with enrolment shortfalls—to identify previously hidden barriers and improve recruitment. Trials 2022; 23:258. [PMID: 35379301 PMCID: PMC8978173 DOI: 10.1186/s13063-022-06187-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/19/2022] [Indexed: 11/30/2022] Open
Abstract
Background Many randomised controlled trials (RCTs) struggle to recruit, despite valiant efforts. The QRI (QuinteT Recruitment Intervention) uses innovative research methods to optimise recruitment by revealing previously hidden barriers related to the perceptions and experiences of recruiters and patients, and targeting remedial actions. It was designed to be integrated with RCTs anticipating difficulties at the outset. A new version of the intervention (QRI-Two) was developed for RCTs already underway with enrolment shortfalls. Methods QRIs in 12 RCTs with enrolment shortfalls during 2007–2017 were reviewed to document which of the research methods used could be rapidly applied to successfully identify recruitment barriers. These methods were then included in the new streamlined QRI-Two intervention which was applied in 20 RCTs in the USA and Europe during 2018–2019. The feasibility of the QRI-Two was investigated, recruitment barriers and proposed remedial actions were documented, and the QRI-Two protocol was finalised. Results The review of QRIs from 2007 to 2017 showed that previously unrecognised recruitment barriers could be identified but data collection for the full QRI required time and resources usually unavailable to ongoing RCTs. The streamlined QRI-Two focussed on analysis of screening/accrual data and RCT documents (protocol, patient-information), with discussion of newly diagnosed barriers and potential remedial actions in a workshop with the RCT team. Four RCTs confirmed the feasibility of the rapid application of the QRI-Two. When the QRI-Two was applied to 14 RCTs underway with enrolment shortfalls, an array of previously unknown/underestimated recruitment barriers related to issues such as equipoise, intervention preferences, or study presentation was identified, with new insights into losses of eligible patients along the recruitment pathway. The QRI-Two workshop enabled discussion of the newly diagnosed barriers and potential remedial actions to improve recruitment in collaboration with the RCT team. As expected, the QRI-Two performed less well in six RCTs at the start-up stage before commencing enrolment. Conclusions The QRI-Two can be applied rapidly, diagnose previously unrecognised recruitment barriers, and suggest remedial actions in RCTs underway with enrolment shortfalls, providing opportunities for RCT teams to develop targeted actions to improve recruitment. The effectiveness of the QRI-Two in improving recruitment requires further evaluation. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06187-y.
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Lorenc A, Wells M, Fulton-Lieuw T, Nankivell P, Mehanna H, Jepson M. Clinicians' Views of Patient-initiated Follow-up in Head and Neck Cancer: a Qualitative Study to Inform the PETNECK2 Trial. Clin Oncol (R Coll Radiol) 2022; 34:230-240. [PMID: 34862101 PMCID: PMC8950325 DOI: 10.1016/j.clon.2021.11.010] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/13/2021] [Accepted: 11/12/2021] [Indexed: 12/23/2022]
Abstract
AIMS Current follow-up for head and neck cancer (HNC) is ineffective, expensive and fails to address patients' needs. The PETNECK2 trial will compare a new model of patient-initiated follow-up (PIFU) with routine scheduled follow-up. This article reports UK clinicians' views about HNC follow-up and PIFU, to inform the trial design. MATERIALS AND METHODS Online focus groups with surgeons (ear, nose and throat/maxillofacial), oncologists, clinical nurse specialists and allied health professionals. Clinicians were recruited from professional bodies, mailing lists and personal contacts. Focus groups explored views on current follow-up and acceptability of the proposed PIFU intervention and randomised controlled trial design (presented by the study co-chief investigator), preferences, margins of equipoise, potential organisational barriers and thoughts about the content and format of PIFU. Data were interpreted using inductive thematic analysis. RESULTS Eight focus groups with 34 clinicians were conducted. Clinicians highlighted already known limitations with HNC follow-up - lack of flexibility to address the wide-ranging needs of HNC patients, expense and lack of evidence - and agreed that follow-up needs to change. They were enthusiastic about the PETNECK2 trial to develop and evaluate PIFU but had concerns that PIFU may not suit disengaged patients and may aggravate patient anxiety/fear of recurrence and delay detection of recurrence. Anticipated issues with implementation included ensuring a reliable route back to clinic and workload burden on nurses and allied health professionals. CONCLUSIONS Clinicians supported the evaluation of PIFU but voiced concerns about barriers to help-seeking. An emphasis on patient engagement, psychosocial issues, symptom reporting and reliable, quick routes back to clinic will be important. Certain patient groups may be less suited to PIFU, which will be evaluated in the trial. Early, meaningful, ongoing engagement with clinical teams and managers around the trial rationale and recruitment process will be important to discourage selective recruitment and address risk-averse behaviour and potential workload burden.
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Affiliation(s)
- A Lorenc
- QuinteT Research Group, Bristol Medical School, University of Bristol, Bristol, UK.
| | - M Wells
- Nursing Directorate, Imperial College Healthcare, NHS Trust / Department of Surgery and Oncology, Imperial College, London, London, UK
| | - T Fulton-Lieuw
- Institute of Head and Neck Studies and Education (InHANSE), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - P Nankivell
- Institute of Head and Neck Studies and Education (InHANSE), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK; University Hospitals, Birmingham NHS Foundation Trust, Birmingham, UK
| | - H Mehanna
- Institute of Head and Neck Studies and Education (InHANSE), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK; University Hospitals, Birmingham NHS Foundation Trust, Birmingham, UK
| | - M Jepson
- QuinteT Research Group, Bristol Medical School, University of Bristol, Bristol, UK
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10
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Griffin DR, Dickenson EJ, Achana F, Griffin J, Smith J, Wall PD, Realpe A, Parsons N, Hobson R, Fry J, Jepson M, Petrou S, Hutchinson C, Foster N, Donovan J. Arthroscopic hip surgery compared with personalised hip therapy in people over 16 years old with femoroacetabular impingement syndrome: UK FASHIoN RCT. Health Technol Assess 2022; 26:1-236. [PMID: 35229713 PMCID: PMC8919110 DOI: 10.3310/fxii0508] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Femoroacetabular impingement syndrome is an important cause of hip pain in young adults. It can be treated by arthroscopic hip surgery or with physiotherapist-led conservative care. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of hip arthroscopy with best conservative care. DESIGN The UK FASHIoN (full trial of arthroscopic surgery for hip impingement compared with non-operative care) trial was a pragmatic, multicentre, randomised controlled trial that was carried out at 23 NHS hospitals. PARTICIPANTS Participants were included if they had femoroacetabular impingement, were aged ≥ 16 years old, had hip pain with radiographic features of cam or pincer morphology (but no osteoarthritis) and were believed to be likely to benefit from hip arthroscopy. INTERVENTION Participants were randomly allocated (1 : 1) to receive hip arthroscopy followed by postoperative physiotherapy, or personalised hip therapy (i.e. an individualised physiotherapist-led programme of conservative care). Randomisation was stratified by impingement type and recruiting centre using a central telephone randomisation service. Outcome assessment and analysis were masked. MAIN OUTCOME MEASURE The primary outcome was hip-related quality of life, measured by the patient-reported International Hip Outcome Tool (iHOT-33) 12 months after randomisation, and analysed by intention to treat. RESULTS Between July 2012 and July 2016, 648 eligible patients were identified and 348 participants were recruited. In total, 171 participants were allocated to receive hip arthroscopy and 177 participants were allocated to receive personalised hip therapy. Three further patients were excluded from the trial after randomisation because they did not meet the eligibility criteria. Follow-up at the primary outcome assessment was 92% (N = 319; hip arthroscopy, n = 157; personalised hip therapy, n = 162). At 12 months, mean International Hip Outcome Tool (iHOT-33) score had improved from 39.2 (standard deviation 20.9) points to 58.8 (standard deviation 27.2) points for participants in the hip arthroscopy group, and from 35.6 (standard deviation 18.2) points to 49.7 (standard deviation 25.5) points for participants in personalised hip therapy group. In the primary analysis, the mean difference in International Hip Outcome Tool scores, adjusted for impingement type, sex, baseline International Hip Outcome Tool score and centre, was 6.8 (95% confidence interval 1.7 to 12.0) points in favour of hip arthroscopy (p = 0.0093). This estimate of treatment effect exceeded the minimum clinically important difference (6.1 points). Five (83%) of six serious adverse events in the hip arthroscopy group were related to treatment and one serious adverse event in the personalised hip therapy group was not. Thirty-eight (24%) personalised hip therapy patients chose to have hip arthroscopy between 1 and 3 years after randomisation. Nineteen (12%) hip arthroscopy patients had a revision arthroscopy. Eleven (7%) personalised hip therapy patients and three (2%) hip arthroscopy patients had a hip replacement within 3 years. LIMITATIONS Study participants and treating clinicians were not blinded to the intervention arm. Delays were encountered in participants accessing treatment, particularly surgery. Follow-up lasted for 3 years. CONCLUSION Hip arthroscopy and personalised hip therapy both improved hip-related quality of life for patients with femoroacetabular impingement syndrome. Hip arthroscopy led to a greater improvement in quality of life than personalised hip therapy, and this difference was clinically significant at 12 months. This study does not demonstrate cost-effectiveness of hip arthroscopy compared with personalised hip therapy within the first 12 months. Further follow-up will reveal whether or not the clinical benefits of hip arthroscopy are maintained and whether or not it is cost-effective in the long term. TRIAL REGISTRATION Current Controlled Trials ISRCTN64081839. 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. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Damian R Griffin
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Edward J Dickenson
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Felix Achana
- Warwick Medical School, University of Warwick, Coventry, UK
| | - James Griffin
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Joanna Smith
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Peter Dh Wall
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Alba Realpe
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nick Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Hobson
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Marcus Jepson
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Stavros Petrou
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Charles Hutchinson
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Nadine Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences NIHR, Keele University, Keele, UK
| | - Jenny Donovan
- Bristol Medical School, University of Bristol, Bristol, UK
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11
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Farrar N, Elliott D, Jepson M, Houghton C, Young B, Donovan J, Rooshenas L. Recruiters' perspectives and experiences of trial recruitment processes: a qualitative evidence synthesis protocol. BMJ Open 2021; 11:e045233. [PMID: 34686547 PMCID: PMC8543629 DOI: 10.1136/bmjopen-2020-045233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Recruitment to randomised trials (RCTs) is often challenging. Reviews of interventions to improve recruitment have highlighted a paucity of effective interventions aimed at recruiters and the need for further research in this area. Understanding the perspectives and experiences of those involved in RCT recruitment can help to identify barriers and facilitators to recruitment, and subsequently inform future interventions to support recruitment. This protocol describes methods for a proposed qualitative evidence synthesis (QES) of recruiters' perspectives and experiences relating to RCT recruitment. METHODS AND ANALYSIS The proposed review will synthesise studies reporting clinical and non-clinical recruiters' perspectives and experiences of recruiting to RCTs. The following databases will be searched: Ovid MEDLINE, CINAHL, EMBASE, PsycInfo, Cochrane Central Register of Controlled Trials, ORRCA and Web of Science. A thematic synthesis approach to analysing the data will be used. An assessment of methodological limitations of each study will be performed using the Critical Appraisal Skills Programme tool. Assessing the confidence in the review findings will be evaluated using the GRADE Confidence in Evidence from Reviews of Qualitative research (GRADE-CERQual) tool. ETHICS AND DISSEMINATION The proposed QES will not require ethical approval as it includes only published literature. The results of the synthesis will be published in a peer-reviewed journal and publicised using social media. The results will be considered alongside other work addressing factors affecting recruitment in order to inform future development and refinement of recruitment interventions. PROSPERO REGISTRATION NUMBER CRD42020141297.
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Affiliation(s)
- Nicola Farrar
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Daisy Elliott
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Marcus Jepson
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Catherine Houghton
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Galway, Ireland
| | - Bridget Young
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Jenny Donovan
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- Population Health Sciences, University of Bristol, Bristol, UK
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12
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Jepson M, Lazaroo M, Pathak S, Blencowe N, Collingwood J, Clout M, Toogood G, Blazeby J. Correction to: Making large-scale surgical trials possible: collaboration and the role of surgical trainees. Trials 2021; 22:615. [PMID: 34517876 PMCID: PMC8436521 DOI: 10.1186/s13063-021-05609-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Marcus Jepson
- QuinteT Research Group, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Michelle Lazaroo
- Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Samir Pathak
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Natalie Blencowe
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,University Hospitals Bristol and Weston NHS Foundation Trust, Trust Headquarters, Marlborough St, Bristol, BS1 3NU, UK
| | - Jane Collingwood
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Madeleine Clout
- Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Giles Toogood
- Department of Hepatobiliary and Transplantation Surgery, St James's University Hospital, Leeds, LS9 7TF, UK
| | - Jane Blazeby
- NIHR Biomedical Research Centre Bristol, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
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13
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Jepson M, Lazaroo M, Pathak S, Blencowe N, Collingwood J, Clout M, Toogood G, Blazeby J. Making large-scale surgical trials possible: collaboration and the role of surgical trainees. Trials 2021; 22:567. [PMID: 34446065 PMCID: PMC8390009 DOI: 10.1186/s13063-021-05536-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/11/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Recruitment to surgical randomised controlled trials (RCTs) can be challenging. The Sunflower study is a large-scale multi-centre RCT that seeks to establish the clinical and cost effectiveness of pre-operative imaging versus expectant management in patients with symptomatic gallstones undergoing laparoscopic cholecystectomy at low or moderate risk of common bile duct stones. Trials such as Sunflower, with a large recruitment target, rely on teamworking. Recruitment can be optimised by embedding a QuinteT Recruitment Intervention (QRI). Additionally, engaging surgical trainees can contribute to successful recruitment, and the NIHR Associate Principal Investigator (API) scheme provides a framework to acknowledge their contributions. METHODS This was a mixed-methods study that formed a component part of an embedded QRI for the Sunflower RCT. The aim of this study was to understand factors that supported and hindered the participation of surgical trainees in a large-scale RCT and their participation in the API scheme. It comprised semi-structured telephone interviews with consultant surgeons and surgical trainees involved in screening and recruitment of patients, and descriptive analysis of screening and recruitment data. Interviews were analysed thematically to explore the perspectives of-and roles undertaken by-surgical trainees. RESULTS Interviews were undertaken with 34 clinicians (17 consultant surgeons, 17 surgical trainees) from 22 UK hospital trusts. Surgical trainees contributed to patient screening, approaches and randomisation, with a major contribution to the randomisation of patients from acute admissions. They were often encouraged to participate in the study by their centre principal investigator, and career development was a typical motivating factor for their participation in the study. The study was registered with the API scheme, and a majority of the trainees interviewed (n = 14) were participating in the scheme. CONCLUSION Surgical trainees can contribute substantial activity to a large-scale multi-centre RCT. Benefits of trainee engagement were identified for trainees themselves, for local sites and for the study as a whole. The API scheme provided a formal framework to acknowledge engagement. Ensuring that training and support for trainees are provided by the trial team is key to optimise success for all stakeholders.
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Affiliation(s)
- Marcus Jepson
- grid.5337.20000 0004 1936 7603QuinteT Research Group, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Michelle Lazaroo
- grid.5337.20000 0004 1936 7603Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Samir Pathak
- grid.5337.20000 0004 1936 7603Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Natalie Blencowe
- grid.5337.20000 0004 1936 7603Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
- grid.410421.20000 0004 0380 7336University Hospitals Bristol and Weston NHS Foundation Trust, Trust Headquarters, Marlborough St, Bristol, BS1 3NU UK
| | - Jane Collingwood
- grid.5337.20000 0004 1936 7603Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Madeleine Clout
- grid.5337.20000 0004 1936 7603Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Giles Toogood
- grid.443984.6Department of Hepatobiliary and Transplantation Surgery, St James’s University Hospital, Leeds, LS9 7TF UK
| | - Jane Blazeby
- grid.5337.20000 0004 1936 7603NIHR Biomedical Research Centre Bristol, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN UK
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14
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Clout M, Blazeby J, Rogers C, Reeves B, Lazaroo M, Avery K, Blencowe NS, Vohra R, Jennings N, Hollingworth W, Thorn J, Jepson M, Collingwood J, Guthrie A, Booth E, Pathak S, Beckingham I, Culliford L, Griffiths EA, Albazaz R, Toogood G. Randomised controlled trial to establish the clinical and cost-effectiveness of expectant management versus preoperative imaging with magnetic resonance cholangiopancreatography in patients with symptomatic gallbladder disease undergoing laparoscopic cholecystectomy at low or moderate risk of common bile duct stones (The Sunflower Study): a study protocol. BMJ Open 2021; 11:e044281. [PMID: 34187817 PMCID: PMC8245448 DOI: 10.1136/bmjopen-2020-044281] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 03/20/2021] [Accepted: 03/28/2021] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Surgery to remove the gallbladder (laparoscopic cholecystectomy (LC)) is the standard treatment for symptomatic gallbladder disease. One potential complication of gallbladder disease is that gallstones can pass into the common bile duct (CBD) where they may remain dormant, pass spontaneously into the bowel or cause problems such as obstructive jaundice or pancreatitis. Patients requiring LC are assessed preoperatively for their risk of CBD stones using liver function tests and imaging. If the risk is high, guidelines recommend further investigation and treatment. Further investigation of patients at low or moderate risk of CBD stones is not standardised, and the practice of imaging the CBD using magnetic resonance cholangiopancreatography (MRCP) in these patients varies across the UK. The consequences of these decisions may lead to overtreatment or undertreatment of patients. METHODS AND ANALYSIS We are conducting a UK multicentre, pragmatic, open, randomised controlled trial with internal pilot phase to compare the effectiveness and cost-effectiveness of preoperative imaging with MRCP versus expectant management (ie, no preoperative imaging) in adult patients with symptomatic gallbladder disease undergoing urgent or elective LC who are at low or moderate risk of CBD stones. We aim to recruit 13 680 patients over 48 months. The primary outcome is any hospital admission within 18 months of randomisation for a complication of gallstones. This includes complications of endoscopic retrograde cholangiopancreatography for the treatment of gallstones and complications of LC. This will be determined using routine data sources, for example, National Health Service Digital Hospital Episode Statistics for participants in England. Secondary outcomes include cost-effectiveness and patient-reported quality of life, with participants followed up for a median of 18 months. ETHICS AND DISSEMINATION This study received approval from Yorkshire & The Humber - South Yorkshire Research Ethics Committee. Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ISRCTN10378861.
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Affiliation(s)
- Madeleine Clout
- Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Jane Blazeby
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Rogers
- Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Barnaby Reeves
- Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Michelle Lazaroo
- Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Kerry Avery
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Natalie S Blencowe
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Ravi Vohra
- Trent Oesophago-Gastric Unit, Nottingham City Hospital, Nottingham, UK
| | - Neil Jennings
- Bariatric Unit, Department of Surgery, Sunderland Royal Hospital, Sunderland, UK
| | | | - Joanna Thorn
- School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Marcus Jepson
- School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Jane Collingwood
- School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Ashley Guthrie
- Clinical Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Elizabeth Booth
- NHS Coventry and Rugby Clinical Commissioning Group, Coventry, UK
| | - Samir Pathak
- Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ian Beckingham
- Division of Gastrointestinal Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lucy Culliford
- Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Ewen A Griffiths
- Department of Upper GI Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Raneem Albazaz
- Clinical Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Giles Toogood
- Department of Hepatobiliary and Transplantation Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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15
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Elliott D, Ochieng C, Jepson M, Blencowe NS, Avery KN, Paramasivan S, Cousins S, Skilton A, Hutchinson P, Jayne D, Birchall M, Blazeby JM, Donovan JL, Rooshenas L. 'Overnight, things changed. Suddenly, we were in it': a qualitative study exploring how surgical teams mitigated risks of COVID-19. BMJ Open 2021; 11:e046662. [PMID: 34135048 PMCID: PMC8210660 DOI: 10.1136/bmjopen-2020-046662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES COVID-19 presents a risk of infection and transmission for operating theatre teams. Guidelines to protect patients and staff emerged and changed rapidly based on expert opinion and limited evidence. This paper presents the experiences and innovations developed by international surgical teams during the early stages of the pandemic to attempt to mitigate risk. DESIGN In-depth, semistructured interviews were audio recorded, transcribed and analysed thematically using methods of constant comparison. PARTICIPANTS 43 participants, including surgeons from a range of specialties (primarily general surgery, otolaryngology, neurosurgery, cardiothoracic and ophthalmology), anaesthetists and those in nursing roles. SETTING The UK, Italy, Spain, the USA, China and New Zealand between March and May 2020. RESULTS Surgical teams sought to mitigate COVID-19 risks by modifying their current practice with an abundance of strategies and innovations. Communication and teamwork played an integral role in how teams adapted, although participants reflected on the challenges of having to improvise in real time. Uncertainties remained about optimal surgical practice and there were significant tensions where teams were forced to balance what was best for patients while contemplating their own safety. CONCLUSIONS The perceptions of risks during a pandemic such as COVID-19 can be complex and context dependent. Management of these risks in surgery must be driven by evidence-based practice resulting from a pragmatic and novel approach to collation of global evidence. The context of surgery has changed dramatically, and surgical teams have developed a plethora of innovations. There is an urgent need for high-quality evidence to inform surgical practice that optimises the safety of both patients and healthcare professionals as the COVID-19 pandemic unfolds.
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Affiliation(s)
- Daisy Elliott
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Cynthia Ochieng
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Marcus Jepson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Natalie S Blencowe
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Kerry Nl Avery
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Sangeetha Paramasivan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Cousins
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Anni Skilton
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | - David Jayne
- Leeds Institute of Medical Research, Level 7 Clinical Sciences Building, St. James's University Hospital, Leeds, UK
| | - Martin Birchall
- Ear Institute, Faculty of Brain Sciences, University College London, London, UK
| | - Jane M Blazeby
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jenny L Donovan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Huppler L, Staight S, Urbonas T, Johnston J, Tryliskyy Y, Jacob M, Collingwood J, Jepson M, Pathak S. V10 The role of surgical trainees in recruiting to multicentre RCTs: an example from the Sunflower Study. BJS Open 2021. [PMCID: PMC8030218 DOI: 10.1093/bjsopen/zrab034.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background The Sunflower Study aims to compare the effectiveness of expectant management and MRCP prior to laparoscopic cholecystectomy (LC) in patients at low or moderate risk of common bile duct stones. This is the largest surgical randomised controlled trial (RCT) in the UK and a secondary aim is to describe trainees’ contributions. Methods Participants are randomised to receive expectant management or MRCP in a 2:1 ratio. Over 13,500 patients from more than 50 UK hospitals are required over five years. Trainees’ contributions are documented as follows: total number signed up to the study; number enrolled in the NIHR associate PI scheme; and the number of patients approached and recruited. The proportion of ‘emergency’ and ‘elective’ patients recruited was also recorded. Results Sunflower has been open since February 2019 and 48 centres are currently participating. A total of 104 trainees have been actively involved and 34 are/have been enrolled in the associate PI scheme. To date, 3992 patients have been screened, by trainees (n = 719,18%), consultants (n = 439,11%) and research nurses (n = 2214,71%). 1996 patients have been recruited, 359(18%) of which by trainees, 319(16%) consultants and 1318(66%) research nurses. Of the recruited patients, 423 (21%) presented as emergencies, recruited by trainees (n = 169,40%), consultants (n = 59,14%) and research nurses (n = 195,46%). Conclusions Trainees have an important role to play in recruiting patients to multicentre surgical RCTs, in particular in emergency settings, which can help improve studies’ generalisability. The associate PI scheme seems to provide an extra incentive for trainees to be involved in an RCT.
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Realpe AX, Foster NE, Dickenson EJ, Jepson M, Griffin DR, Donovan JL. Patient experiences of receiving arthroscopic surgery or personalised hip therapy for femoroacetabular impingement in the context of the UK fashion study: a qualitative study. Trials 2021; 22:211. [PMID: 33726810 PMCID: PMC7962311 DOI: 10.1186/s13063-021-05151-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND UK FASHIoN was a multicentre randomised controlled trial comparing hip arthroscopic surgery (HA) with personalised hip therapy (PHT, physiotherapist-led conservative care), for patients with hip pain attributed to femoroacetabular impingement (FAI) syndrome. Our aim was to describe the treatment and trial participation experiences of patients, to contextualise the trial results and offer further information to assist treatment decision-making in FAI. METHODS We conducted in-depth semi-structured telephone interviews with a purposive sample of trial participants from each of the trial arms. They were interviewed after they received treatment and completed their first year of trial participation. Thematic analysis and constant comparison analytical approaches were used to identify themes of patient treatment experiences during the trial. RESULTS Forty trial participants were interviewed in this qualitative study. Their baseline characteristics were similar to those in the main trial sample. On average, their hip-related quality of life (iHOT-33 scores) at 12 months follow-up were lower than average for all trial participants, indicating poorer hip-related quality of life as a consequence of theoretical sampling. Patient experiences occurred in five patient groups: those who felt their symptoms improved with hip arthroscopy, or with personal hip therapy, patients who felt their hip symptoms did not change with PHT but did not want HA, patients who decided to change from PHT to HA and a group who experienced serious complications after HA. Interviewees mostly described a trouble-free, enriching and altruistic trial participation experience, although most participants expected more clinical follow-up at the end of the trial. CONCLUSION Both HA and PHT were experienced as beneficial by participants in the trial. Treatment success appeared to depend partly on patients' prior own expectations as well as their outcomes, and future research is needed to explore this further. Findings from this study can be combined with the primary results to inform future FAI patients. TRIAL REGISTRATION Arthroscopic surgery for hip impingement versus best conventional care ( ISRCTN64081839 ). 28/02/2014.
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Affiliation(s)
- A X Realpe
- Population Health Sciences, University of Bristol, Canynge Hall 4.07, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - N E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - E J Dickenson
- University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - M Jepson
- Population Health Sciences, University of Bristol, Canynge Hall 4.07, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - D R Griffin
- University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - J L Donovan
- Population Health Sciences, University of Bristol, Canynge Hall 4.07, 39 Whatley Road, Bristol, BS8 2PS, UK
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Birchall M, Blazeby J, Blencowe N, Donovan J, Elliott D, Jepson M, Hutchinson P, Jayne D, Skilton A. Understanding risks, mitigation and innovation for surgery in a COVID-19 world. Br J Surg 2020; 107:e247. [PMID: 32410252 PMCID: PMC7272802 DOI: 10.1002/bjs.11691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 11/10/2022]
Affiliation(s)
- M Birchall
- Ear Institute, Faculty of Brain Sciences, UCL, London, UK
| | - J Blazeby
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Cambridge, UK.,Population Health Sciences, University of Bristol, Cambridge, UK
| | - N Blencowe
- Population Health Sciences, University of Bristol, Cambridge, UK
| | - J Donovan
- Population Health Sciences, University of Bristol, Cambridge, UK
| | - D Elliott
- Population Health Sciences, University of Bristol, Cambridge, UK
| | - M Jepson
- Population Health Sciences, University of Bristol, Cambridge, UK
| | - P Hutchinson
- Cambridge Neuroscience, University of Cambridge, Cambridge, UK
| | - D Jayne
- Faculty of Medicine and Health, School of Medicine, University of Leeds, Leeds, UK
| | - A Skilton
- Population Health Sciences, University of Bristol, Cambridge, UK
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Brierley RC, Gaunt D, Metcalfe C, Blazeby JM, Blencowe NS, Jepson M, Berrisford RG, Avery KNL, Hollingworth W, Rice CT, Moure-Fernandez A, Wong N, Nicklin J, Skilton A, Boddy A, Byrne JP, Underwood T, Vohra R, Catton JA, Pursnani K, Melhado R, Alkhaffaf B, Krysztopik R, Lamb P, Culliford L, Rogers C, Howes B, Chalmers K, Cousins S, Elliott J, Donovan J, Heys R, Wickens RA, Wilkerson P, Hollowood A, Streets C, Titcomb D, Humphreys ML, Wheatley T, Sanders G, Ariyarathenam A, Kelly J, Noble F, Couper G, Skipworth RJE, Deans C, Ubhi S, Williams R, Bowrey D, Exon D, Turner P, Daya Shetty V, Chaparala R, Akhtar K, Farooq N, Parsons SL, Welch NT, Houlihan RJ, Smith J, Schranz R, Rea N, Cooke J, Williams A, Hindmarsh C, Maitland S, Howie L, Barham CP. Laparoscopically assisted versus open oesophagectomy for patients with oesophageal cancer-the Randomised Oesophagectomy: Minimally Invasive or Open (ROMIO) study: protocol for a randomised controlled trial (RCT). BMJ Open 2019; 9:e030907. [PMID: 31748296 PMCID: PMC6887040 DOI: 10.1136/bmjopen-2019-030907] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/17/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Surgery (oesophagectomy), with neoadjuvant chemo(radio)therapy, is the main curative treatment for patients with oesophageal cancer. Several surgical approaches can be used to remove an oesophageal tumour. The Ivor Lewis (two-phase procedure) is usually used in the UK. This can be performed as an open oesophagectomy (OO), a laparoscopically assisted oesophagectomy (LAO) or a totally minimally invasive oesophagectomy (TMIO). All three are performed in the National Health Service, with LAO and OO the most common. However, there is limited evidence about which surgical approach is best for patients in terms of survival and postoperative health-related quality of life. METHODS AND ANALYSIS We will undertake a UK multicentre randomised controlled trial to compare LAO with OO in adult patients with oesophageal cancer. The primary outcome is patient-reported physical function at 3 and 6 weeks postoperatively and 3 months after randomisation. Secondary outcomes include: postoperative complications, survival, disease recurrence, other measures of quality of life, spirometry, success of patient blinding and quality assurance measures. A cost-effectiveness analysis will be performed comparing LAO with OO. We will embed a randomised substudy to evaluate the safety and evolution of the TMIO procedure and a qualitative recruitment intervention to optimise patient recruitment. We will analyse the primary outcome using a multi-level regression model. Patients will be monitored for up to 3 years after their surgery. ETHICS AND DISSEMINATION This study received ethical approval from the South-West Franchay Research Ethics Committee. We will submit the results for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ISRCTN10386621.
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Affiliation(s)
- Rachel C Brierley
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Daisy Gaunt
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Chris Metcalfe
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Natalie S Blencowe
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Marcus Jepson
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Kerry N L Avery
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - William Hollingworth
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Caoimhe T Rice
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Aida Moure-Fernandez
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Newton Wong
- Department of Cellular Pathology, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Joanna Nicklin
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Anni Skilton
- Medical Illustration, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Alex Boddy
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - James P Byrne
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Tim Underwood
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Ravi Vohra
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - James A Catton
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - Kish Pursnani
- Department of Upper GI Surgery, Royal Preston Hospital, Preston, UK
| | - Rachel Melhado
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Bilal Alkhaffaf
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Richard Krysztopik
- Gastroenterology Department, Royal United Hospital Bath NHS Trust, Bath, UK
| | - Peter Lamb
- General Surgery Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Lucy Culliford
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Chris Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Benjamin Howes
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Katy Chalmers
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Sian Cousins
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Jenny Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Rachael Heys
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Robin A Wickens
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Paul Wilkerson
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew Hollowood
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Christopher Streets
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Dan Titcomb
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Tim Wheatley
- Upper GI Surgery, Derriford Hospital, Plymouth, UK
| | | | | | - Jamie Kelly
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Fergus Noble
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Graeme Couper
- General Surgery Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Chris Deans
- General Surgery Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sukhbir Ubhi
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - Robert Williams
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - David Bowrey
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - David Exon
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - Paul Turner
- Department of Upper GI Surgery, Royal Preston Hospital, Preston, UK
| | | | - Ram Chaparala
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Khurshid Akhtar
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Naheed Farooq
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Simon L Parsons
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - Neil T Welch
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - Rebecca J Houlihan
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Joanne Smith
- Upper GI Surgery, Derriford Hospital, Plymouth, UK
| | - Rachel Schranz
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Nicola Rea
- General Surgery Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jill Cooke
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | | | - Carolyn Hindmarsh
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Sally Maitland
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - Lucy Howie
- Gastroenterology Department, Royal United Hospital Bath NHS Trust, Bath, UK
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White J, Jepson M, McAuliffe S, Cridland K, Malliaris P, Haines T. “Patient education – you do not have the time not to do this”. A qualitative exploration of expert clinician attitudes of education in the management of rotator cuff tendinopathy. J Sci Med Sport 2019. [DOI: 10.1016/j.jsams.2019.08.115] [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: 10/25/2022]
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Dooley J, Armstrong RA, Jepson M, Squire Y, Hinchliffe RJ, Mouton R. Qualitative study of clinician and patient perspectives on the mode of anaesthesia for emergency surgery. Br J Surg 2019; 107:e142-e150. [PMID: 31368512 PMCID: PMC6973173 DOI: 10.1002/bjs.11243] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/29/2019] [Accepted: 04/29/2019] [Indexed: 12/23/2022]
Abstract
Background Although delivering a chosen mode of anaesthesia for certain emergency surgery procedures is potentially beneficial to patients, it is a complex intervention to evaluate. This qualitative study explored clinician and patient perspectives about mode of anaesthesia for emergency surgery. Methods Snowball sampling was used to recruit participants from eight National Health Service Trusts that cover the following three emergency surgery settings: ruptured abdominal aortic aneurysms, hip fractures and inguinal hernias. A qualitative researcher conducted interviews with clinicians and patients. Thematic analysis was applied to the interview transcripts. Results Interviews were conducted with 21 anaesthetists, 21 surgeons, 14 operating theatre staff and 23 patients. There were two main themes. The first, impact of mode of anaesthesia in emergency surgery, had four subthemes assessing clinician and patient ideas about: context and the ‘best’ mode of anaesthesia; balance in choosing it over others; change and developments in anaesthesia; and the importance of mode of anaesthesia in emergency surgery. The second, tensions in decision‐making about mode of anaesthesia, comprised four subthemes: clinical autonomy and guidelines in anaesthesia; conforming to norms in mode of anaesthesia; the relationship between expertise, preference and patient involvement; and team dynamics in emergency surgery. The results highlight several interlinking factors affecting decision‐making, including expertise, preference, habit, practicalities, norms and policies. Conclusion There is variation in practice in choosing the mode of anaesthesia for surgery, alongside debate as to whether anaesthetic autonomy is necessary or results in a lack of willingness to change.
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Affiliation(s)
- J Dooley
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
| | - R A Armstrong
- Anaesthetic Department, Southmead Hospital, Bristol, UK
| | - M Jepson
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Y Squire
- Anaesthetic Department, Southmead Hospital, Bristol, UK
| | - R J Hinchliffe
- Bristol Surgical Trials Centre, Bristol Medical School, Bristol, UK
| | - R Mouton
- Anaesthetic Department, Southmead Hospital, Bristol, UK
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Rooshenas L, Paramasivan S, Jepson M, Donovan JL. Intensive Triangulation of Qualitative Research and Quantitative Data to Improve Recruitment to Randomized Trials: The QuinteT Approach. Qual Health Res 2019; 29:672-679. [PMID: 30791819 DOI: 10.1177/1049732319828693] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Randomized controlled trials (RCTs) can provide high quality evidence about the comparative effectiveness of health care interventions, but many RCTs struggle with or fail to complete recruitment. RCTs are built on the principles of the experimental method, but their planning, conduct, and interpretation can depend on complex social, behavioral, and cultural factors that may be best understood through qualitative research. Most qualitative studies undertaken alongside RCTs involve interviews that produce data that are used in a supportive or supplicatory role, but there is potential for qualitative research to be more influential. In this article, we describe the research methods underpinning the "QuinteT" (Qualitative Research Integrated Within Trials) approach to understand and address RCT recruitment difficulties. The QuinteT Recruitment Intervention (QRI) brings together multiple qualitative strategies and quantitative data and uses triangulation to understand recruitment issues rapidly. These nuanced understandings are used to inform the implementation of collaborative actions to improve recruitment.
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Jepson M, Elliott D, Conefrey C, Wade J, Rooshenas L, Wilson C, Beard D, Blazeby JM, Birtle A, Halliday A, Stein R, Donovan JL. An observational study showed that explaining randomization using gambling-related metaphors and computer-agency descriptions impeded randomized clinical trial recruitment. J Clin Epidemiol 2018; 99:75-83. [PMID: 29505860 PMCID: PMC6015122 DOI: 10.1016/j.jclinepi.2018.02.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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: 11/23/2017] [Revised: 02/12/2018] [Accepted: 02/26/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To explore how the concept of randomization is described by clinicians and understood by patients in randomized controlled trials (RCTs) and how it contributes to patient understanding and recruitment. STUDY DESIGN AND SETTING Qualitative analysis of 73 audio recordings of recruitment consultations from five, multicenter, UK-based RCTs with identified or anticipated recruitment difficulties. RESULTS One in 10 appointments did not include any mention of randomization. Most included a description of the method or process of allocation. Descriptions often made reference to gambling-related metaphors or similes, or referred to allocation by a computer. Where reference was made to a computer, some patients assumed that they would receive the treatment that was "best for them". Descriptions of the rationale for randomization were rarely present and often only came about as a consequence of patients questioning the reason for a random allocation. CONCLUSIONS The methods and processes of randomization were usually described by recruiters, but often without clarity, which could lead to patient misunderstanding. The rationale for randomization was rarely mentioned. Recruiters should avoid problematic gambling metaphors and illusions of agency in their explanations and instead focus on clearer descriptions of the rationale and method of randomization to ensure patients are better informed about randomization and RCT participation.
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Affiliation(s)
- Marcus Jepson
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, Bristol, United Kingdom.
| | - Daisy Elliott
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, Bristol, United Kingdom
| | - Carmel Conefrey
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, Bristol, United Kingdom
| | - Julia Wade
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, Bristol, United Kingdom
| | - Leila Rooshenas
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, Bristol, United Kingdom
| | - Caroline Wilson
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, Bristol, United Kingdom
| | - David Beard
- Royal College of Surgeons Surgical Intervention Trials Unit (SITU), University of Oxford, Oxford, United Kingdom
| | - Jane M Blazeby
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, Bristol, United Kingdom
| | - Alison Birtle
- Rosemere Cancer Centre, Royal Preston Hospital, Sharoe Green Lane North, 12 Fulwood, Preston, Lancashire PR2 9HT4, United Kingdom
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX3 9DU, United Kingdom
| | - Rob Stein
- University College London Hospitals (UCLH), Biomedical Research Centre (BMC), University College London Hospitals, 1st Floor Central, 250 Euston Road, London NW1 2PG, UK
| | - Jenny L Donovan
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, Bristol, United Kingdom; National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Trust, Bristol, United Kingdom
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Griffin DR, Dickenson EJ, Wall PDH, Achana F, Donovan JL, Griffin J, Hobson R, Hutchinson CE, Jepson M, Parsons NR, Petrou S, Realpe A, Smith J, Foster NE. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet 2018; 391:2225-2235. [PMID: 29893223 PMCID: PMC5988794 DOI: 10.1016/s0140-6736(18)31202-9] [Citation(s) in RCA: 346] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 04/19/2018] [Accepted: 04/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Femoroacetabular impingement syndrome is an important cause of hip pain in young adults. It can be treated by arthroscopic hip surgery, including reshaping the hip, or with physiotherapist-led conservative care. We aimed to compare the clinical effectiveness of hip arthroscopy with best conservative care. METHODS UK FASHIoN is a pragmatic, multicentre, assessor-blinded randomised controlled trial, done at 23 National Health Service hospitals in the UK. We enrolled patients with femoroacetabular impingement syndrome who presented at these hospitals. Eligible patients were at least 16 years old, had hip pain with radiographic features of cam or pincer morphology but no osteoarthritis, and were believed to be likely to benefit from hip arthroscopy. Patients with bilateral femoroacetabular impingement syndrome were eligible; only the most symptomatic hip was randomly assigned to treatment and followed-up. Participants were randomly allocated (1:1) to receive hip arthroscopy or personalised hip therapy (an individualised, supervised, and progressive physiotherapist-led programme of conservative care). Randomisation was stratified by impingement type and recruiting centre and was done by research staff at each hospital, using a central telephone randomisation service. Patients and treating clinicians were not masked to treatment allocation, but researchers who collected the outcome assessments and analysed the results were masked. The primary outcome was hip-related quality of life, as measured by the patient-reported International Hip Outcome Tool (iHOT-33) 12 months after randomisation, and analysed in all eligible participants who were allocated to treatment (the intention-to-treat population). This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN64081839, and is closed to recruitment. FINDINGS Between July 20, 2012, and July 15, 2016, we identified 648 eligible patients and recruited 348 participants: 171 participants were allocated to receive hip arthroscopy and 177 to receive personalised hip therapy. Three further patients were excluded from the trial after randomisation because they did not meet the eligibility criteria. Follow-up at the primary outcome assessment was 92% (319 of 348 participants). At 12 months after randomisation, mean iHOT-33 scores had improved from 39·2 (SD 20·9) to 58·8 (27·2) for participants in the hip arthroscopy group, and from 35·6 (18·2) to 49·7 (25·5) in the personalised hip therapy group. In the primary analysis, the mean difference in iHOT-33 scores, adjusted for impingement type, sex, baseline iHOT-33 score, and centre, was 6·8 (95% CI 1·7-12·0) in favour of hip arthroscopy (p=0·0093). This estimate of treatment effect exceeded the minimum clinically important difference (6·1 points). There were 147 patient-reported adverse events (in 100 [72%] of 138 patients) in the hip arthroscopy group) versus 102 events (in 88 [60%] of 146 patients) in the personalised hip therapy group, with muscle soreness being the most common of these (58 [42%] vs 69 [47%]). There were seven serious adverse events reported by participating hospitals. Five (83%) of six serious adverse events in the hip arthroscopy group were related to treatment, and the one in the personalised hip therapy group was not. There were no treatment-related deaths, but one patient in the hip arthroscopy group developed a hip joint infection after surgery. INTERPRETATION Hip arthroscopy and personalised hip therapy both improved hip-related quality of life for patients with femoroacetabular impingement syndrome. Hip arthroscopy led to a greater improvement than did personalised hip therapy, and this difference was clinically significant. Further follow-up will reveal whether the clinical benefits of hip arthroscopy are maintained and whether it is cost effective in the long term. FUNDING The Health Technology Assessment Programme of the National Institute of Health Research.
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Affiliation(s)
- Damian R Griffin
- University of Warwick, Coventry, UK; University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK.
| | - Edward J Dickenson
- University of Warwick, Coventry, UK; University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Peter D H Wall
- University of Warwick, Coventry, UK; University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | | | | | | | - Charles E Hutchinson
- University of Warwick, Coventry, UK; University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | | | | | - Alba Realpe
- University of Warwick, Coventry, UK; University of Bristol, Bristol, UK
| | - Joanna Smith
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
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Barnes RK, Jepson M, Thomas C, Jackson S, Metcalfe C, Kessler D, Cramer H. Using conversation analytic methods to assess fidelity to a talk-based healthcare intervention for frequently attending patients. Soc Sci Med 2018; 206:38-50. [DOI: 10.1016/j.socscimed.2018.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 03/22/2018] [Accepted: 04/09/2018] [Indexed: 10/17/2022]
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Mills N, Gaunt D, Blazeby JM, Elliott D, Husbands S, Holding P, Rooshenas L, Jepson M, Young B, Bower P, Tudur Smith C, Gamble C, Donovan JL. Training health professionals to recruit into challenging randomized controlled trials improved confidence: the development of the QuinteT randomized controlled trial recruitment training intervention. J Clin Epidemiol 2018; 95:34-44. [PMID: 29191445 PMCID: PMC5844671 DOI: 10.1016/j.jclinepi.2017.11.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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: 03/28/2017] [Revised: 10/31/2017] [Accepted: 11/21/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The objective of this study was to describe and evaluate a training intervention for recruiting patients to randomized controlled trials (RCTs), particularly for those anticipated to be difficult for recruitment. STUDY DESIGN AND SETTING One of three training workshops was offered to surgeons and one to research nurses. Self-confidence in recruitment was measured through questionnaires before and up to 3 months after training; perceived impact of training on practice was assessed after. Data were analyzed using two-sample t-tests and supplemented with findings from the content analysis of free-text comments. RESULTS Sixty-seven surgeons and 32 nurses attended. Self-confidence scores for all 10 questions increased after training [range of mean scores before 5.1-6.9 and after 6.9-8.2 (scale 0-10, all 95% confidence intervals are above 0 and all P-values <0.05)]. Awareness of hidden challenges of recruitment following training was high-surgeons' mean score 8.8 [standard deviation (SD), 1.2] and nurses' 8.4 (SD, 1.3) (scale 0-10); 50% (19/38) of surgeons and 40% (10/25) of nurses reported on a 4-point Likert scale that training had made "a lot" of difference to their RCT discussions. Analysis of free text revealed this was mostly in relation to how to convey equipoise, explain randomization, and manage treatment preferences. CONCLUSION Surgeons and research nurses reported increased self-confidence in discussing RCTs with patients, a raised awareness of hidden challenges and a positive impact on recruitment practice following QuinteT RCT Recruitment Training. Training will be made more available and evaluated in relation to recruitment rates and informed consent.
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Affiliation(s)
- Nicola Mills
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK.
| | - Daisy Gaunt
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Jane M Blazeby
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Daisy Elliott
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Samantha Husbands
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Peter Holding
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - Leila Rooshenas
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Marcus Jepson
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Bridget Young
- MRC North West Hub for Trials Methodology Research, Institute of Psychology Health and Society, University of Liverpool, Block B, Waterhouse Building, Brownlow Street, Liverpool L69 3GL, UK
| | - Peter Bower
- MRC North West Hub for Trials Methodology Research, Centre for Primary Care, University of Manchester, Williamson Building, Manchester M13 9PL, UK
| | - Catrin Tudur Smith
- MRC North West Hub for Trials Methodology Research, Institute of Translational Medicine, University of Liverpool, Block F Waterhouse Building, 1-5 Brownlow Street, Liverpool L69 3GL, UK
| | - Carrol Gamble
- MRC North West Hub for Trials Methodology Research, Institute of Translational Medicine, University of Liverpool, Block F Waterhouse Building, 1-5 Brownlow Street, Liverpool L69 3GL, UK
| | - Jenny L Donovan
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK; NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC), University Hospitals Bristol NHS Foundation Trust, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK
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Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, Shirkey BA, Donovan JL, Gwilym S, Savulescu J, Moser J, Gray A, Jepson M, Tracey I, Judge A, Wartolowska K, Carr AJ. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet 2018; 391:329-338. [PMID: 29169668 PMCID: PMC5803129 DOI: 10.1016/s0140-6736(17)32457-1] [Citation(s) in RCA: 256] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 06/20/2017] [Accepted: 08/29/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Arthroscopic sub-acromial decompression (decompressing the sub-acromial space by removing bone spurs and soft tissue arthroscopically) is a common surgery for subacromial shoulder pain, but its effectiveness is uncertain. We did a study to assess its effectiveness and to investigate the mechanism for surgical decompression. METHODS We did a multicentre, randomised, pragmatic, parallel group, placebo-controlled, three-group trial at 32 hospitals in the UK with 51 surgeons. Participants were patients who had subacromial pain for at least 3 months with intact rotator cuff tendons, were eligible for arthroscopic surgery, and had previously completed a non-operative management programme that included exercise therapy and at least one steroid injection. Exclusion criteria included a full-thickness torn rotator cuff. We randomly assigned participants (1:1:1) to arthroscopic subacromial decompression, investigational arthroscopy only, or no treatment (attendance of one reassessment appointment with a specialist shoulder clinician 3 months after study entry, but no intervention). Arthroscopy only was a placebo as the essential surgical element (bone and soft tissue removal) was omitted. We did the randomisation with a computer-generated minimisation system. In the surgical intervention groups, patients were not told which type of surgery they were receiving (to ensure masking). Patients were followed up at 6 months and 1 year after randomisation; surgeons coordinated their waiting lists to schedule surgeries as close as possible to randomisation. The primary outcome was the Oxford Shoulder Score (0 [worst] to 48 [best]) at 6 months, analysed by intention to treat. The sample size calculation was based upon a target difference of 4·5 points (SD 9·0). This trial has been registered at ClinicalTrials.gov, number NCT01623011. FINDINGS Between Sept 14, 2012, and June 16, 2015, we randomly assigned 313 patients to treatment groups (106 to decompression surgery, 103 to arthroscopy only, and 104 to no treatment). 24 [23%], 43 [42%], and 12 [12%] of the decompression, arthroscopy only, and no treatment groups, respectively, did not receive their assigned treatment by 6 months. At 6 months, data for the Oxford Shoulder Score were available for 90 patients assigned to decompression, 94 to arthroscopy, and 90 to no treatment. Mean Oxford Shoulder Score did not differ between the two surgical groups at 6 months (decompression mean 32·7 points [SD 11·6] vs arthroscopy mean 34·2 points [9·2]; mean difference -1·3 points (95% CI -3·9 to 1·3, p=0·3141). Both surgical groups showed a small benefit over no treatment (mean 29·4 points [SD 11·9], mean difference vs decompression 2·8 points [95% CI 0·5-5·2], p=0·0186; mean difference vs arthroscopy 4·2 [1·8-6·6], p=0·0014) but these differences were not clinically important. There were six study-related complications that were all frozen shoulders (in two patients in each group). INTERPRETATION Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinically important. Additionally, surgical decompression appeared to offer no extra benefit over arthroscopy only. The difference between the surgical groups and no treatment might be the result of, for instance, a placebo effect or postoperative physiotherapy. The findings question the value of this operation for these indications, and this should be communicated to patients during the shared treatment decision-making process. FUNDING Arthritis Research UK, the National Institute for Health Research Biomedical Research Centre, and the Royal College of Surgeons (England).
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK.
| | - Jonathan L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK; Royal College of Surgeons (England) Surgical Interventional Trials Unit (SITU), Botnar Research Centre, University of Oxford, Headington, Oxford, UK
| | - Beverly A Shirkey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol
| | - Stephen Gwilym
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Julian Savulescu
- Institute for Science and Ethics, University of Oxford, Littlegate House, Oxford, UK
| | - Jane Moser
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Alastair Gray
- Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Headington, Oxford, UK
| | - Marcus Jepson
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, University of Oxford, Headington, Oxford, UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Karolina Wartolowska
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, National Institute of Health Research (NIHR) Biomedical Research Centre, University of Oxford, Headington, Oxford, UK.
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Wilson C, Rooshenas L, Paramasivan S, Elliott D, Jepson M, Strong S, Birtle A, Beard DJ, Halliday A, Hamdy FC, Lewis R, Metcalfe C, Rogers CA, Stein RC, Blazeby JM, Donovan JL. Development of a framework to improve the process of recruitment to randomised controlled trials (RCTs): the SEAR (Screened, Eligible, Approached, Randomised) framework. Trials 2018; 19:50. [PMID: 29351790 PMCID: PMC5775609 DOI: 10.1186/s13063-017-2413-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 12/14/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Research has shown that recruitment to trials is a process that stretches from identifying potentially eligible patients, through eligibility assessment, to obtaining informed consent. The length and complexity of this pathway means that many patients do not have the opportunity to consider participation. This article presents the development of a simple framework to document, understand and improve the process of trial recruitment. METHODS Eight RCTs integrated a QuinteT Recruitment Intervention (QRI) into the main trial, feasibility or pilot study. Part of the QRI required mapping the patient recruitment pathway using trial-specific screening and recruitment logs. A content analysis compared the logs to identify aspects of the recruitment pathway and process that were useful in monitoring and improving recruitment. Findings were synthesised to develop an optimised simple framework that can be used in a wide range of RCTs. RESULTS The eight trials recorded basic information about patients screened for trial participation and randomisation outcome. Three trials systematically recorded reasons why an individual was not enrolled in the trial, and further details why they were not eligible or approached, or declined randomisation. A framework to facilitate clearer recording of the recruitment process and reasons for non-participation was developed: SEAR - Screening, to identify potentially eligible trial participants; Eligibility, assessed against the trial protocol inclusion/exclusion criteria; Approach, the provision of oral and written information and invitation to participate in the trial, and Randomised or not, with the outcome of randomisation or treatment received. CONCLUSIONS The SEAR framework encourages the collection of information to identify recruitment obstacles and facilitate improvements to the recruitment process. SEAR can be adapted to monitor recruitment to most RCTs, but is likely to add most value in trials where recruitment problems are anticipated or evident. Further work to test it more widely is recommended.
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Affiliation(s)
- Caroline Wilson
- School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Leila Rooshenas
- School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Sangeetha Paramasivan
- School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Daisy Elliott
- School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Marcus Jepson
- School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Sean Strong
- School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Alison Birtle
- Rosemere Cancer Centre, Royal Preston Hospital, Sharoe Green Land North, Fulwood, Preston, Lancashire PR2 9HT UK
| | - David J. Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 7LD UK
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, OX3 9DU UK
| | - Freddie C. Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, OX3 9DU UK
| | - Rebecca Lewis
- Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), Institute of Cancer Research, 15 Cotswold Road, Sutton, SM2 5NG UK
| | - Chris Metcalfe
- School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
- Bristol Randomised Trials Collaboration University of Bristol, School of Social and Community Medicine, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Chris A. Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Level 7 Queens Building, Bristol Royal Infirmary, Bristol, BS2 8HW UK
| | - Robert C. Stein
- NIHR University College London Hospitals Biomedical Research Centre, 149 Tottenham Court Road, London, W1T 7DN UK
| | - Jane M. Blazeby
- School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Jenny L. Donovan
- School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS UK
- Collaboration for Leadership in Applied Health Research and Care West, University Hospitals Bristol, 9th Floor, Whitefriars Lewins, Bristol, BS1 2NT UK
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Blackshaw H, Carding P, Jepson M, Mat Baki M, Ambler G, Schilder A, Morris S, Degun A, Yu R, Husbands S, Knowles H, Walton C, Karagama Y, Heathcote K, Birchall M. Does laryngeal reinnervation or type I thyroplasty give better voice results for patients with unilateral vocal fold paralysis (VOCALIST): study protocol for a feasibility randomised controlled trial. BMJ Open 2017; 7:e016871. [PMID: 28965097 PMCID: PMC5640104 DOI: 10.1136/bmjopen-2017-016871] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 11/24/2022] Open
Abstract
INTRODUCTION A functioning voice is essential for normal human communication. A good voice requires two moving vocal folds; if one fold is paralysed (unilateral vocal fold paralysis (UVFP)) people suffer from a breathy, weak voice that tires easily and is unable to function normally. UVFP can also result in choking and breathlessness. Current treatment for adults with UVFP is speech therapy to stimulate recovery of vocal fold (VF) motion or function and/or injection of the paralysed VF with a material to move it into a more favourable position for the functioning VF to close against. When these therapies are unsuccessful, or only provide temporary relief, surgery is offered. Two available surgical techniques are: (1) surgical medialisation; placing an implant near the paralysed VF to move it to the middle (thyroplasty) and/or repositioning the cartilage (arytenoid adduction) or (2) restoring the nerve supply to the VF (laryngeal reinnervation). Currently there is limited evidence to determine which surgery should be offered to adults with UVFP. METHODS AND ANALYSIS A feasibility study to test the practicality of running a multicentre, randomised clinical trial of surgery for UVFP, including: (1) a qualitative study to understand the recruitment process and how it operates in clinical centres and (2) a small randomised trial of 30 participants recruited at 3 UK sites comparing non-selective laryngeal reinnervation to type I thyroplasty. Participants will be followed up for 12 months. The primary outcome focuses on recruitment and retention, with secondary outcomes covering voice, swallowing and quality of life. ETHICS AND DISSEMINATION Ethical approval was received from National Research Ethics Service-Committee Bromley (reference 11/LO/0583). In addition to dissemination of results through presentation and publication of peer-reviewed articles, results will be shared with key clinician and patient groups required to develop the future large-scale randomised controlled trial. TRIAL REGISTRATION NUMBER ISRCTN90201732; 16 December 2015.
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Affiliation(s)
| | - Paul Carding
- School of Allied Health, Australian National Catholic University, North Sydney, New South Wales, Australia
| | - Marcus Jepson
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Marina Mat Baki
- Faculty of Medicine, National University of Malaysia, Malaysia
| | - Gareth Ambler
- Statistical Science, University College London, London, UK
| | - Anne Schilder
- Ear Institute, University College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Aneeka Degun
- Ear Institute, University College London, London, UK
| | - Rosamund Yu
- UCL Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Samantha Husbands
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Helen Knowles
- Royal National Throat, Nose and Ear Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Chloe Walton
- School of Allied Health, Australian National Catholic University, North Sydney, New South Wales, Australia
| | - Yakubu Karagama
- Department of Otolaryngology-Head & Neck Surgery, Manchester Royal Infirmary, Manchester, UK
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Mehanna HM, Sen M, Chester JD, Sanghera P, Paleri V, Gaunt P, Babrah J, Hartley AGJ, Kong A, Al-Booz H, Foran B, Miles E, Robinson M, Jepson M, Donnovan J, Yap C, Firth C, Gaunt C, Bowden SJ, Forster MD. Phase III randomised controlled trial (RCT) comparing alternative regimens for escalating treatment of intermediate and high-risk oropharyngeal cancer (CompARE). J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.tps6091] [Citation(s) in RCA: 7] [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] [Indexed: 11/20/2022] Open
Abstract
TPS6091 Background: Patients with intermediate and high-risk oropharyngeal cancer (OPC) have poorer response to standard treatment and poorer overall survival compared to low-risk OPC. The CompARE trial is designed to test alternative approaches to intensification of treatment for these patients to improve survival. Methods: CompARE is a pragmatic phase III open-label multicenter RCT with an adaptive multi-arm multi-stage design. Eligible OPC patients include those with; HPV negative, T1-T4, N1-N3 or T3-4, N0 or HPV positive current smokers (or ≥ 10 pack years previous smoking history) with T1-T4, N2b-N3. The primary outcome measure is overall survival. Secondary outcome measures include quality of life, toxicity, swallowing outcomes, feeding tube incidence, surgical complications and cost-effectiveness. The trial is powered to detect a hazard ratio of 0.69 (an improvement of 10% in OS at 3-years) requiring 128 control events. It is estimated that the study will take 6.5 years to recruit sufficient patients to experience the number of events needed. Planned interim futility analyses using event-free survival (EFS) will be performed when 70 and 114 control EFS events have occurred. Current treatment arms are; (1) control: standard treatment of 3-weekly cisplatin 100mg/m2 or weekly 40mg/m2 with Intensity Modulated Radiotherapy (IMRT) using 70Gy in 35F +/- neck dissection determined by clinical and radiological assessment 3-months post treatment. (3) IMRT 64Gy in 25F + cisplatin 100mg/m2 day 1 of week 1 and week 5 or weekly 40mg/m2+/- neck dissection as per standard treatment. (4) Resection of primary + selective neck dissection followed by standard treatment. (5) One cycle of induction durvalumab 1500mg followed by standard treatment then durvalumab 1500mg every four weeks for a total of 6 months. Recruitment to arm (2) involving induction chemotherapy from the original protocol is suspended. Since July 2015, 42 patients have been randomised with 16 sites open to recruitment. The Data Monitoring Committee last reviewed progress and conduct of the trial in September 2016 and recommended continuation. ISRCTN Number: 41478539, CRUK CRUK/13/026 Clinical trial information: 41478539.
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Affiliation(s)
| | - Mehmet Sen
- St James's Institute of Oncology, Leeds, United Kingdom
| | | | - Paul Sanghera
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Vinidh Paleri
- Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, United Kingdom
| | - Piers Gaunt
- University of Birmingham, Birmingham, United Kingdom
| | | | - Andrew G. J. Hartley
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Anthony Kong
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - H Al-Booz
- Bristol Haematology and Oncology Centre, Bristol, United Kingdom
| | - Bernadette Foran
- Weston Park Hospital, Academic Unit of Clinical Oncology, Sheffield, United Kingdom
| | | | - Max Robinson
- Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | | | | | - Christina Yap
- University of Birmingham, Birmingham, United Kingdom
| | | | - Claire Gaunt
- University of Birmingham, Birmingham, United Kingdom
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Rooshenas L, Elliott D, Wade J, Jepson M, Paramasivan S, Strong S, Wilson C, Beard D, Blazeby JM, Birtle A, Halliday A, Rogers CA, Stein R, Donovan JL. Conveying Equipoise during Recruitment for Clinical Trials: Qualitative Synthesis of Clinicians' Practices across Six Randomised Controlled Trials. PLoS Med 2016; 13:e1002147. [PMID: 27755555 PMCID: PMC5068710 DOI: 10.1371/journal.pmed.1002147] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/07/2016] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) are essential for evidence-based medicine and increasingly rely on front-line clinicians to recruit eligible patients. Clinicians' difficulties with negotiating equipoise is assumed to undermine recruitment, although these issues have not yet been empirically investigated in the context of observable events. We aimed to investigate how clinicians conveyed equipoise during RCT recruitment appointments across six RCTs, with a view to (i) identifying practices that supported or hindered equipoise communication and (ii) exploring how clinicians' reported intentions compared with their actual practices. METHODS AND FINDINGS Six pragmatic UK-based RCTs were purposefully selected to include several clinical specialties (e.g., oncology, surgery) and types of treatment comparison. The RCTs were all based in secondary-care hospitals (n = 16) around the UK. Clinicians recruiting to the RCTs were interviewed (n = 23) to understand their individual sense of equipoise about the RCT treatments and their intentions for communicating equipoise to patients. Appointments in which these clinicians presented the RCT to trial-eligible patients were audio-recorded (n = 105). The appointments were analysed using thematic and content analysis approaches to identify practices that supported or challenged equipoise communication. A sample of appointments was independently coded by three researchers to optimise reliability in reported findings. Clinicians and patients provided full written consent to be interviewed and have appointments audio-recorded. Interviews revealed that clinicians' sense of equipoise varied: although all were uncertain about which trial treatment was optimal, they expressed different levels of uncertainty, ranging from complete ambivalence to clear beliefs that one treatment was superior. Irrespective of their personal views, all clinicians intended to set their personal biases aside to convey trial treatments neutrally to patients (in accordance with existing evidence). However, equipoise was omitted or compromised in 48/105 (46%) of the recorded appointments. Three commonly recurring practices compromised equipoise communication across the RCTs, irrespective of clinical context. First, equipoise was overridden by clinicians offering treatment recommendations when patients appeared unsure how to proceed or when they asked for the clinician's expert advice. Second, clinicians contradicted equipoise by presenting imbalanced descriptions of trial treatments that conflicted with scientific information stated in the RCT protocols. Third, equipoise was undermined by clinicians disclosing their personal opinions or predictions about trial outcomes, based on their intuition and experience. These broad practices were particularly demonstrated by clinicians who had indicated in interviews that they held less balanced views about trial treatments. A limitation of the study was that clinicians volunteering to take part in the research might have had a particular interest in improving their communication skills. However, the frequency of occurrence of equipoise issues across the RCTs suggests that the findings are likely to be reflective of clinical recruiters' practices more widely. CONCLUSIONS Communicating equipoise is a challenging process that is easily disrupted. Clinicians' personal views about trial treatments encroached on their ability to convey equipoise to patients. Clinicians should be encouraged to reflect on personal biases and be mindful of the common ways in which these can arise in their discussions with patients. Common pitfalls that recurred irrespective of RCT context indicate opportunities for specific training in communication skills that would be broadly applicable to a wide clinical audience.
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Affiliation(s)
- Leila Rooshenas
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Daisy Elliott
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Julia Wade
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Marcus Jepson
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Sangeetha Paramasivan
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Sean Strong
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Caroline Wilson
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jane M. Blazeby
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Alison Birtle
- Rosemere Cancer Centre, Royal Preston Hospital, Preston, United Kingdom
| | | | - Chris A. Rogers
- Clinical Trials and Evaluation Unit, Bristol Royal Infirmary, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Rob Stein
- University College London Hospitals, London, United Kingdom
| | - Jenny L. Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Trust, Bristol, United Kingdom
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Jepson M, Laybourne A, Williams V, Cyhlarova E, Williamson T, Robotham D. Indirect payments: when the Mental Capacity Act interacts with the personalisation agenda. Health Soc Care Community 2016; 24:623-630. [PMID: 25931130 DOI: 10.1111/hsc.12236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 06/04/2023]
Abstract
This paper reports findings from a study that aimed to explore how practitioners were bringing together the demands of the personalisation agenda, in particular the offer of direct payments (DPs), with the Mental Capacity Act, and to investigate current practices of offering and administering indirect payments for people who lack capacity to consent to them, including the use of 'suitable person' proxies under the new regulations (DH, 2009). The study adopted a qualitative interview-based design; participants were social work practitioners (67) and recipients of 'indirect' payments (18) in six local authorities in England in 2011-2012. The paper reports on five key decision-making points in the indirect payments process: the decision to take on an indirect payment, the assessment of mental capacity, the identification of a suitable person, the establishment of the care recipient's best interests and the decisions about how to execute the indirect payment. We found that practitioners and suitable people had different experiences of the system, although in both cases, there was overarching support for the benefits of enabling people who lack capacity to consent to a DP to receive their social care funding in the form of an 'indirect' payment via a proxy suitable person.
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Affiliation(s)
- Marcus Jepson
- School for Policy Studies/School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Val Williams
- Norah Fry Research Centre, School for Policy Studies, University of Bristol, Bristol, UK
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Abbott D, Jepson M, Hastie J. Men living with long-term conditions: exploring gender and improving social care. Health Soc Care Community 2016; 24:420-427. [PMID: 25816903 DOI: 10.1111/hsc.12222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 06/04/2023]
Abstract
Disabled men have traditionally been seen as incomplete men or as entirely gender-less. Research which has looked at the intersection of disability and male gender has largely treated disabled men as a homogeneous group with little reference to, for example, impairment-related differences. The ongoing move towards self-directed, personalised social care in England suggests that support needs relating to gender may be taken more seriously. A qualitative study with 20 men with Duchenne muscular dystrophy in England in 2013 explored the men's experiences of the organisation and delivery of social care as it pertained to their sense of being men. Our main finding was that social care in its broadest sense did little to support a positive sense of masculinity or male gender. More often than not the organisation and delivery of social care people de-gendered or emasculated many of the men who took part in the study. Our paper speaks to the need to explore impairment-specific issues for disabled men; to deliver a more person-centred approach to social care which recognises the importance of the social and sexual lives of disabled men; and to create ways in which men can support and empower each other to assert essential human rights relating to independence, dignity and liberty.
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Affiliation(s)
- David Abbott
- Norah Fry Research Centre, School for Policy Studies, University of Bristol, Bristol, UK
| | - Marcus Jepson
- Norah Fry Research Centre, School for Policy Studies, University of Bristol, Bristol, UK
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Donovan JL, Rooshenas L, Jepson M, Elliott D, Wade J, Avery K, Mills N, Wilson C, Paramasivan S, Blazeby JM. Optimising recruitment and informed consent in randomised controlled trials: the development and implementation of the Quintet Recruitment Intervention (QRI). Trials 2016; 17:283. [PMID: 27278130 PMCID: PMC4898358 DOI: 10.1186/s13063-016-1391-4] [Citation(s) in RCA: 151] [Impact Index Per Article: 18.9] [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: 10/24/2015] [Accepted: 05/06/2016] [Indexed: 11/27/2022] Open
Abstract
Background Pragmatic randomised controlled trials (RCTs) are considered essential to determine effective interventions for routine clinical practice, but many fail to recruit participants efficiently, and some really important RCTs are not undertaken because recruitment is thought to be too difficult. The ‘QuinteT Recruitment Intervention’ (QRI) aims to facilitate informed decision making by patients about RCT participation and to increase recruitment. This paper presents the development and implementation of the QRI. Methods The QRI developed iteratively as a complex intervention. It emerged from the National Institute for Health Research (NIHR) ProtecT trial and has been developed further in 13 RCTs. The final version of the QRI uses a combination of standard and innovative qualitative research methods with some simple quantification to understand recruitment and identify sources of difficulties. Results The QRI has two major phases: understanding recruitment as it happens and then developing a plan of action to address identified difficulties and optimise informed consent in collaboration with the RCT chief investigator (CI) and the Clinical Trials Unit (CTU). The plan of action usually includes RCT-specific, as well as generic, aspects. The QRI can be used in two ways: it can be integrated into the feasibility/pilot or main phase of an RCT to prevent difficulties developing and optimise recruitment from the start, or it can be applied to an ongoing RCT experiencing recruitment shortfalls, with a view to rapidly improving recruitment and informed consent or gathering evidence to justify RCT closure. Conclusions The QRI provides a flexible way of understanding recruitment difficulties and producing a plan to address them while ensuring engaged and well-informed decision making by patients. It can facilitate recruitment to the most controversial and important RCTs. QRIs are likely to be of interest to the CIs and CTUs developing proposals for ‘difficult’ RCTs or for RCTs with lower than expected recruitment and to the funding bodies wishing to promote efficient recruitment in pragmatic RCTs. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1391-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK. .,Collaboration for Leadership in Applied Health Research and Care West at University Hospitals Bristol, Bristol, BS1 2NT, UK.
| | - Leila Rooshenas
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Marcus Jepson
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Daisy Elliott
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Julia Wade
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Kerry Avery
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Nicola Mills
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Caroline Wilson
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Sangeetha Paramasivan
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Jane M Blazeby
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
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Jepson M, Townsend D, Wade J, Conefrey C, Donovan J. “It's what we call a randomised control trial” exploring how randomisation is presented by recruiters in RCTs. Trials 2015. [PMCID: PMC4659310 DOI: 10.1186/1745-6215-16-s2-o36] [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: 11/30/2022] Open
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Barnes RK, Jepson M, Heawood A. Using conversation analytic methods to explore the content, delivery and receipt of complex healthcare interventions. Trials 2015. [PMCID: PMC4660064 DOI: 10.1186/1745-6215-16-s2-p77] [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: 11/10/2022] Open
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Beard D, Rees J, Rombach I, Cooper C, Cook J, Merritt N, Gray A, Gwilym S, Judge A, Savulescu J, Moser J, Donovan J, Jepson M, Wilson C, Tracey I, Wartolowska K, Dean B, Carr A. The CSAW Study (Can Shoulder Arthroscopy Work?) - a placebo-controlled surgical intervention trial assessing the clinical and cost effectiveness of arthroscopic subacromial decompression for shoulder pain: study protocol for a randomised controlled trial. Trials 2015; 16:210. [PMID: 25956385 PMCID: PMC4443660 DOI: 10.1186/s13063-015-0725-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [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: 01/06/2015] [Accepted: 04/15/2015] [Indexed: 11/22/2022] Open
Abstract
Background Arthroscopic subacromial decompression (ASAD) is a commonly performed surgical intervention for shoulder pain. The rationale is that removal of a bony acromial spur relieves symptoms by decompressing rotator cuff tendons passing through the subacromial space. However, the efficacy of this procedure is uncertain. The objective of this trial was to compare the efficacy and cost-effectiveness of ASAD in patients with subacromial pain using appropriate control groups, including placebo intervention. Methods/Design The trial is a three-group, parallel design, pragmatic, randomised controlled study. The intervention content for each group (ASAD, active monitoring with specialist reassessment (AMSR) and investigational shoulder arthroscopy only (AO)) enables assessment of (1) the efficacy of the surgery against no surgery; (2) the need for a specific component of the surgery—namely, removal of the bony spur; and (3) quantification of the placebo effect. Concealed allocation was performed using a 1:1:1 randomisation ratio and using age, sex, baseline Oxford Shoulder Score (OSS) and centre as minimisation criteria. The primary outcome measure is the OSS at 6 months post randomisation. A total of 300 patients recruited over 24 months from a minimum of 14 UK shoulder units over 24 months were required to detect a difference of 4.5 points on the OSS (standard deviation, 9) with 90% power and to allow for 15% loss to follow-up. Secondary outcomes include cost-effectiveness, pain, complications and patient satisfaction. A substantial qualitative research component is included. The primary analysis will be conducted on the modified intention-to-treat analysis. Sensitivity analysis will be used to assess the robustness of the results with regard to the underlying assumptions about missing data using multiple imputation. Discussion This trial uses an innovative design to account for the known placebo effects of surgery, but it also will delineate the mechanism for any benefit from surgery. The investigational AO group is considered a placebo intervention (not sham surgery), as it includes all components of subacromial decompression except the critical surgical element. Some discussion is also dedicated to the challenges of conducting placebo surgery trials. Trial registrations UK Clinical Research Network UKCRN12104. Registered 22 May 2012. International Standard Randomised Controlled Trial ISRCTN33864128. Registered 22 June 2012. ClinicalTrials.gov NCT01623011. Registered 15 June 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0725-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - Jonathan Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - Jonathan Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - Alastair Gray
- Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK.
| | - Stephen Gwilym
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - Julian Savulescu
- Institute for Science and Ethics, University of Oxford, Suite 8, Littlegate House, 16/17 St Ebbe's Street, Oxford, OX1 1PT, UK.
| | - Jane Moser
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - Jenny Donovan
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Marcus Jepson
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Caroline Wilson
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK.
| | - Karolina Wartolowska
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - Benjamin Dean
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
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Heslop P, Noble A, Hoghton M, Jepson M, Marriott A. Authors' reply to Waite. BMJ 2014; 348:g1915. [PMID: 24603576 DOI: 10.1136/bmj.g1915] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Pauline Heslop
- Norah Fry Research Centre, School for Policy Studies, University of Bristol, Bristol BS8 1TZ, UK
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Heslop P, Marriott A, Hoghton M, Jepson M, Noble A. Caring for a woman with intellectual disabilities who refuses clinical diagnostic investigations. BMJ 2014. [DOI: 10.1136/bmj.f7645] [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] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Williams V, Boyle G, Jepson M, Swift P, Williamson T, Heslop P. Best interests decisions: professional practices in health and social care. Health Soc Care Community 2014; 22:78-86. [PMID: 23981053 DOI: 10.1111/hsc.12066] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/27/2013] [Indexed: 06/02/2023]
Abstract
This paper reports on data collected in 2011 from a national study about the operation of the best interests principle, a key feature of the Mental Capacity Act (MCA) 2005 for England and Wales. The objective was to provide a picture of current professional practices in best interests decision-making. Four contrasting sample sites were selected, in which National Health Service trusts, social care and other organisations were recruited to participate. A multimethod design was followed, including an online survey with 385 participants, followed by qualitative research through a telephone survey of 68 participants, and face-to-face semi-structured interviews following up 25 best interests cases, with different perspectives on the process in 12 of those cases. The current paper reports only on the qualitative findings. The findings indicate that the MCA was successful in providing a structure for these practitioners, and that the five principles of the MCA were in general adhered to. A variety of perceived risks led to best interests processes being undertaken, and a typical scenario was for a period of hospitalisation or ill health to trigger a best interests decision process about a social care and or a life decision. The study supported previous research in finding the notion of capacity the most difficult aspect of the MCA, and it provides evidence of some specific capacity assessment practices, including problematic ones relating to 'insight'. Best interests decisions were often made by consensus, with practitioners taking on different roles within the process. Meetings played a key part, but other ways of involving people lacking capacity and significant others were also important. It was recommended that the issues highlighted in this research could be clarified further in the Code of Practice, or within risk guidance.
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Affiliation(s)
- Val Williams
- Norah Fry Research Centre, University of Bristol, Bristol, UK
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Abstract
Abstract
A survey carried out by the authors in the West Midlands area of England found that use of, and access to, community pharmaceutical services appeared to be lower among ethnic minority customers than in the majority population, although their needs were probably higher. The survey has been published in full elsewhere. In this article, the authors summarise the main results of their survey, and compare these with the results from a similar study involving respondents predominantly from the white population. They also discuss some of the methodological difficulties in carrying out research into ethnic minority health issues.
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Affiliation(s)
- J Jesson
- Pharmacy Practice Research Group, Institute of Pharmaceutical Sciences, Aston University, Birmingham, England B4 7ET
| | - S Sadler
- MEL Research, Aston Science Park, Birmingham
| | - R Pocock
- MEL Research, Aston Science Park, Birmingham
| | - M Jepson
- Pharmacy Practice Research Group, Institute of Pharmaceutical Sciences, Aston University, Birmingham, England B4 7ET
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Rempe D, Vangeison G, Hamilton J, Li Y, Jepson M, Federoff HJ. Synapsin I Cre transgene expression in male mice produces germline recombination in progeny. Genesis 2006; 44:44-9. [PMID: 16419044 DOI: 10.1002/gene.20183] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The cre/LoxP system can produce conditional loss of gene function in specific cell types such as neurons. A transgenic mouse line, utilized by multiple studies, used the Synapsin I promoter to drive expression of cre (SynCre) to achieve neuronal-specific cre expression. Herein we describe that cre expression can also be observed in SynCre mice within the testes after being bred into a floxed transgenic mouse line. Cre transcript was expressed in testes resulting in recombination of the floxed substrate in testes. In the majority of cases, progeny of male SynCre mice inherited a germline recombined floxed allele, while this was never observed in progeny from female mice carrying the SynCre allele. This observation should alert investigators to a potential confound using these mice and enables male germ cell "deletor" strategies.
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Pattni K, Jepson M, Stenmark H, Banting G. A PtdIns(3)P-specific probe cycles on and off host cell membranes during Salmonella invasion of mammalian cells. Curr Biol 2001; 11:1636-42. [PMID: 11676927 DOI: 10.1016/s0960-9822(01)00486-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [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: 11/19/2022]
Abstract
Salmonella invade nonphagocytic cells by eliciting their own internalization; upon contact with the host cell, the bacteria induce membrane ruffles highly localized to the point of contact between the invading bacterium and the host cell. The bacterium is then internalized into an unusual cytosolic organelle, the Salmonella-containing vacuole (SCV). Early endosomal markers (including EEA1) have recently been shown to be associated with the SCV shortly after invasion. EEA1, a protein involved in early endosome fusion, is recruited to early endosomal membranes in part by the interaction between its FYVE finger and phosphatidylinositol 3-phosphate [PtdIns(3)P], a characteristic lipid of early endosomes. This suggests a possible role for PtdIns(3)P during Salmonella infection. To investigate this, we generated a highly specific probe for PtdIns(3)P that was used to follow invasion of Salmonella in nonphagocytic cells. Here, we show that PtdIns(3)P is present on the membranes of SCVs shortly after invasion and also that it is present on the membrane ruffles produced immediately prior to invasion. We also show that this specific probe cycles on and off the membranes of nascent SCVs even when PtdIns 3-kinase activity is inhibited, demonstrating that invading Salmonella influence the composition of the membranes that envelop them during invasion.
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Affiliation(s)
- K Pattni
- Department of Biochemistry, University of Bristol, Bristol, United Kingdom
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Jepson M, Bullifent HL, Crane D, Flores-Diaz M, Alape-Giron A, Jayasekeera P, Lingard B, Moss D, Titball RW. Tyrosine 331 and phenylalanine 334 in Clostridium perfringens alpha-toxin are essential for cytotoxic activity. FEBS Lett 2001; 495:172-7. [PMID: 11334886 DOI: 10.1016/s0014-5793(01)02385-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [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: 11/29/2022]
Abstract
Differences in the biological properties of the Clostridium perfringens phospholipase C (alpha-toxin) and the C. bifermentans phospholipase C (Cbp) have been attributed to differences in their carboxy-terminal domains. Three residues in the carboxy-terminal domain of alpha-toxin, which have been proposed to play a role in membrane recognition (D269, Y331 and F334), are not conserved in Cbp (Y, L and I respectively). We have characterised D269Y, Y331L and F334I variant forms of alpha-toxin. Variant D269Y had reduced phospholipase C activity towards aggregated egg yolk phospholipid but increased haemolytic and cytotoxic activity. Variants Y331L and F334I showed a reduction in phospholipase C, haemolytic and cytotoxic activities indicating that these substitutions contribute to the reduced haemolytic and cytotoxic activity of Cbp.
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Affiliation(s)
- M Jepson
- Defense Evaluation Research Agency, CBD Porton Down, Salisbury, UK
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Abstract
Many Gram-negative pathogens use a type III secretion apparatus to deliver effector molecules into host cells to subvert cellular processes in favour of the pathogen. Enteropathogenic Escherichia coli (EPEC) uses such a system to deliver the Tir effector molecule into host cells. In this paper, we show that the gene upstream of tir, orf19, encodes an additional type III secreted effector protein. Orf19 is delivered into host cells by a mechanism independent of endocytosis, but dependent on EspB. Orf19 is targeted to host mitochondria, where it appears to interfere with the ability to maintain membrane potential. Although the precise role of Orf19 remains to be elucidated, its interaction with mitochondria suggests a possible role in the subversion of key functions of these organelles, such as energy production or control of cell death. This is the first example of a type III secreted protein targeted to mitochondria; it is probable that homologues (present in EPEC and Shigella species) and other bacterial effectors will also target this organelle.
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Affiliation(s)
- B Kenny
- Department of Pathology and Microbiology, School of Medical Sciences, University Walk, Bristol, UK.
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Abstract
A range of clostridial species produce phospholipases C. The zinc metallo phospholipases C have related sequences but different properties. All of these enzymes may be arranged, like alpha-toxin as two-domain proteins. Differences in enzymatic, haemolytic and toxic properties may be explained by differences in amino acids at key positions.
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Affiliation(s)
- M Jepson
- Defence Evaluation and Research Agency, CBD, Porton Down, Salisbury, Wiltshire SP4 0JQ, UK
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Naylor CE, Jepson M, Crane DT, Titball RW, Miller J, Basak AK, Bolgiano B. Characterisation of the calcium-binding C-terminal domain of Clostridium perfringens alpha-toxin. J Mol Biol 1999; 294:757-70. [PMID: 10610794 DOI: 10.1006/jmbi.1999.3279] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [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: 11/22/2022]
Abstract
Alpha-toxin is the key determinant in gas-gangrene. The toxin, a phospholipase C, cleaves phosphatidylcholine in eukaryotic cell membranes. Calcium ions have been shown to be required for the specific binding of toxin to membranes prior to phospholipid cleavage. Reported X-ray crystallographic structures of the toxin show that the C-terminal domain has a fold that is analogous to the eukaryotic calcium and membrane-binding C2 domains. We report the binding sites for three calcium ions that have been identified, by crystallographic methods, in the C-terminal domain of the protein close to the postulated membrane-binding surface. The position of these ions at the tip of the domain, and their function (to facilitate membrane binding) is similar to that of calcium ions observed bound to C2 domains. Using the optical spectroscopic techniques of circular dichroism (CD) and fluorescence spectroscopy, pronounced changes to both near and far-UV CD and tryptophan emission fluorescence upon addition of calcium to the C-terminal domain of alpha-toxin have been observed. The changes in near-UV CD, fluorescence enhancement and a 2 nm blue-shift in the fluorescence emission spectrum are consistent with tryptophan residue(s) becoming more immobilised in a hydrophobic environment. Calcium binding appears to be low-affinity: Kd approximately 175-250 microM at pH 8 assuming a 1:1 stoichiometry. as measured by spectroscopic methods.
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Affiliation(s)
- C E Naylor
- Department of Crystallography, Birkbeck College, London, UK
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Jepson M, Howells A, Bullifent HL, Bolgiano B, Crane D, Miller J, Holley J, Jayasekera P, Titball RW. Differences in the carboxy-terminal (Putative phospholipid binding) domains of Clostridium perfringens and Clostridium bifermentans phospholipases C influence the hemolytic and lethal properties of these enzymes. Infect Immun 1999; 67:3297-301. [PMID: 10377104 PMCID: PMC116509 DOI: 10.1128/iai.67.7.3297-3301.1999] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [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: 11/20/2022] Open
Abstract
The phospholipases C of C. perfringens (alpha-toxin) and C. bifermentans (Cbp) show >50% amino acid homology but differ in their hemolytic and toxic properties. We report here the purification and characterisation of alpha-toxin and Cbp. The phospholipase C activity of alpha-toxin and Cbp was similar when tested with phosphatidylcholine in egg yolk or in liposomes. However, the hemolytic activity of alpha-toxin was more than 100-fold that of Cbp. To investigate whether differences in the carboxy-terminal domains of these proteins were responsible for differences in the hemolytic and toxic properties, a hybrid protein (NbiCalpha) was constructed comprising the N domain of Cbp and the C domain of alpha-toxin. The hemolytic activity of NbiCalpha was 10-fold that of Cbp, and the hybrid enzyme was toxic. These results confirm that the C-terminal domain of these proteins confers different properties on the enzymatically active N-terminal domain of these proteins.
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Affiliation(s)
- M Jepson
- Defence Evaluation and Research Agency, CBD Porton Down, Salisbury, Wiltshire SP4 0JQ, United Kingdom
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Abstract
This is a discussion paper which generates some important research questions for educationalists. The teaching of food skills are at danger of being lost from the school cirriculum by changes imposed by the National Curriculum. This sinister (i.e., unexplained/undefined) development generates potential problems for the teaching of cookery and for the food and eating traditions of British society. The central concern for nutrition educationalists is that cooking is becoming more and more de-domesticated and consequently will become more systemised, more mass produced; in which case, young people need not be educated in basic cooking skills.
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Affiliation(s)
- S Stitt
- Centre for Consumer Education & Research, Liverpool John Moores University, IM Marsh
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