Trial Forge Guidance 4: a guideline for reporting the results of randomised Studies Within A Trial (SWATs)

BACKGROUND

Evidence to support decisions on trial processes is minimal. One way to generate this evidence is to use a Study Within A Trial (SWAT) to test trial processes or explore methodological uncertainties. SWAT evidence relies on replication to ensure sufficient power and broad applicability of findings. Prompt reporting is therefore essential; however, SWAT publications are often the first to be abandoned in the face of other time pressures. Reporting guidance for embedded methodology trials does exist but is not widely used. We sought therefore to build on these guidelines to develop a straightforward, concise reporting standard, which remains adherent to the CONSORT guideline.

METHODS

An iterative process was used to develop the guideline. This included initial meetings with key stakeholders, development of an initial guideline, pilot testing of draft guidelines, further iteration and pilot testing, and finalisation of the guideline.

RESULTS

We developed a reporting guideline applicable to randomised SWATs, including replications of previous evaluations. The guideline follows the Consolidated Standards for Reporting Trials (CONSORT) statement and provides example text to ensure ease and clarity of reporting across all domains.

CONCLUSIONS

The SWAT reporting guideline will aid authors, reviewers, and journal editors to produce and review clear, structured reports of randomised SWATs, whilst also adhering to the CONSORT guideline.

TRIAL REGISTRATION

EQUATOR Network - Guidelines Under Development ( https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-clinical-trials/#SWAT ). Registered on 25 March 2021.

AB0156 INTRA-ARTICULAR AGRIN PROVIDES DIRECT PAIN RELIEF IN OSTEOARTHRITIS AND CARTILAGE DEFECTS

Background

Osteoarthritis is the leading cause of disability worldwide with a financial burden estimated between 1.5 and 2% of the GDP in all westernised countries. The main driver of progression in osteoarthritis is cartilage loss, which may be associated with bone changes, low degree synovitis and lesions to menisci and ligaments. These pathological features result in pain, which contributes to chronic disability.

Improving cartilage integrity without pain relief does not help patients and results in failure in clinical trials. Therefore, there is a need for therapeutics that induce rapid pain relief and long-term cartilage regeneration.

We previously showed that Agrin results in cartilage regeneration and in this study, following on the serendipitous finding of rapid pain relief after Agrin administration we explore its analgesic effect in animal models of osteochondral defects and osteoarthritis.

Objectives

Test the analgesic potential of Agrin in post-surgical pain associated with osteochondral defects in mice and sheep.

Determine whether Agrin can relieve chronic pain induced by osteoarthritis in mice.

Investigate the therapeutic potential of Agrin in models of primary and injury-induced secondary osteoarthritis.

Methods

Acute post-surgical pain: Surgery was performed on skeletally mature male mice and female sheep to create critical-sized osteochondral defects; defects were filled with collagen gel containing PBS or Agrin. Animals were sacrificed 8 weeks (mice) and 6 months (sheep) after surgery. Pain was measured in mice using von Frey filaments and incapacitance readings. Sheep were fitted with accelerometers for the duration of the study.

Osteoarthritic pain: Osteoarthritis was surgically induced in skeletally mature male mice by menisco-ligament injury (MLI). Control mice received sham surgery. Nine weeks post-surgery, once chronic pain was established, mice were injected intra-articularly with recombinant Agrin. Pain was measured by von Frey filaments and incapacitance.

Treatment in therapeutic regime: Tamoxifen-inducible transgenic mice overexpressing Agrin under the AggrecanCre promotor were generated. Skeletally mature male mice were subjected to menisco-ligament injury surgery. Four weeks later, tamoxifen was administered to overexpress Agrin in the cartilage. Pain was measured by von Frey filaments and incapacitance.

Ex-vivo: MicroCT, X-ray, Kellgren-Laurence scoring, histology, OARSI scoring and immunohistochemistry.

Results

In sheep, Agrin administration induced regeneration in osteochondral defects and, more importantly, reduced the levels of secondary osteoarthritis. This was associated with a rapid and sustained symptomatic relief.

In mice, Agrin expression was lost in the dorsal root ganglia corresponding to the limb subjected to MLI but not in the dorsal root ganglia corresponding to the sham operated limbs.

Intra-articular recombinant Agrin in mice with established OA (9 weeks after MLI surgery) resulted in pain relief as early as three hours after administration. Acute administration of recombinant Agrin does not have any analgesic effects in sham operated mice.

Inducible, cartilage-specific Agrin-overexpression mice were protected from developing pain associated with instability-induced osteoarthritis.

In mice with acute osteochondral defects, intra-articular Agrin administration resulted in pain relief for at least five days.

In humans, the loss of Agrin in the articular cartilage correlated significantly with the Mankin score of patients undergoing knee replacement surgery.

Conclusion

Agrin has analgesic properties in both the acute phases of cartilage damage and in established osteoarthritis. Our findings support the therapeutic use of Agrin for joint surface regeneration and pain relief.

Disclosure of Interests

Suzanne Eldridge: None declared, Aida Barawi: None declared, Anne-Sophie Thorup: None declared, Beatriz F Fernandez: None declared, Sabah Bharde: None declared, Shafaq Sikandar: None declared, Zeyu Guan: None declared, Magdalena Kaneva: None declared, Helen Lydon: None declared, Fran Henson: None declared, Cosimo De Bari: None declared, Andrew McCaskie: None declared, Francesco Dell’Accio Consultant of: Prof Dell’Accio has consulted for Samumed, Grant/research support from: A PhD studentship unrelated to this abstract is funded by UCB

Stepped-wedge randomized controlled trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation

Background

The effectiveness of laparoscopic ventral mesh rectopexy (LVMR) in patients with defecatory disorders secondary to internal rectal prolapse is poorly evidenced. A UK-based multicenter randomized controlled trial was designed to determine the clinical efficacy of LVMR compared to controls at medium-term follow-up.

Methods

The randomized controlled trial was conducted from March 1, 2015 TO January 31, 2019. A stepped-wedge RCT design permitted observer-masked data comparisons between patients awaiting LVMR (controls) with those who had undergone surgery. Adult participants with radiologically confirmed IRP refractory to conservative treatment were randomized to three arms with different delays before surgery. Efficacy outcome data were collected at equally stepped time points (12, 24, 36, 48, 60, and 72 weeks). Clinical efficacy of LVMR compared to controls was defined as ≥ 1.0-point reduction in Patient Assessment of Constipation-Quality of Life and/or Symptoms (PAC-QOL and/or PAC-SYM) scores at 24 weeks. Secondary outcome measures included 14-day diary data, the Generalized Anxiety Disorder scale (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), St Marks incontinence score, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), the chronic constipation Behavioral Response to Illness Questionnaire (CC-BRQ), and the Brief Illness Perception Questionnaire (BIPQ).

Results

Of a calculated sample size of 114, only 28 patients (100% female) were randomized from 6 institutions (due mainly to national pause on mesh-related surgery). Nine were assigned to the T0 arm, 10 to T12, and 9 to T24. There were no substantial differences in baseline characteristics between the three arms. Compared to baseline, significant reduction (improvement) in PAC-QOL and PAC-SYM scores were observed at 24 weeks post-surgery (– 1.09 [95% CI – 1.76, – 0.41], p = 0.0019, and – 0.92 [– 1.52, – 0.32], p = 0.0029, respectively) in the 19 patients available for analysis (9 were excluded for dropout [n = 2] or missing primary outcome [n = 7]). There was a clinically significant long-term reduction in PAC-QOL scores (− 1.38 [− 2.94, 0.19], p = 0.0840 at 72 weeks). Statistically significant improvements in PAC-SYM scores persisted to 72 weeks (− 1.51 [− 2.87, − 0.16], p = 0.0289). Compared to baseline, no differences were found in secondary outcomes, except for significant improvements at 24 and 48 weeks on CC-BRQ avoidance behavior (− 14.3 [95% CI − 23.3, − 5.4], and − 0.92 [− 1.52, − 0.32], respectively), CC-BRQ safety behavior (− 13.7 [95% CI − 20.5, − 7.0], and − 13.0 [− 19.8, − 6.1], respectively), and BIPQ negative perceptions (− 16.3 [95% CI − 23.5, − 9.0], and − 10.5 [− 17.9, − 3.2], respectively).

Conclusions

With the caveat of under-powering due to poor recruitment, the study presents the first randomized trial evidence of short-term benefit of LVMR for internal rectal prolapse.

Trial registration

ISRCTN Registry (ISRCTN11747152).

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02633-w.

AB0039 AGRIN REPAIRS BONE AND CARTILAGE IN VIVO

Background:

Cartilage defects in the joints are reported in 61% of all arthroscopies1&2. The size of the cartilage repair market is estimated to be $2.195 million by 20253. Cartilage defects can evolve into osteoarthritis, in which abnormal load results in cartilage breakdown, joint pain and reduced mobility. Osteoarthritis is the leading cause of permanent disability and absenteeism and affects up to 1/3 of the people over 60yrs. In western countries osteoarthritis costs 1.5-2% of the GDP4. Joint replacement with a prosthesis restores some degree of independence but in up to 20% of patients it does not meet expectations 5 and has a limited life span. There is no pharmacological intervention that arrests or reverts the course of osteoarthritis, despite the desperate need.

We previously published that agrin plays an important role in cartilage homeostasis6. The addition of agrin to chondrocytes in vivo resulted in enhanced cartilage formation, suggesting a potential role for agrin in cartilage repair.

Objectives:

Investigate the potential of agrin for use in cartilage repair.

Methods:

Critical size osteochondral defects were generated in mice and sheep and injected intraarticularly with type I collagen gel containing agrin or vehicle. Animals were monitored for 8 weeks or 6 months respectively. MicroCT, histological analysis, qPCR, linage tracking, reporter assays, chondrogenesis assay, immunohistochemistry were performed.

Results:

A single intraarticular administration of agrin induced regeneration of critical-size osteochondral defects in mice, restoring the tissue architecture and bone-cartilage interface. Agrin stem cells to the site of injury and, through simultaneous activation of CREB and suppression of canonical WNT signalling, induced GDF5 expression and differentiation into stable articular chondrocytes, forming stable articular cartilage. In sheep, agrin treatment resulted in regeneration of bone and cartilage, which promoted increased ambulatory activity.

Conclusion:

Agrin orchestrates repair morphogenesis at the joint surface by modulating multiple signalling pathways, supporting the therapeutic use of agrin for joint surface regeneration.

References:

[1]Curl, W. W. et al. Cartilage injuries: a review of 31,516 knee arthroscopies. Arthrosc. J. Arthrosc. Relat. Surg. Off. Publ. Arthrosc. Assoc. N. Am. Int. Arthrosc. Assoc. 13, 456–460 (1997).

[2]Hjelle, K., Solheim, E., Strand, T., Muri, R. & Brittberg, M. Articular cartilage defects in 1,000 knee arthroscopies. Arthrosc. J. Arthrosc. Relat. Surg. Off. Publ. Arthrosc. Assoc. N. Am. Int. Arthrosc. Assoc. 18, 730–734 (2002).

[3]Cartilage Repair Market Size, Share, Industry Analysis 2018-2025 | AMR. Allied Market Research https://www.alliedmarketresearch.com/cartilage-repair-market.

[4]Hiligsmann, M. et al. Health economics in the field of osteoarthritis: an expert’s consensus paper from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin. Arthritis Rheum. 43, 303–313 (2013).

[5]Dieppe, P., Lim, K. & Lohmander, S. Who should have knee joint replacement surgery for osteoarthritis? Int. J. Rheum. Dis. 14, 175–180 (2011).

[6]Eldridge, S., et al. Agrin mediates chondrocyte homeostasis and requires both LRP4 and α-dystroglycan to enhance cartilage formation in vitro and in vivo. Annals of the rheumatic diseases 75 (6), 1228-1235 (2016).

Acknowledgements:

We thank the technical staff in the ARM Lab and Staff at the University of Aberdeen’s Animal Facility and Microscopy and Histology Facility for support. Funding: We gratefully acknowledge funding support of this work by the MRC (MR/L022893/1, MR/N010973/1,and MR/P026362/1), Versus Arthritis (19667, 21515, 20886, and 21621), Rosetrees Trust (A1205), the Medical College of St Bartholomew’s Hospital Trust, and the William Harvey Research Foundation.

Disclosure of Interests:

Suzanne Eldridge: None declared, Aida Barawi: None declared, Hui Wang: None declared, Anke Roelofs: None declared, Magdalena Kaneva: None declared, Zeyu Guan: None declared, Helen Lydon: None declared, Bethan Thomas: None declared, Anne-Sophie Thorup: None declared, Beatriz F Fernandez: None declared, Sara Caxaria: None declared, Danielle Strachan: None declared, Ahmed Ali: None declared, Kanatheepan Shanmuganathan: None declared, Costantino Pitzalis: None declared, James Whiteford: None declared, Fran Henson: None declared, Andrew McCaskie: None declared, Cosimo De Bari: None declared, Francesco Dell’Accio Consultant of: F.D. has received consultancy fees from Samumed and UCB.

OP0200 BLOCKING ROR2 IMPROVES CARTILAGE INTEGRITY AND PROVIDES PAIN RELIEF IN OSTEOARTHRITIS

Background:

Osteoarthritis (OA) is the leading cause of chronic disability worldwide, affecting 12% of the population, and yet we still do not have a disease-modifying treatment. Cartilage breakdown is the hallmark of OA, and patients suffer from pain and loss of joint function/independence, severely affecting quality of life. Therefore, there is a huge unmet clinical need.

Receptor tyrosine kinase–like orphan receptor 2 (ROR2) is a non-canonical WNT receptor that regulates the planar cell polarity pathway, controlling limb outgrowth during development. During skeletal development, chondrocytes require ROR2 to undergo hypertrophy throughout the process of endochondral bone formation1. Loss of function mutations in humans causes Recessive Robinow Syndrome, leading to limb shortening and brachydactyly2,3.

Although absent from healthy adult articular cartilage, our initial studies identified high expression levels of ROR2 in chondrocytes from patients with OA, suggesting a role in the disease process

Objectives:

To test the potential of ROR2 blockade as a disease-modifying treatment for OA.

Methods:

Human cartilage organoid model in nude mice, menisco-ligament injury (MLI) model of OA in mice, behavioural studies, in vitro studies in cells.

Results:

ROR2/WNT5A signaling was increased in osteoarthritic cartilage. Blocking ROR2 was sufficient to induce articular chondrogenesis and suppress expression of aggrecanases in a mesenchymal stem cell line, and to support cartilage formation in a human cartilage organoid model in nude mice using primary chondrocytes from patients with OA.

In the MLI model of OA, blocking ROR2 in therapeutic regime using atelocollagen-conjugated siRNA resulted in reduced cartilage destruction and in rapid and sustained pain relief. Due to the limited expression pattern of ROR2 in adulthood, no systemic or local toxicity were expected, nor were any observed4.

With the current technology, ROR2 blockade requires intra-articular (IA) injections of siRNA conjugated to atelocollagen every 5 days. Preliminary efficacy data of potentially longer-acting ROR2 blockers are promising.

The mechanism of action of ROR2 blockade was independent of modulation of canonical WNT signaling.

ROR2/WNT5A promoted nuclear localization of YAP, which required both Rho and G-proteins. YAP signaling downstream of ROR2 also required Rho, but not G-proteins. YAP and TEAD inhibition was required, but not sufficient, for the chondrogenic effect of blocking ROR2. Therefore, additional, yet unknown mechanisms must be involved downstream of ROR2.

Conclusion:

ROR2 blockade has potential as a disease-modifying treatment for OA, resulting in cartilage protection and rapid and sustained pain relief in a murine model. This will be crucial for clinical success of any treatment for OA and promote patient compliance.

Our current siRNA-atelocollagen based technology requires IA injections too frequently to be acceptable for patients. We are developing ROR2 blockade which can be administered systemically or IA not more often than every 3 months - work funded by FOREUM.

References:

[1]DeChiara, T. M. et al. Ror2, encoding a receptor-like tyrosine kinase, is required for cartilage and growth plate development. Nat. Genet.24, 271–4 (2000).

[2]Bokhoven, H. Van, Celli, J. & Kayserili, H. Mutation of the gene encoding the ROR2 tyrosine kinase causes autosomal recessive Robinow syndrome. Nature25, 423–426 (2000).

[3]Afzal, A., Rajab, A., Fenske, C. & Oldridge, M. Recessive Robinow syndrome, allelic to dominant brachydactyly type B, is caused by mutation of ROR2. Nature25, 419–422 (2000).

[4]Thorup, A.-S. et al. ROR2 blockade as a therapy for osteoarthritis. Sci. Transl. Med.12, eaax3063 (2020).

Acknowledgements:

We gratefully acknowledge funding support of this work by the Medical College of St Bartholomew’s Hospital Trust, the William Harvey Research Foundation, FOREUM foundation for research in rheumatology (1016807), the MRC (MR/L022893/1, MR/N010973/1, MR/P026362/1, MR/K013076/1), Versus Arthritis (21515, 20886, 21621, 20859), and the DFG Emmy-Noether program (BE4328/5-1).

Disclosure of Interests:

Anne-Sophie Thorup: None declared, Danielle Strachan: None declared, Sara Caxaria: None declared, Blandine Poulet: None declared, Bethan Thomas: None declared, Suzanne Eldridge: None declared, Giovanna Nalesso: None declared, James Whiteford: None declared, Costantino Pitzalis: None declared, Thomas Aigner: None declared, Roger Corder: None declared, Jessica Bertrand: None declared, Francesco Dell’Accio Consultant of: Samumed and UCB

The Rare Lesser Metatarsal Bipartite Sesamoid A Case Report

Sesamoid bones and accessory ossicles are common incidental findings on radiographs. These can occasionally become symptomatic, usually after a precipitating event such as an injury or overuse, or they can be incidental findings unrelated to the presenting pathology. The aim of this study was to highlight a rare case of a bipartite fifth metatarsal sesamoid bone and to review previous literature regarding sesamoid bones and accessory ossicles.

How to design efficient cluster randomised trials

Cluster randomised trials have diminishing returns in power and precision as cluster size increases. Making the cluster a lot larger while keeping the number of clusters fixed might yield only a very small increase in power and precision, owing to the intracluster correlation. Identifying the point at which observations start making a negligible contribution to the power or precision of the study—which we call the point of diminishing returns—is important for designing efficient trials. Current methods for identifying this point are potentially useful as rules of thumb but don’t generally work well. We introduce several practical aids to help researchers design cluster randomised trials in which all observations make a material contribution to the study. Power curves enable identification of the point at which observations begin to make a negligible contribution to a study for a given target difference. Under this paradigm, the number needed per arm under individual randomisation gives an upper bound on the cluster size, which should not be exceeded. Corresponding precision curves can be useful for accommodating flexibility in the choice of target difference and show the point at which confidence intervals around the estimated effect size no longer decrease. To design efficient trials, the number of clusters and cluster size should be determined concurrently, not independently. Funders and researchers should be aware of diminishing returns in cluster trials. Researchers should routinely plot power or precision curves when performing sample size calculations so that the implications of cluster sizes can be transparent. Even when data appear to be “free,” in the sense that few resources are needed to obtain the data, excessive cluster sizes can have important ramifications

Effectiveness of group body psychotherapy for negative symptoms of schizophrenia: multicentre randomised controlled trial

BACKGROUND

Negative symptoms of schizophrenia have a severe impact on functional outcomes and treatment options are limited. Arts therapies are currently recommended but more evidence is required.

AIMS

To assess body psychotherapy as a treatment for negative symptoms compared with an active control (trial registration: ISRCTN84216587).

METHOD

Schizophrenia out-patients were randomised into a 20-session body psychotherapy or Pilates group. The primary outcome was negative symptoms at end of treatment. Secondary outcomes included psychopathology, functional, social and treatment satisfaction outcomes at treatment end and 6-months later.

RESULTS

In total, 275 participants were randomised. The adjusted difference in negative symptoms was 0.03 (95% CI -1.11 to 1.17), indicating no benefit from body psychotherapy. Small improvements in expressive deficits and movement disorder symptoms were detected in favour of body psychotherapy. No other outcomes were significantly different.

CONCLUSIONS

Body psychotherapy does not have a clinically relevant beneficial effect in the treatment of patients with negative symptoms of schizophrenia.

Evaluating hospital at home and early discharge schemes for patients with an acute exacerbation of COPD

Hospital at home and early discharge schemes for patients experiencing an acute exacerbation of their chronic obstructive pulmonary disease, appear to be an effective and safe option for selected patients and these services have become increasingly common. Here we discuss the evaluation of such schemes including: the rationale for evaluation; aspects of quality which might be considered for evaluation; the role of evaluation frameworks, quantitative and qualitative evaluation and steps in planning an evaluation.

Therapeutic potential of an orally effective small molecule inhibitor of plasminogen activator inhibitor for asthma

Asthma is one of the most common respiratory diseases. Although progress has been made in our understanding of airway pathology and many drugs are available to relieve asthma symptoms, there is no cure for chronic asthma. Plasminogen activator inhibitor 1 (PAI-1), a primary inhibitor of tissue-type and urokinase-type plasminogen activators, has pleiotropic functions besides suppression of fibrinolysis. In this study, we show that administration of TM5275, an orally effective small-molecule PAI-1 inhibitor, 25 days after ovalbumin (OVA) sensitization-challenge, significantly ameliorated airway hyperresponsiveness in an OVA-induced chronic asthma model. Furthermore, we show that TM5275 administration significantly attenuated OVA-induced infiltration of inflammatory cells (neutrophils, eosinophils, and monocytes), the increase in the levels of OVA-specific IgE and Th2 cytokines (IL-4 and IL-5), the production of mucin in the airways, and airway subepithelial fibrosis. Together, the results suggest that the PAI-1 inhibitor TM5275 may have therapeutic potential for asthma through suppressing eosinophilic allergic response and ameliorating airway remodeling.

Exercise for depression in care home residents: a randomised controlled trial with cost-effectiveness analysis (OPERA)

BACKGROUND

Many older people living in care homes (long term residential care or nursing homes) are depressed. Exercise is a promising non-drug intervention for preventing and treating depression in this population.

OBJECTIVE

To evaluate the impact of a 'whole-home' intervention, consisting of training for residential and nursing home staff backed up with a twice-weekly, physiotherapist-led exercise class on depressive symptoms in care home residents.

DESIGN

A cluster randomised controlled trial with a cost-effectiveness analysis to compare (1) the prevalence of depression in intervention homes with that in control homes in all residents contributing data 12 months after homes were randomised (cross-sectional analysis); (2) the number of depressive symptoms at 6 months between intervention and control homes in residents who were depressed at pre-randomisation baseline assessment (depressed cohort comparison); and (3) the number of depressive symptoms at 12 months between intervention and control homes in all residents who were present at pre-randomisation baseline assessment (cohort comparison).

SETTING

Seventy-eight care homes in Coventry and Warwickshire and north-east London.

PARTICIPANTS

Care home residents aged ≥ 65 years.

INTERVENTIONS

Control intervention: Depression awareness training programme for care home staff. Active intervention: A 'whole-home' exercise intervention, consisting of training for care home staff backed up with a twice-weekly, physiotherapist-led exercise group.

MAIN OUTCOME MEASURES

Geriatric Depression Scale-15, proxy European Quality of Life-5 Dimensions (EQ-5D), cost-effectiveness from an National Health Service perspective, peripheral fractures and death.

RESULTS

We recruited a total of 1054 participants. Cross-sectional analysis: We obtained 595 Geriatric Depression Scale-15 scores and 724 proxy EQ-5D scores. For the cohort analyses we obtained 765 baseline Geriatric Depression Scale-15 scores and 776 proxy EQ-5D scores. Of the 781 who we assessed prior to randomisation, 765 provided a Geriatric Depression Scale-15 score. Of these 374 (49%) were depressed and constitute our depressed cohort. Resource-use and quality-adjusted life-year data, based on proxy EQ-5D, were available for 798 residents recruited prior to randomisation. We delivered 3191 group exercise sessions with 31,705 person attendances and an average group size of 10 (5.3 study participants and 4.6 non-study participants). On average, our participants attended around half of the possible sessions. No serious adverse events occurred during the group exercise sessions. In the cross-sectional analysis the odds for being depressed were 0.76 [95% confidence interval (CI) 0.53 to 1.09] lower in the intervention group at 12 months. The point estimates for benefit for both the cohort analysis (0.13, 95% CI -0.33 to 0.60) and depressed cohort (0.22, 95% CI -0.52 to 0.95) favoured the control intervention. There was no evidence of differences in fracture rates or mortality (odds ratio 1.07, 95% CI 0.79 to 1.48) between the two groups. There was no evidence of differences in the other outcomes between the two groups. Economic analysis: The additional National Health Service cost of the OPERA intervention was £374 per participant (95% CI -£655 to £1404); the mean difference in quality-adjusted life-year was -0.0014 (95% CI -0.0728 to 0.0699). The active intervention was thus dominated by the control intervention, which was more effective and less costly.

CONCLUSION

The results do not support the use of a whole-home physical activity and moderate-intensity exercise programme to reduce depression in care home residents.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN43769277.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 18. See the Health Technology Assessment programme website for further project information.

Trials in primary care: statistical issues in the design, conduct and evaluation of complex interventions

Trials carried out in primary care typically involve complex interventions that require considerable planning if they are to be implemented successfully. The role of the statistician in promoting both robust study design and appropriate statistical analysis is an important contribution to a multi-disciplinary primary care research group. Issues in the design of complex interventions have been addressed in the Medical Research Council's new guidance document and over the past 7 years by the Royal Statistical Society's Primary Health Care Study Group. With the aim of raising the profile of statistics and building research capability in this area, particularly with respect to methodological issues, the study group meetings have covered a wide range of topics that have been of interest to statisticians and non-statisticians alike. The aim of this article is to provide an overview of the statistical issues that have arisen over the years related to the design and evaluation of trials in primary care, to provide useful examples and references for further study and ultimately to promote good practice in the conduct of complex interventions carried out in primary care and other health care settings. Throughout we have given particular emphasis to statistical issues related to the design of cluster randomised trials.

Effects of the Diabetes Manual 1:1 structured education in primary care

AIMS

To determine the effects of the Diabetes Manual on glycaemic control, diabetes-related distress and confidence to self-care of patients with Type 2 diabetes.

METHODS

A cluster randomized, controlled trial of an intervention group vs. a 6-month delayed-intervention control group with a nested qualitative study. Participants were 48 urban general practices in the West Midlands, UK, with high population deprivation levels and 245 adults with Type 2 diabetes with a mean age of 62 years recruited pre-randomization. The Diabetes Manual is 1:1 structured education designed for delivery by practice nurses. Measured outcomes were HbA(1c), cardiovascular risk factors, diabetes-related distress measured by the Problem Areas in Diabetes Scale and confidence to self-care measured by the Diabetes Management Self-Efficacy Scale. Outcomes were assessed at baseline and 26 weeks.

RESULTS

There was no significant difference in HbA(1c) between the intervention group and the control group [difference -0.08%, 95% confidence interval (CI) -0.28, 0.11]. Diabetes-related distress scores were lower in the intervention group compared with the control group (difference -4.5, 95% CI -8.1, -1.0). Confidence to self-care Scores were 11.2 points higher (95% CI 4.4, 18.0) in the intervention group compared with the control group. The patient response rate was 18.5%.

CONCLUSIONS

In this population, the Diabetes Manual achieved a small improvement in patient diabetes-related distress and confidence to self-care over 26 weeks, without a change in glycaemic control. Further study is needed to optimize the intervention and characterize those for whom it is more clinically and psychologically effective to support its use in primary care.

Can a self-management programme delivered by a community pharmacist improve asthma control? A randomised trial

BACKGROUND

No randomised studies have addressed whether self-management for asthma can be successfully delivered by community pharmacists. Most randomised trials of asthma self-management have recruited participants from secondary care; there is uncertainty regarding its effectiveness in primary care. A randomised controlled study was undertaken to determine whether a community pharmacist could improve asthma control using self-management advice for individuals recruited during attendance at a community pharmacy.

METHODS

Twenty four adults attending a community pharmacy in Tower Hamlets, east London for routine asthma medication were randomised into two groups: the intervention group received self-management advice from the pharmacist with weekly telephone follow up for 3 months and the control group received no input from the pharmacist. Participants self-completed the North of England asthma symptom scale at baseline and 3 months later.

RESULTS

The groups were well matched at baseline for demographic characteristics and mean (SD) symptom scores (26.3 (4.8) and 27.8 (3.7) in the intervention and control groups, respectively). Symptom scores improved in the intervention group and marginally worsened in the control group to 20.3 (4.2) and 28.1 (3.5), respectively (p<0.001; difference adjusted for baseline scores=7.0 (95% CI 4.4 to 9.5).

CONCLUSIONS

A self-management programme delivered by a community pharmacist can improve asthma control in individuals recruited at a community pharmacy. Further studies should attempt to confirm these findings using larger samples and a wider range of outcome measures.

Did the London Initiative Zone investment programme affect general practice structure and performance in East London? A time series analysis of cervical screening coverage and asthma prescribing

A programme of incentives was set up in the London Initiative Zones to improve primary care in inner London based on the findings of the Tomlinson Enquiry in 1992. This descriptive study is a 4-y time series analysis of changes in general practice structure in East London as the result of London Initiative Zone investment, and an exploration of the possible effect of investment on practice performance. We used routinely available administrative data for the whole analysis. General practice characteristics and two selected performance indicators: the asthma prophylaxis to bronchodilator ratio and cervical cytology screening rate, for all practices in the East London and the City Health Authority for 4 y, 1993-1996, were used. Both reflect practice efficiency, but relate to different aspects of practice performance. The prescribing indicator is more indicative of the quality of clinical practise, whereas cervical screening coverage relates more to the characteristics of the practice population and to practice organisation. Repeated measures analyses were used to identify trends and to explore the relationship between changes in practice characteristics and performance. Graphical methods were used to compare East London trends with the rest of England. There were significant improvements in practice structure as the consequence of London Initiative Zone investment. There was a positive association with improvements in practice performance, but East London still lagged some way behind national patterns. The findings suggest that while improvements in asthma prescribing follow the national trend, practices have difficulty in achieving and sustaining the 80% target for cervical cytology screening, and that an overall population coverage of 80% may be in doubt.Increased investment in practice staffing may be influential in improving some aspects of performance. However, in common with other inner cities, a greater effort and more innovative strategies may be needed to achieve a standard of performance equal to the best.

Transformations of sigma-pi nets: obtaining reflected functions by reflecting weight matrices

This paper presents a methodology that reflected functions by reflecting the weight matrices of an artificial neural network. One of the major problems with the connectionist approach is that trained neural networks can only associate fixed sets of input-output mappings. We provide a methodology which allows the post-trained net to associate different input-output mappings. The different mappings are reflected in a horizontal axis, reflected in a vertical axis and scaling of the initial mapping. The methodology does not train the net on the different mappings but it transforms the weight matrix of the neural network. This paper describes a novel way of utilising sigma-pi neural networks. Our new methodology manipulates sigma-pi unit's weight matrices which transform the unit's output. The weights are cast in a matrix formulation, and then transformations can be performed on the weight matrix of the sigma-pi net. To test the new methodology, the following three steps were carried out on a neural network: (1) the network was trained to perform a mapping function, f; (2) the weights of the network were transformed; and (3) the network was tested to evaluate whether it performs the reflection in the vertical axis,f(ref-vert)(x) = a - f(x). This reflects the function in one dimension. A reflection transformation was used to manipulate the network's weight matrices to obtain a reflection in the vertical axis. Note that the network was not trained to perform the reflection in the vertical axis. The transformation of the weight matrix transformed the function the output performs. This article explains the theory which enables us to perform transformations of sigma-pi networks and obtain reflections of the output by reflecting the weight matrices. These transforms empower the network to perform related mapping tasks once one mapping task has been learnt. This article explains how each transformation is performed and it considers whether a set of 'standard' transformations can indeed be derived.

Relationship style between GPs and community mental health teams affects referral rates

BACKGROUND

Community mental health teams (CMHTs) are the established model for supporting patients with serious mental illness in the community. However, up to 25% of those with psychotic disorders are managed solely by primary care teams. Effective management depends upon locally negotiated referral and shared care arrangements between CMHTs and primary care.

AIM

To examine whether the style of working relationship between general practices and CMHTs affects the numbers and types of referrals from general practices to CMHTs, taking into account population and practice factors and provision of other mental health services which may influence referral rates.

DESIGN OF STUDY

Cross-sectional study.

SETTING

All 161 general practices in East London and the City Health Authority.

METHOD

Questionnaire survey to all general practices to identify style of relationship. Collection of routinely available referral data to all statutory mental health services over a two-year period. Main outcome measures were number and types of referrals from general practices to CMHTs.

RESULTS

The average annual referral rate to the eleven CMHTs in east London is 10 per 1000 adult population annually. The teams show a sixfold variation in rates of referral from all sources. Where good working relationships (a consultation-liaison style) exist between CMHTs and general practice, there are greater numbers of referrals requiring both long and short-term work by CMHTs. Two-stage multivariate models explained 47% of the referral variation between practices. Where primary care-based psychologists work with practices there are greater numbers of CMHT referrals, but less use of psychiatric services.

CONCLUSION

Shifting to a consultation-liaison relationship should increase rates of referral of patients with serious mental illness, including those who can most benefit from the skills of CMHTs. Increasing the provision of primary care-based psychology might improve practice use of mental health services, reducing avoidable outpatient psychiatric referrals.

Women who experience domestic violence and women survivors of childhood sexual abuse: a survey of health professionals' attitudes and clinical practice

Health professionals do not wish to routinely screen women for a history of domestic violence or childhood sexual abuse. However, over 80% believe that these are significant health care issues. Routine screening should not be prioritised until evidence of benefit has been established.

Prescribing rates for psychotropic medication amongst east London general practices: low rates where Asian populations are greatest

OBJECTIVES

The aim of this study was to examine the contribution of Asian ethnicity to the variation in rates of practice prescribing for antidepressant and anxiolytic medication, taking into account other population and practice organizational factors.

METHODS

A practice-based cross-sectional survey was carried out of the prescribing of antidepressants and anxiolytics (daily defined dosages) in 164 general practices. The study was set in East London and the City Health Authority, which includes the multiethnic inner London boroughs of Hackney, Tower Hamlets, Newham and the City of London. The main outcome measures were the annual prescribing rates for each group of drugs, calculated as the total annual daily defined dosages divided by the practice population, and the ratio of antidepressant/ anxiolytic annual prescribing rates.

RESULTS

Prescribing rates for antidepressants showed a 25-fold variation between practices; this was greater for anxiolytics. The median annual prescribing rate for all antidepressants combined was 4.13 (interquartile range 2.50-5.88). For all anxiolytics and hypnotics combined the median annual prescribing rate was 3.55 (interquartile range 1.71-6.36). Univariate analysis showed that Asian ethnicity alone accounted for 28% of the variation in antidepressant prescribing and 20.5% of the variation in the anxiolytic prescribing. A backwards multiple regression model using 10 explanatory practice and population variables accounted for 47.7% of the variance in antidepressant prescribing and 34% of the variance in the anxiolytic prescribing.

CONCLUSION

In practices where the proportion of Asian patients is high, both antidepressant and anxiolytic prescribing is low. This is important for understanding interpractice prescribing variation and for setting levels of drug budgets. This study confirms that the low rates of non-psychotic disorders presented by Asian populations is not a selective feature of access to secondary care, but is evident in the prescribing behaviour of GPs. Uncertainty remains as to how much this is due to a lower prevalence rate, "culture-bound syndromes" or practical difficulties in diagnosis and management within the general practice setting.

Sample size calculations for intervention trials in primary care randomizing by primary care group: an empirical illustration from one proposed intervention trial

Because of the central role of the general practice in the delivery of British primary care, intervention trials in primary care often use the practice as the unit of randomization. The creation of primary care groups (PCGs) in April 1999 changed the organization of primary care and the commissioning of secondary care services. PCGs will directly affect the organization and delivery of primary, secondary and social care services. The PCG therefore becomes an appropriate target for organizational and educational interventions. Trials testing these interventions should involve randomization by PCG. This paper discusses the sample size required for a trial in primary care assessing the effect of a falls prevention programme among older people. In this trial PCGs will be randomized. The sample size calculations involve estimating intra-PCG correlation in primary outcome: fractured femur rate for those 65 years and over. No data on fractured femur rate were available at PCG level. PCGs are, however, similar in size and often coterminous with local authorities. Therefore, intra-PCG correlation in fractured femur rate was estimated from the intra-local authority correlation calculated from routine data. Three alternative trial designs are considered. In the first design, PCGs are selected for inclusion in the trial from the total population of England (eight regions). In the second design, PCGs are selected from two regions only. The third design is similar to the second except that PCGs are stratified by region and baseline value of fracture rate. Intracluster correlation is estimated for each of these designs using two methods: an approximation which assumes cluster sizes are equal and an alternative method which takes account of the fact that cluster sizes vary. Estimates of sample size required vary between 26 and 7 PCGs in each intervention group, depending on the trial design and the method used to calculate sample size. Not unexpectedly, stratification by baseline value of the outcome variable decreases the sample size required. In our analyses, geographic restriction of the population to be sampled reduces between-cluster variability in the primary outcome. This leads to an increase in precision. When allowance for variable cluster size is made, the increase in precision is not as great as would be expected with equal cluster sizes. This paper highlights the usefulness of routine data in work of this kind, and establishes one of the essential prerequisites for our proposed trial and other trials using primary outcomes with similar between-PCG variation: a feasible sample size.

Lessons from the London Initiative Zone Educational Incentives funding: associations between practice characteristics, funding, and courses undertaken

BACKGROUND

Following the Tomlinson report of 1992, London Initiative Zone Educational Incentives (LIZEI) funding was introduced for a three-year period to improve recruitment, retention, and educational opportunities for general practitioners working within inner London.

AIM

To test the hypothesis that general practices that show evidence of good organisation achieved better access to LIZEI funding than less organised practices.

METHOD

Observational practice-based study involving all 164 general practices in EAst London and the City Health Authority during the first two years of the scheme, April 1995 to March 1997.

RESULTS

Univariate analysis showed that higher levels of LIZEI funding were associated with practices where there was evidence of good organisation, including higher targets for cervical cytology screening and immunisation rates for under two-year-olds, better asthma prescribing, and training status. Using ten practice and population explanatory variables, multiple regression models were developed for fundholding and non-fundholding practices. Among non-fundholding practices, the asthma prescribing ratio was the variable with the greatest predictive value, explaining 14.7% of the variation in LIZEI funding between practices. Strong positive associations existed between taking further degrees and diplomas, practice size, training, and non-fundholding status.

CONCLUSION

Larger practices, training practices, and those that demonstrated aspects of good practice organisation gained more LIZEI funding: an example of the 'inverse funding law'. Practices within a multifund, based in the Newham locality, gained LIZEI funding regardless of practice organisation. Networks of practices, and, potentially, primary care groups, have a role in equalising the opportunities for education and development between practices in east London.

Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial

OBJECTIVES

To determine whether postal prompts to patients who have survived an acute coronary event and to their general practitioners improve secondary prevention of coronary heart disease.

DESIGN

Randomised controlled trial.

SETTING

52 general practices in east London, 44 of which had received facilitation of local guidelines for coronary heart disease.

PARTICIPANTS

328 patients admitted to hospital for myocardial infarction or unstable angina.

INTERVENTIONS

Postal prompts sent 2 weeks and 3 months after discharge from hospital. The prompts contained recommendations for lowering the risk of another coronary event, including changes to lifestyle, drug treatment, and making an appointment to discuss these issues with the general practitioner or practice nurse.

MAIN OUTCOME MEASURES

Proportion of patients in whom serum cholesterol concentrations were measured; proportion of patients prescribed beta blockers (6 months after discharge); and proportion of patients prescribed cholesterol lowering drugs (1 year after discharge).

RESULTS

Prescribing of beta bockers (odds ratio 1.7, 95% confidence interval 0.8 to 3.0, P>0.05) and cholesterol lowering drugs (1.7, 0. 8 to 3.4, P>0.05) did not differ between intervention and control groups. A higher proportion of patients in the intervention group (64%) than in the control group (38%) had their serum cholesterol concentrations measured (2.9, 1.5 to 5.5, P<0.001). Secondary outcomes were significantly improved for consultations for coronary heart disease, the recording of risk factors, and advice given. There were no significant differences in patients' self reported changes to lifestyle or to the belief that it is possible to modify the risk of another coronary event.

CONCLUSIONS

Postal prompts to patients who had had acute coronary events and to their general practitioners in a locality where guidelines for coronary heart disease had been disseminated did not improve prescribing of effective drugs for secondary prevention or self reported changes to lifestyle. The prompts did increase consultation rates related to coronary heart disease and the recording of risk factors in the practices. Effective secondary prevention of coronary heart disease requires more than postal prompts and the dissemination of guidelines.

Return rates and partner notification in HIV-positive men seeking anonymous versus confidential antibody testing

This study investigated whether HIV-positive men who seek confidential versus anonymous HIV counseling and testing differ in demographic variables, risk behaviors, return rates for posttest appointments, and agreement to partner notification. chi 2 tests were not statistically significant for return rates for post-test appointments or partner notification between the two groups. HIV-positive individuals in the confidential groups were more likely to utilize medical and follow-up services than those in the anonymous group. Anonymous and confidential counseling and testing both appear to achieve the public health objectives of HIV case finding and referral. Hypotheses are offered regarding what may be a progression of testing behaviors (i.e., from anonymous to confidential) with suggestions for future research are suggested.

Can postal prompts from general practitioners improve the uptake of breast screening? A randomised controlled trial in one east London general practice

OBJECTIVE

To determine the effect on the uptake of breast screening of a personalized letter from the general practitioner recommending mammography, sent to coincide with an invitation from the NHS breast screening programme.

DESIGN

Randomised control trial with stratification of prognostic variables.

SETTING

A group practice in Hackney, east London.

SUBJECTS

473 women invited for breast screening by the City and East London Breast Screening Service.

OUTCOME MEASURE

Attendance for mammography.

RESULTS

All women in the randomised trial were followed up; 134 of 236 (57%) randomly allocated to receive the prompting letter attended for mammography compared with 120 of 234 (51%) controls This difference was not significant (chi 2 = 1.43, p = 0.23)

CONCLUSION

Personal recommendation by a letter prompting attendance for mammography from the general practitioner known best to women due to be screened did not improve uptake of breast screening in this east London practice. Other strategies are needed to increase uptake of mammography in inner cities.

Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London

OBJECTIVE

To determine whether locally developed guidelines on asthma and diabetes disseminated through practice based education improve quality of care in non-training, inner city general practices.

DESIGN

Randomised controlled trial with each practice receiving one set of guidelines but providing data on the management of both conditions.

SUBJECTS

24 inner city, non-training general practices.

SETTING

East London.

MAIN OUTCOME MEASURES

Recording of key variables in patient records (asthma: peak flow rate, review of inhaler technique, review of asthma symptoms, prophylaxis, occupation, and smoking habit; diabetes: blood glucose concentration, glycaemic control, funduscopy, feet examination, weight, and smoking habit); size of practice disease registers; prescribing in asthma; and use of structured consultation "prompts."

RESULTS

In practices receiving diabetes guidelines, significant improvements in recording were seen for all seven diabetes variables. Both groups of practices showed improved recording of review of inhaler technique, smoking habit, and review of asthma symptoms. In practices receiving asthma guidelines, further improvement was seen only in recording of review of inhaler technique and quality of prescribing in asthma. Sizes of disease registers were unchanged. The use of structured prompts was associated with improved recording of four of seven variables on diabetes and all six variables on asthma.

CONCLUSIONS

Local guidelines disseminated via practice based education improve the management of diabetes and possibly of asthma in inner city, non-training practices. The use of simple prompts may enhance this improvement.

Declining first-marriage rates in England and Wales: A change in timing or a rejection of marriage?

Two different methods devised by Ryder and by Le Bras and Roussel are used "to assess how far the changes in first-marriage rates in England and Wales arise from a shift to marrying at later ages or from a decline in the popularity of formal marriage. The two methods yield consistent results, and indicate that the majority of young people...will continue to marry but that during the 1970s many were postponing marriage. The pattern of cohabitation and prevailing attitudes to marriage are compatible with such a finding. Recent marriage patterns in England and Wales are found to differ from those in France and Sweden." (summary in FRE)

Aging human RPE: morphometric analysis of macular, equatorial, and peripheral cells

Retinal pigment epithelium (RPE) of 50 human eyes, five from each 10 decades of life, were analyzed using ultrastructural morphometric techniques. Content of three types of pigments, lipofuscin, melanin, and complex granules, (melanolipofuscin, melanolysosomes) were recorded for cells from macular, equatorial, and peripheral retinal specimens. Areas occupied by pigments, nucleus, and cytoplasmic space were calculated. Data were analyzed by a computer for age-related changes and effects of fixation delay time. The largest increase in lipofuscin granules occurred between the first and second decade of life, and further increases occurred with age. The content of "pure" melanin declined with age, whereas the number of complex melanin granules increased. Macular RPE contained more complex granules than nonmacular RPE, particularly in young eyes. The volume of RPE cytoplasm not occupied by pigments ("free space") decreased with age. No significant effects of fixation delays between 2 and 9 hours postmortem were found on the parameters studied here. These findings may serve as a baseline for estimating normalcy of human RPE specimens.