Evaluation of the tolerability and safety of [225Ac]Ac-PSMA-I&T in patients with metastatic prostate cancer: a phase I dose escalation study

BACKGROUND

Life expectancy of patients with metastatic castration-resistant prostate cancer (mCRPC) is still limited despite several systemic treatments. Within five years after diagnosis of primary prostate cancer, 10-20% of the patients have mCRPC and curation is not an option. Radionuclide therapy (RNT) targeted against prostate-specific membrane antigen (PSMA) emerged as a new treatment option and showed effective results in patients with mCRPC. Survival benefit after [177Lu]Lu-PSMA RNT has already been demonstrated in several clinical trials. However, [225Ac]Ac-PSMA (225Ac-PSMA) appears to be an even more promising radiopharmaceutical for the treatment of mCRPC. The use of alpha emitting radionuclides offers advantages over beta emitting radionuclides due to the high linear energy transfer effective for killing tumor cells and the limited range to reduce the radiation effects on the healthy tissue. However, these results are based on retrospective data and safety data of 225Ac-PSMA are still limited. Therefore, a prospective trial is needed to determine the optimal amount of activity that can be administered.

METHODS

The 225Ac-PSMA-Imaging & Therapy (I&T) trial is an investigator-initiated phase I, single-center, open label, repeated dose-escalation and expansion trial. Patient with PSMA-positive mCRPC after at least one line of chemotherapy and/or one line of nonsteroidal antiandrogen will be treated with 225Ac-PSMA-I&T in increasing amount of activity per cycle. Dose-escalation following an accelerated 3 + 3 design which allows to open the next dose-level cohort in the absence of dose limiting toxicity while the previous one is still ongoing. Up to 4 treatment cohorts will be explored including up to 3 dose-escalation cohorts and one expansion cohort where patients will be administered with the recommended dose. A total of up to 30 patients will be enrolled in this trial. All patients will be evaluated for safety. Additionally, dosimetry was performed for the patients in the dose-escalation cohorts after the first 225Ac-PSMA-I&T administration.

DISCUSSION

This trial will assess the safety and tolerability of 225Ac-PSMA-I&T in patients with mCRPC to recommend the optimal dose for the phase II trial.

TRIAL REGISTRATION

ClinicalTrials.gov, (NCT05902247). Retrospectively registered 13 June 2023.

Effectiveness of call system implementation for postpartum hemorrhage in a tertiary emergency medical center: a retrospective cohort study

BACKGROUND

Postpartum hemorrhage is the leading cause of maternal death and severe maternal morbidity worldwide. Previous studies have reported the importance of multidisciplinary treatment approaches for postpartum hemorrhage; however, only a few studies have shown a clear improvement in maternal outcomes. Therefore, this study aimed to investigate the efficacy of a call system for postpartum hemorrhage in a tertiary emergency facility for rapid multidisciplinary treatment and its effect on maternal outcomes.

METHODS

This single-center retrospective cohort study included patients transferred to our hospital due to postpartum hemorrhage between April 1, 2013, and March 31, 2019. The primary outcome was mortality, and the secondary outcomes were morbidity (duration of hospital stay, duration of intensive care unit stay, admission to the intensive care unit, respirator use, duration of ventilator support, acute kidney injury, transfusion-associated circulatory overload/transfusion-related acute lung injury, hysterectomy, composite adverse events, blood transfusion initiation time, blood transfusion volume, and treatment for postpartum hemorrhage). An in-hospital call system implementation commenced on April 1, 2016. The study outcomes were compared 3 years before and after implementing the call system.

RESULTS

The blood transfusion initiation time and duration of hospital stay were significantly shortened after implementing the call system for postpartum hemorrhage. No maternal deaths were observed after implementing the system.

CONCLUSIONS

Implementing call systems specialized for postpartum hemorrhage in tertiary emergency facilities may improve maternal outcomes.

Does the Academy of Breastfeeding Medicine's Clinical Protocol #36 'The Mastitis Spectrum' promote overtreatment and risk worsened outcomes for breastfeeding families? Commentary

BACKGROUND

In 2022 the Academy of Breastfeeding Medicine (ABM) published Clinical Protocol #36: The Mastitis Spectrum, which aims to update clinical approaches to management of benign lactation-related breast inflammation. The protocol has been timely because of the exponential increase in knowledge about the human milk microbiome over the past decade. This Commentary aims to continue respectful debate amongst clinicians and researchers within the Academy of Breastfeeding Medicine and more broadly, confident that we share a fundamental commitment to promote breastfeeding and support the well-being of lactating women, their infants and their families.

ANALYSIS

Although Clinical Protocol #36 offers advances, it does not fulfil the principles of best practice implementation science for translation of evidence into clinical guidelines. Clinical Protocol #36 inaccurately represents studies; misrepresents theoretical models as proven aetiologies; does not consistently attribute sources; does not reliably apply the SORT taxonomy; and relies upon single case reports. As a result, various recommendations in Clinical Protocol #36 lack an evidence-base or credible underlying theoretical model. This includes recommendations to use 'lymphatic drainage' massage, therapeutic ultrasound, and oral lecithin. Similarly, based on a contestable theoretical model which is presented as fact, Clinical Protocol #36 makes the recommendation to either reduce frequency of milk removal or to maintain current frequency of milk removal during an episode of breast inflammation. Although Clinical Protocol #36 limits this advice to cases of 'hyperlactation', the diagnosis 'hyperlactation' itself is undefinable. As a result, this recommendation may put breastfeeding women who present with breast inflammation at risk of worsened inflammation and decreased breast milk production.

CONCLUSION

Clinical Protocol #36 offers some advances in the management of breast inflammation. However, Clinical Protocol #36 also exposes clinicians to two international trends in healthcare which undermine health system sustainability: overdiagnosis, including by over-definition, which increases risk of overtreatment; and antibiotic over-use, which worsens the crisis of global antimicrobial resistance. Clinical Protocol #36 also recommends unnecessary or ineffective interventions which may be accessed by affluent patients within advanced economies but are difficult to access for the global majority. The Academy of Breastfeeding Medicine may benefit from a review of processes for development of Clinical Protocols.

Re-irradiation in Paediatric Tumours of the Central Nervous System: National Guidelines from the Swedish Workgroup of Paediatric Radiotherapy

There is a lack of clinical protocols for re-irradiation in paediatric central nervous system (CNS) tumours. To fill this void, the Swedish Workgroup of Paediatric Radiotherapy (SBRTG) compiled national guidelines on re-irradiation in paediatric CNS tumours (diffuse intrinsic pontine glioma, ependymoma, germinoma and medulloblastoma). These have been in clinical practice since 2019 in all paediatric radiotherapy centres in Sweden. Since the implementation, the guidelines have been complemented with a yearly review on clinical outcome and toxicities in all paediatric patients treated according to the guidelines. This article presents the Swedish national guidelines on re-irradiation in paediatric CNS tumours.

Bangpungtongsung-san for patients with major depressive disorder: study protocol for a randomized controlled phase II clinical trial

BACKGROUND

Bangpungtongsung-san (BTS) is a representative herbal medicine that has been widely used for patients with obesity in east Asian countries. Various preclinical studies have demonstrated the anti-depressive effect of BTS granules in various animal models of depression. This phase II trial aimed to explore the efficacy and safety of BTS in human patients with depression.

METHODS

A total of 126 patients diagnosed with major depressive disorder and who are not underweight (body mass index ≥ 18.5 kg/m²) will be enrolled in this study. Eligible participants will be randomly allocated into three groups: the high-dose BTS, low-dose BTS, and placebo groups in a 1:1:1 ratio. BTS or placebo granules will be orally administered twice a day for 8 weeks. The BTS and placebo granules will be made to have identical color, scent, and shape, and participants and investigators will be blinded to the allocation. The primary efficacy endpoint is the change from baseline of the 17-item Hamilton Depression Rating Scale total score at 8 weeks. The superiority of the high- and low-dose BTS granules to the placebo granules will be tested.

DISCUSSION

The results of this clinical trial will provide evidence on the efficacy and safety of BTS for patients with major depressive disorder. This study will be conducted in accordance with ethical and regulatory guidelines, and the results will be submitted and published in international peer-reviewed journals.

TRIAL REGISTRATION

CRIS registration Number: KCT0007571; registered on 2022/07/26 ( https://cris.nih.go.kr/cris/search/detailSearch.do/23192 ).

Enhanced recovery after surgery in pediatric urology: Current evidence and future practice

PURPOSE

To offer an up-to-date appraisal of the current status of enhanced recovery after surgery (ERAS) protocols in pediatric urology and to provide a guide for the clinical urologist.

MATERIALS AND METHODS

We performed a comprehensive literature search and scoping review on ERAS protocols in pediatric urology using Pubmed (from 1946), Cochrane library, and MEDLINE to December 2021 with the terms ''enhanced recovery'', ''protocolised care'', ''post-operative protocol", ''fast-track surgery'' and ''pediatric urology". Studies were excluded if they did not include perioperative intervention related to urological procedures, no full-text available and in non-English language.

RESULTS

To date, eight clinical studies (involving 1153 patients) have been published on ERAS protocols in pediatric urology. The patients involved ranged from neonates to adolescents, and the urological procedures included bladder augmentation, the Mitrofanoff procedure, laparoscopic pyeloplasty, laparoscopic nephrectomy, hypospadias repair, etc. Multidisciplinary components such as surgical and anesthetic considerations have been employed in ERAS protocols. The length of hospital stay was significantly lower in the ERAS groups with earlier enteral feeding resumption and return of bowel function in pediatric urology patients. The implementation of ERAS protocols does not result in higher complication and readmission rates; instead, some studies have even demonstrated a significant reduction in complication occurrence.

CONCLUSION

ERAS is novel to pediatric urology with a limited scale of published data in the literature. Initial clinical studies revealed that ERAS appears to be efficacious in the field of pediatric urology. Further prospective studies formulating a standardized multimodal protocol are encouraged to better understand key components of ERAS and incorporate ERAS into clinical practice to optimize surgical outcomes for pediatric urology procedures.

An fMRI protocol for administering liquid incentives to human participants

This protocol describes the materials and approaches for administering liquid incentives to human participants during fMRI scanning. We first describe preparation of the liquid solutions (e.g., neutral solution and saltwater) and liquid delivery setups. We then detail steps to connect the setups to the computer-controlled syringe pump in the MRI control room, followed by procedures for testing the syringe pump dispensing a liquid bolus during the task. Description of custom software and required adapters for implementing the liquid setup are included. For complete details on the use and execution of this protocol, please refer to Yee et al. (2021).

Protocol to utilize fresh uncultured human lung tumor cells for personalized functional diagnostics

Drug sensitivity data acquired from solid tumor-derived cultures are often unsuitable for personalized treatment guidance due to the lengthy turnaround time. Here, we present a protocol for determining ex vivo drug sensitivities using fresh uncultured human lung tumor-derived EpCAM⁺ epithelial cells (FUTCs). We describe steps for drug testing in FUTCs to identify tumor cell-selective single or combination therapy in 72 h of sample processing. The FUTC-based approach can also be used to predict in vivo resistance to known targeted therapies. For complete details on the use and execution of this protocol, please refer to Talwelkar et al. (2021).

Lipid profiling analyses from mouse models and human infants

This protocol outlines a translational lipidomic approach to discover lipid biomarkers that could predict morphometric body and histological organ measurements (e.g., weight and adiposity gains) during specific stages of life (e.g., early life). We describe procedures ranging from animal experimentation and histological analyses to downstream analytical steps through lipid profiling, both in mice and humans. This protocol represents a reliable and versatile approach to translate and validate candidate lipid biomarkers from animal models to a human cohort. For complete details on the use and execution of this protocol, please refer to Olga et al. (2021).

The effects of Rosa foetida extract along with self-care education on primary dysmenorrhea: study protocol for a randomized clinical trial

Background

Dysmenorrhea is one of the most common disorders among young women. Medicinal herbs are one of the alternative methods for the treatment of dysmenorrhea. This study will investigate the effect of Rosa foetida extract, along with self-care behavior education on primary dysmenorrhea among female students of Babol University of medical sciences.

Methods/design

A randomized clinical trial will be performed on single students, aged 18 to 24 years. The research samples will be divided into three groups. The students will receive self-care behavior education on dysmenorrhea. Following the education, two of the groups will receive Rosa foetida extract capsules and placebo capsules in two consecutive cycles every 8 h for two successive days, respectively. The capsules will have similar physical appearance. The third group will not receive any medication. Data will be collected through demographic characteristic questionnaire, visual analog scale, dysmenorrhea self-care behaviors scale questionnaire, pictorial chart, and menstrual distress scale questionnaire. In order to determine and compare the effect of pharmacological and educational interventions on the severity of dysmenorrhea in groups, an ANOVA analysis of variance test with repeated measures will be used by SPSS software version 22.

Discussion

The results will show the effects of Rosa foetida extract along with self-care behavior education on primary dysmenorrhea, and beneficial effects that may be found in the trial of this plant may be of use for women with the same problem.

Ethics and dissemination

The study is approved by the Ethics Committee of Babol University of Medical Sciences (IR.MUBABOL.REC.1397.059).

Trial registration

IRCT 20190318043086N1. Registered on 14 June 2019.

Influence of Postponed Follow-Up after Cochlear Implant Activation during the COVID-19 Pandemic on Aided Sound Field Detection and Speech Recognition

INTRODUCTION

The objective of this study was to assess the influence of postponing the first post-activation follow-up due to the COVID-19 pandemic on the aided sound field detection thresholds and speech recognition of cochlear implant (CI) users.

METHODS

A retrospective review was performed at a tertiary referral center. Two groups of adult CI recipients were evaluated: (1) patients whose first post-activation follow-up was postponed due to COVID-19 closures (postponed group; n = 10) and (2) a control group that attended recommended post-activation follow-ups prior to the COVID-19 pandemic (control group; n = 18). For both groups, electric thresholds were estimated at initial activation based on comfort levels and were measured behaviorally at subsequent post-activation follow-ups. For the control group, behavioral thresholds were measured at the 1-month follow-up. For the postponed group, behavioral thresholds were not measured until 3 months post-activation since the 1-month follow-up was postponed. The aided pure-tone average (PTA) and word recognition results were compared between groups at the 3-month follow-up and at an interim visit 2-9 weeks later.

RESULTS

At the 3-month follow-up, the postponed group had significantly poorer word recognition (23 vs. 42%, p = 0.027) and aided PTA (42 vs. 37 dB HL, p = 0.041) than the control group. No significant differences were observed between 3-month data from the control group and interim data from the postponed group.

CONCLUSIONS

The postponed follow-up after CI activation was associated with poorer outcomes, both in terms of speech recognition and aided audibility. However, these detrimental effects were reversed following provision of an individualized map, with behaviorally measured electric threshold and comfort levels. While adult CI recipients demonstrate an improvement in speech recognition with estimated electric thresholds, the present results suggest that behavioral mapping within the initial weeks of device use may support optimal outcomes.

Sedation protocols in the pediatric intensive care unit: fact or fiction?

Comfort of the critically unwell pediatric patient is paramount to ensuring good outcomes. Analgesia-based, multimodal sedative approaches are the foundation for comfort, whereby pain is addressed first and then sedation titrated to a predefined target based on the goals of care. Given the heterogeneity of patients within the pediatric critical care population, the approach must be individualized based on the age and developmental stage of the child, physiologic status, and degree of invasive treatment required. In both the adult and pediatric intensive care unit (PICU), sedation titration is practiced as standard of care to meet therapeutic goals with a focus on facilitating early rehabilitation and extubation while avoiding under- and over-sedation. Sedation protocols have been developed as methods to reduce variability and optimize goal-directed therapy. Components of a sedation protocol include routine analgesia and sedation scoring with validated tools at specified intervals and a predefined algorithm that allows the titration of analgesia and sedation based on those assessments. Sedation protocols are designed to improve communication and documentation of sedation goals while also empowering the bedside team to respond rapidly to changes in a patient's clinical status. Previously it was thought that sedation protocols would consistently reduce duration of mechanical ventilation (MV) and length of stay (LOS) for patients in the PICU, however, this has not been the case. Nonetheless, introduction of sedation protocols has provided several benefits, including: (I) reduction in benzodiazepine usage; (II) improvements in interprofessional communication surrounding sedation goals and management of sedation goals; and (III) reductions in iatrogenic withdrawal symptoms. Successful implementation of sedation protocols requires passionate clinical champions and a robust implementation, education, and sustainability plan. Emerging evidence suggests that sedation protocols as part of a bundle of quality improvement initiatives will form the basis of future studies to improve short- and long-term outcomes after PICU discharge. In this review, we aim to define sedation protocols in the context of pediatric critical care and highlight important considerations for clinical practice and research.

Combination of gemcitabine, nab-paclitaxel, and S-1(GAS) as the first-line treatment for patients with locally advanced or advanced pancreatic ductal adenocarcinoma: study protocol for an open-label, single-arm phase I study

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is still a highly fatal malignancy among the most common cancers. More powerful treatments are expecting to bring hope for patients. Biweekly gemcitabine/nab-paclitaxel/S-1 (GAS) was proved safe and effective for patients with locally advanced pancreatic cancer in Japan. The objective of this study is to evaluate the feasibility and toxicity of GAS (repeated every 3 weeks) in the treatment of locally advanced or advanced pancreatic cancer and determine the recommended dose of S-1 in this combination.

METHODS

This is an open-label, single-arm, and single-center phase I trial. Patients who have been diagnosed with locally advanced or advanced PDAC pathologically without previous systemic treatments will be enrolled and be treated with GAS chemotherapy every 3 weeks (nab-paclitaxel 125 mg/m 2, ivgtt, day1, 8; gemcitabine 1000 mg/m2, day1, 8; different doses of S-1 within a dose escalation scheme) until the presence of disease progression (PD), intolerable adverse events (AEs), or requirement of patients and researchers. The primary endpoints are maximum tolerated dose (MTD) and dose-limiting toxicity (DLT). The secondary endpoints include safety, objective response rate (ORR), progression-free survival (PFS) and overall survival (OS).

DISCUSSION

This trial will adjust the administration of GAS to make it more effective for Chinese patients, while exploring the toxicity and feasibility of this adjustment.

TRIAL REGISTRATION

ChiCTR, ( ChiCTR1900027833 ). Registered 30 November 2019.

Protocol for oral transplantation of maternal fecal microbiota to newborn infants born by cesarean section

Infants born by cesarean section have an intestinal microbiota that differs from that of infants delivered vaginally. Here, we report a protocol for performing oral transplantation of maternal fecal microbiota to newborn infants born by elective cesarean section. The crucial step of this protocol is the health screening process. This protocol can only be applied to healthy mothers and infants.

For complete details on the use and execution of this protocol, please refer to Korpela et al. (2020).

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Intestinal microbiota differs between infants born vaginally and by cesarean section

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Protocol for oral transplantation of maternal fecal microbiota to cesarean-born infants

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The crucial step in the protocol is the health screening process

Evidence-based protocol for diagnosis and treatment of hepatorenal syndrome is independently associated with lower mortality

BACKGROUND

Hepatorenal syndrome (HRS) is the deadliest complication of cirrhosis. The purpose of this study is to analyze if the use of a protocol for HRS is associated with higher survival in these patients.

METHODS

An evidence-based protocol for the diagnosis and treatment of HRS was instituted in 2013. Data from medical records from 2010 to 2016 were obtained by searching the hospital database for patients who received terlipressin, in the three years before and after the institution of the protocol. Data were reviewed to confirm the diagnosis of HRS and multiple variables were collected. Liver-specific scores were calculated and a stepwise Cox regression approach was used for univariate and multivariate analysis.

RESULTS

The study included 46 patients, 20 from the pre-protocol period and 26 from the post-protocol period. Respectively, mortality at 30 days, 90 days and 365 days was 75%, 75% and 90% for the pre-protocol period, and 61%, 69% and 80% for the post-protocol period. In the multivariate analysis, an aspartate aminotransferase (AST) of <40U/L, the pre-protocol period and higher Child-Turcotte-Pugh scores were associated with higher 30-day and 90-day mortality. The total mean dose of terlipressin and human albumin used per patient was reduced from 27mg to 22mg and from 236g to 144g, respectively, after the institution of the protocol. This was not associated with higher mortality.

CONCLUSION

The use of an evidence-based protocol for the treatment of HRS translated into a higher survival. The authors suggest that the use of evidence-based protocols for the diagnosis and treatment of HRS could reduce cost and mortality in tertiary hospitals.

Measurement of intraorgan fat and hepatic output of triglycerides in human type 2 diabetes by magnetic resonance and intralipid infusion techniques

Liver fat content and the linked rate of export of triglyceride are central to the etiology of type 2 diabetes, as well as to the cardiovascular effects of fatty liver disease. Measurement in humans of intrahepatic and intrapancreatic fat content is described using magnetic resonance techniques and quantification of the rate of hepatic secretion of very low density lipoprotein using a non-isotopic competitive blocking of tissue uptake. This protocol is non-invasive, can be repeated sequentially, and does not involve ionizing radiation. For complete details on the use and execution of this protocol, please refer to (Taylor et al., 2018) and (Al-Mrabeh et al., 2020b).

Collaborative care in the treatment of opioid use disorder and mental health conditions in primary care: A clinical study protocol

BACKGROUND

People with opioid use disorder (OUD) often have a co-occurring psychiatric disorder, which elevates the risk of morbidity and mortality. Promising evidence supports the use of collaborative care for treating people with OUD in primary care. Whether collaborative care interventions that treat both OUD and psychiatric disorders will result in better outcomes is presently unknown.

METHODS

The Whole Health Study is a 3-arm randomized controlled trial designed to test collaborative care treatment for OUD and the psychiatric disorders that commonly accompany OUD. Approximately 1200 primary care patients aged ≥18 years with OUD and depression, anxiety, or PTSD will be randomized to one of three conditions: (1) Augmented Usual Care, which consists of a primary care physician (PCP) waivered to prescribe buprenorphine and an addiction psychiatrist to consult on medication-assisted treatment; (2) Collaborative Care, which consists of a waivered PCP, a mental health care manager trained in psychosocial treatments for OUD and psychiatric disorders, and an addiction psychiatrist who provides consultation for OUD and mental health; or (3) Collaborative Care Plus, which consists of all the elements of the Collaborative Care arm plus a Certified Recovery Specialist to help with treatment engagement and retention. Primary outcomes are six-month rates of opioid use and six-month rates of remission of co-occurring psychiatric disorders.

DISCUSSION

The Whole Health Study will investigate whether collaborative care models that address OUD and co-occurring depression, anxiety, or PTSD will result in better patient outcomes. The results will inform clinical care delivery during the current opioid crisis.

CLINICAL TRIALS REGISTRATION

www.clinicaltrials.gov registration: NCT04245423.

Distance of insertion points in a mattress suture from the wound margin for ideal primary closure in alveolar mucosa: an in vitro experimental study

Purpose

This study was conducted to determine how the distance of the near insertion points in a vertical mattress suture from the wound margin influences the pattern of primary closure in an in vitro experimental model.

Methods

Pairs of 180 porcine gingival and alveolar mucosa samples were harvested from 90 pig jaws and fixed to a specially designed model. A vertical mattress suture was performed with the near insertion point at 3 different distances from the wound margin (1-, 3-, and 5-mm) on both the gingival and mucosal samples (6 groups; n=30 for each group). The margin discrepancy and the presence of epithelium between the wound margins were measured on histologic slides.

Results

The margin discrepancy decreased significantly as the near insertion point became closer to the wound margin both in mucosal tissue (0.241±0.169 mm, 0.945±0.497 mm, and 1.306±0.773 mm for the 1-, 3-, and 5-mm groups, respectively) and in gingival tissue (0.373±0.304 mm, 0.698±0.431 mm, and 0.713±0.691 mm, respectively). The frequency of complications of wound margin adaptation reduced as the distance of the near insertion point from the wound margin decreased both in the mucosal and gingival tissues.

Conclusions

Placing the near insertion point close to the wound margin enhances the precision of wound margin approximation/adaptation using a vertical mattress suture.

Optimized workflow for single-cell transcriptomics on infectious diseases including COVID-19

In December 2019, a new coronavirus, SARS-CoV-2, which causes the respiratory illness that led to the COVID-19 pandemic, was reported. In the face of such a new pathogen, special precautions must be taken to examine potentially infectious materials due to the lack of knowledge on disease transmissibility, infectivity, and molecular pathogenicity. Here, we present a complete and safe workflow for performing scRNA-seq experiments on blood samples of infected patients from cell isolation to data analysis using the micro-well based BD Rhapsody platform. For complete information on the use and execution of this protocol, please refer to Schulte-Schrepping et al. (2020).

Effectiveness and safety of Chinese herbal medicines for hepatitis B virus-related acute-on-chronic liver failure: study protocol for a multicenter randomized controlled trial

OBJECTIVE

To conduct a multicenter randomized controlled trial of the efficacy of standardized Chinese herbal medicines (CHMs) against acute- on-chronic liver failure (ACLF) and provide reproducible and high-level evidence for clinical practice.

METHODS

This is a prospective, multicenter, centrally randomized controlled trial. Patients diagnosed with hepatitis B virus-related ACLF (n = 510) will be allocated to the standard medical therapy or CHM group at a 1∶1 ratio. Two CHMs will be used on the basis of the traditional Chinese medicine syndrome: Liangxue Jiedu granules for excess syndromes and Yiqi Jiedu granules for deficiency syndromes. The primary outcome is transplant-free survival at week 12. The secondary outcomes are (a) transplant-free survival at week 24, (b) liver function as assessed using the model for end-stage liver disease score at week 12, (c) liver function as assessed using the Child-Pugh score at week 12, and (d) the incidence of complications at week 12.

DISCUSSION

The effectiveness and safety of CHM formulations will be assessed following treatment for ACLF.

Study protocol for an open-label, single-arm, phase Ib/II study of combination of toripalimab, nab-paclitaxel, and gemcitabine as the first-line treatment for patients with unresectable pancreatic ductal adenocarcinoma

Background

Pancreatic ductal adenocarcinoma (PDAC) is a fatal disease with a dismal response to single-use of immune checkpoint inhibitors (ICIs). ICIs combined with systemic therapy has shown efficacy and safety in various solid tumors. Nab-paclitaxel and gemcitabine (AG), as the standard first-line treatment for advanced PDAC, has been widely used in recent years. The combination of ICIs and AG chemotherapy appears to be a promising option in the treatment of PDAC.

Methods

This is an open-label, single-arm, and single-center phase Ib/II trial. The enrolled subjects are the unresectable (locally advanced or metastatic) PDAC patients without previous systemic treatments. All subjects receive an intravenous injection of gemcitabine 1000 mg/m² and nab-paclitaxel 125 mg/m² on day 1 and day 8, along with toripalimab 240 mg at day 1 every 3 weeks. The subjects may discontinue the treatment because of progression disease (PD), intolerable toxicities, requirements of patients or researchers. For local advanced patients who are evaluated as partial response (PR), surgeons need to assess the surgical possibility. The primary objective of this trial is to evaluate the safety and overall survival (OS) of this combination therapy; and the secondary objective is related to the assessment of objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), and the rate of resection or R0 resection after receiving toripalimab plus AG treatment. Besides, we expect to identify the predictive biomarkers (such as MMR protein and PD-L1 expression, the number of TILs, the small RNA of EBV and so on) and explore the correlation between these biomarkers and tumor response to this combined regimen.

Discussion

This trial is the first attempt to evaluate the efficacy and safety of the combination of toripalimab plus AG chemotherapy as a first-line treatment for unresectable PDAC patients. The results of this phase Ib/II study will provide preliminary evidence for further assessment of this combined therapeutic regimen for unresectable PDAC patients.

Trial registration

Trial registration: ChiCTR (ChiCTR2000032293). Registered 25 April 2020 - Retrospectively registered.

Effect of plum-blossom needling versus tropicamide eye drops on adolescent myopia: protocol for a randomized crossover trial

OBJECTIVE

Myopia is the most common eye problem and affects an estimated 28.3% of the global population. Its incidence is increasing annually. Myopia treatment is limited to correcting visual acuity. Acupuncture is one of the main therapies in traditional Chinese medicine and includes plum-blossom needling, which has been widely used for both the prevention and treatment of adolescent myopia. We hypothesized that plum-blossom needling would be effective in treating myopia compared with a tropicamide eye drops control.

METHODS

This is a crossover randomized controlled trial involving adolescents with myopia. Participants will be randomized 1∶1 to plum-blossom needle or tropicamide eye drops arms. Subjects in each arm will be treated for 20 d, followed by a 1-month washout period and treatment change for another 20 d. The primary outcome is uncorrected distance and cycloplegic refractive errors. The secondary outcomes comprise corneal curvature, lens thickness, axial length, ciliary body thickness, accommodation amplitude, the NRA/PRA (negative/positive relative accommodation), flexible adjustment, and near point of convergence. The outcome measures will be assessed at baseline, after the first treatment course (the first month), at the end of the washout period (the second month), after the second treatment course (the third month), and at follow-up (the sixth month).

DISCUSSION

The results of the trial will help to provide evidence for the efficacy of plum-blossom needling for myopia in China.

"Efficacy and safety of the Qiguiyin formula in severe pneumonia: study protocol for a randomized, double-blind, placebo-controlled clinical trial"

OBJECTIVE

To evaluate the clinical efficacy and safety of Qiguiyin (QGY) formula in patients with severe pneumonia in China compared with a placebo.

METHODS

This is a multicenter double-blind, placebo-controlled, randomized clinical trial with two parallel arms. There will be 530 patients enrolled and randomized into either the experimental group (QGY formula) or the control group (placebo). Therapies for patients in the two groups above will be based on the conventional therapy. The primary outcome is 28-day mortality. Secondary outcomes include: (a) duration of hospital stay; (b) duration of time in the intensive care unit (ICU) stays; (c) duration of mechanical ventilation; (d) antibiotic DDD value(which means the doses of antibotics during the treatment period); (e) serum procalcitonin (PCT) level; (f) serum C-reactive protein (CRP) level; (g) Pneumonia severity index (PSI) score; (h) Sequential Organ Failure Assessment (SOFA) score; (i) sputum culture results; (j) blood routine examination results; (k) routine urine test results; (l) stool routine examination results; (m) electrocardiogram results; (n) alanine aminotransferase levels; (o) aspartate amino transferase levels; (p) total bilirubin; (q) creatinine levels; (r) urea nitrogen levels; and (s) adverse events.

ETHICS AND DISSEMINATION

The protocol has been approved by the Research Ethics Committee of Beijing Hospital of Traditional Chinese Medicine, Affiliated with Capital Medical University (2018BL- 053-02). This trial aims to provide evidence for QGY formula combined with conventional therapy in treating patients with severe bacterial pneumonia, and to verify the clinical effectiveness and safety of QGY formula in China compared with placebo. Additionally, this trial will reveal the effect of QGY formula on delaying/reversing the characteristics of drug-resistant bacteria.

[PROtocol-based MObilizaTION on intensive care units : Design of a cluster randomized pilot study]

BACKGROUND

Despite convincing evidence for early mobilization of patients on intensive care units (ICU), implementation in practice is limited. Protocols for early mobilization, including in- and exclusion criteria, assessments, safety criteria, and step schemes may increase the rate of implementation and mobilization.

HYPOTHESIS

Patients (population) on ICUs with a protocol for early mobilization (intervention), compared to patients on ICUs without protocol (control), will be more frequently mobilized (outcome).

METHODS

A multicenter, stepped-wedge, cluster-randomized pilot study is presented. Five ICUs will receive an adapted, interprofessional protocol for early mobilization in randomized order. Before and after implementation, mobilization of ICU patients will be evaluated by randomized monthly one-day point prevalence surveys. Primary outcome is the percentage of patients mobilized out of bed, operationalized as a score of ≥3 on the ICU Mobility Scale. Secondary outcome parameters will be presence and/or length of mechanical ventilation, delirium, stay on ICU and in hospital, barriers to early mobilization, adverse events, and process parameters as identified barriers, used strategies, and adaptions to local conditions.

EXPECTED RESULTS

Exploratory evaluation of study feasibility and estimation of effect sizes as the basis for a future explanatory study.

Blood components requests at an orthopedic hospital: a critical survey

Introduction

The correct completion of the blood components request form is the starting point to ensure good transfusion care. Many guidelines have been developed to search for hemoglobin values that trigger the need for transfusion and show the importance of Patient Blood Management, a scientific evidence-based approach in processes where transfusion is a possibility, such as in elective surgeries.

Objective

The cross-sectional study aimed to analyze the transfusion requests at a complex orthopedic hospital over a one-year period.

Method

The completion quality was classified as Good, Regular, Bad or Very Bad, according to the information given by the physician. Transfusion medicine professionals analyzed the transfusion indication reported on the request form and classified it as Correct, Not based on Patient Blood Management (PBM), in accordance or not with the institutional Maximum Surgical Blood Order Schedule, Impossible to evaluate due to lack of information on the form, and Incorrect.

Results

The study categorized the completion quality of 2011 requests as Good (8.80%), Regular (9.30%), Bad (72.75%) and Very Bad (9.15%). Analysis of the indications revealed that 54.90% of the requests were in accordance with the current blood transfusion recommendations, and on 23.12% of the forms this field had not been filled out.

Conclusion

The majority of blood components (63%) requests are in tune with current blood transfusion recommendations, despite the great number of incorrectly completed forms; nevertheless, it is mandatory to reach much better appropriateness rates.

Introduction to contrast-enhanced ultrasound of the brain in neonates and infants: current understanding and future potential

Contrast-enhanced ultrasound (CEUS) is a valuable bedside imaging technique that enables both qualitative and quantitative assessment of cerebral perfusion. In neonates and infants whose fontanelles remain open, the technique is particularly useful as it delineates cerebral pathology with high soft-tissue contrast. The technique has the potential to be a valuable alternative to computed tomography (CT) or magnetic resonance imaging (MRI) in critically ill neonates and infants in need of bedside imaging. While further studies are needed to validate the technique, preliminary data in this regard appear promising. This review introduces the current understanding and future potential of brain CEUS.

Surveying the management of Achilles tendon ruptures in the Netherlands: lack of consensus and need for treatment guidelines

PURPOSE

This study aimed to describe and analyse usual care of Achilles tendon ruptures (ATRs) by orthopaedic surgeons and trauma surgeons in the Netherlands.

METHODS

A nationwide online survey of ATR management was sent to all consultant orthopaedic and trauma surgeons in the Netherlands, requesting participation of those involved in ATR management. Data on individual characteristics and the entire ATR management (from diagnosis to rehabilitation) were gathered. Consensus was defined as ≥ 70% agreement on an answer.

RESULTS

A total of 91 responses (70 orthopaedic surgeons and 21 trauma surgeons) were analysed. There was consensus on the importance of the physical examination in terms of diagnosis (> 90%) and a lack of consensus on diagnostic imaging (ultrasound/MRI). There was consensus that non-surgical treatment is preferred for sedentary and systemically diseased patients and surgery for patients who are younger and athletic and present with larger tendon gap sizes. There was consensus on most of the non-surgical methods used: initial immobilisation in plaster cast with the foot in equinus position (90%) and its gradual regression (82%) every 2 weeks (85%). Only length of immobilisation lacked consensus. Surgery was generally preferred, but there was a lack of consensus on the entire followed protocol. Orthopaedic and trauma surgeons differed significantly on their surgical (p = 0.001) and suturing techniques (p = 0.002) and methods of postoperative immobilisation (p < 0.001). Orthopaedic surgeons employed open repair and Bunnell sutures more often, whereas trauma surgeons used minimally invasive approaches and bone anchors. Rehabilitation methods and advised time until weight-bearing and return to sport varied. Orthopaedic surgeons advised a significantly longer time until return to sport after both non-surgical treatment (p = 0.001) and surgery (p = 0.002) than trauma surgeons.

CONCLUSION

This is the first study to describe the entire ATR management. The results show a lack of consensus and wide variation in management of ATRs in the Netherlands. This study shows that especially the methods of the perioperative and rehabilitation phases were inconclusive and differed between orthopaedic and trauma surgeons. Further research into optimal ATR management regimens is recommended. In addition, to achieve uniformity in management more multidisciplinary collaboration between Dutch and international surgeons treating ATRs is needed.

LEVEL OF EVIDENCE

Cross-sectional survey, Level V.

The effects of mental practice based on motor imagery for mobility recovery after subacute stroke: Protocol for a randomized controlled trial

BACKGROUND AND PURPOSE

Mental practice of motor imagery has shown beneficial effects in stroke recovery. However, there are few clinical trials investigating it on the subacute phase. This study will investigate the effects of mental practice in the mobility of patients with subacute stroke.

MATERIALS AND METHODS

Randomized controlled trial including persons with subacute stroke (<3 months). All participants will receive physical exercises and will be randomly allocated into an experimental group (Mental Practice) or into a control group (cognitive training) for 4 weeks(12 sessions).

RESULTS

Primary outcomes will be assessed at baseline and after intervention and will be related to mobility, using Timed Up and Go test and 5 m walking speed test. Whereas secondary outcomes will be muscular strength, biomechanical strategies, mental health and quality of life.

CONCLUSION

The beneficial effects that may be found in this trial can be greatly relevant in clinical practice, justifying this scientific question.

Distortion Correction Protocol for 3T Stereotactic Magnetic Resonance Imaging: A Clinical Study

BACKGROUND

With application of 3T magnetic resonance imaging (MRI) to functional neurosurgery procedures and given the inherent requirement of millimetric precision, the need to develop a method for correction of geometric image distortion emerged. The aim of this study was to demonstrate clinical safety and practical viability of a correction protocol in patients scheduled to undergo stereotactic procedures using 3T MRI.

METHODS

This prospective study comprised 20 patients scheduled to undergo computed tomography (CT) stereotactic functional procedures or encephalic brain lesion biopsies. The CT images were references for MRI geometric accuracy calculations. For each scan, 2 images were obtained: normal and reversed images. Eight distinct points on CT and MRI were selected summing 152 points that were based on a power analysis calculation value >0.999. One patient was excluded because of the inability to find reliable common landmark points on CT and MRI.

RESULTS

The distortion range was 0-5.6 mm and increased proportionally with stereotactic isocenter distance, meaning the distortion was greater in the periphery. After correction, the minimum and maximum distortion found was 0 mm and 3.5 mm, respectively. There was no significant difference between CT and MRI corrected x-coordinates (P > 0.05).

CONCLUSIONS

The proposed method can satisfactorily correct geometric distortions in clinical 3T MRI studies. Clinical use of the technique can be practical and efficient after software automation of the process. The method can be applied to all spin-echo MRI sequences.

Results of the modification of an acute pancreatitis management protocol in Intensive Care medicine

OBJECTIVE

To determine whether the implementation of a protocol for the management of patients with acute pancreatitis (AP) in an Intensive Care Unit (ICU) improves the clinical outcomes.

DESIGN

A retrospective, before-after observational case series study was carried out.

STUDY PERIOD

1 January 2001 to 31 December 2016, divided in 2 periods (pre-protocol 2001-2007, post-protocol 2008-2016).

SCOPE

An ICU with 48 beds and a recruitment population of 700,000 inhabitants.

PARTICIPANTS

AP patients admitted to the ICU, with no exclusion criteria.

INTERVENTIONS

The recommendations proposed in the 7th Consensus Conference of the SEMICYUC on AP (5 September 2007) were applied in the second period.

MAIN VARIABLES OF INTEREST

Patient age, sex, APACHE II, SOFA, study period, pre-ICU hospital stay, nutrition, surgery, antibiotic prophylaxis, hospital mortality, ICU length of stay, hospital length of stay, determinant-based classification.

RESULTS

The study comprised 286 patients (94 in the pre-protocol period, 192 in the post-protocol period), with a global in-hospital mortality rate of 23.1% (n=66). Application of the protocol decreased the pre-ICU hospital stay and the use of antibiotic prophylaxis, and increased the use of enteral nutrition. Hospital mortality decreased in the second period (35.1 vs. 17.18%; P=.001), with no significant changes in ICU and hospital stays. In the multivariate logistic regression analysis, the variable period of treatment remained as a variable of statistical significance in terms of hospital mortality (OR 0.34 for the period 2008-2016, 95% CI 0.15-0.74).

CONCLUSIONS

The implementation of a protocol could result in decreased mortality among AP patients admitted to the ICU.

A systematic review of orthodontic retention systems: The verdict

INTRODUCTION

Retention during both the active and passive phases of treatment has given rise to numerous publications concerning its efficacy, the range of systems available and its variability over time. There are currently many different retention protocols regularly used by orthodontists; however, their efficacy and duration are still subject to debate. There is as yet no consensus as to which retention protocol is the most effective or for how long the retention device needs to be worn. The aim of this research was to perform a systematic review of the scientific literature in order to evaluate the efficacy of the different retention systems and clinical protocols among those most widely used, so as to make recommendations beneficial to both patient and practitioner.

MATERIALS AND METHODS

A search of the literature was performed in the following databases: PubMed (MEDLINE), ScienceDirect and Cochrane Library. The search was limited to publications in English and French during the period 2006-2016.

RESULTS

Out of 1952 references initially identified, 17 articles corresponded to our inclusion criteria. The results show that: fixed retention is more effective than removable retainers for the maintenance of incisor alignment during the first six months of retention; there is no significant difference in efficacy between the different fixed retention systems; there is no significant difference in efficacy between the vacuum-formed systems and the Hawley retainer; part-time use of removable retainers (between 8-10h/day) is sufficient; the most widely used retention protocol combines a vacuum-formed splint or Hawley retainer in the upper arch with mandibular fixed retention.

CONCLUSION

Despite the large number of studies devoted to orthodontic retention only a few articles corresponded to the methodological criteria of bio statistical analysis. Also, on account of the variations in experimental protocols, the levels of proof relating to the efficacy of different systems are very weak. Research into this topic should first seek to normalize methods of analysis and then perform randomized controlled long-term trials to shed light on this problem.

Multi-disciplinary clinical protocol for the diagnosis of bulbar amyotrophic lateral sclerosis

INTRODUCTION AND OBJECTIVES

The objective of this study was to examine the role of different specialists in the diagnosis of amyotrophic lateral sclerosis (ALS), to understand changes in verbal expression and phonation, respiratory dynamics and swallowing that occurred rapidly over a short period of time.

MATERIALS AND METHODS

22 patients with bulbar ALS were submitted for voice assessment, ENT evaluation, Multi-Dimensional Voice Program (MDVP), spectrogram, electroglottography, fiberoptic endoscopic evaluation of swallowing.

RESULTS

In the early stage of the disease, the oral tract and velopharyngeal port were involved. Three months after the initial symptoms, most of the patients presented hoarseness, breathy voice, dysarthria, pitch modulation problems and difficulties in pronunciation of explosive, velar and lingual consonants. Values of MDVP were altered. Spectrogram showed an additional formant, due to nasal resonance. Electroglottography showed periodic oscillation of the vocal folds only during short vocal cycle. Swallowing was characterized by weakness and incoordination of oro-pharyngeal muscles with penetration or aspiration.

CONCLUSIONS

A specific multidisciplinary clinical protocol was designed to report vocal parameters and swallowing disorders that changed more quickly in bulbar ALS patients. Furthermore, the patients were stratified according to involvement of pharyngeal structures, and severity index.

A non-controlled, single arm, open label, phase II study of intravenous and intratumoral administration of ParvOryx in patients with metastatic, inoperable pancreatic cancer: ParvOryx02 protocol

BACKGROUND

Metastatic pancreatic cancer has a dismal prognosis, with a mean six-month progression-free survival of approximately 50% and a median survival of about 11 months. Despite intensive research, only slight improvements of clinical outcome could be achieved over the last decades. Hence, new and innovative therapeutic strategies are urgently required. ParvOryx is a drug product containing native parvovirus H-1 (H-1PV). Since H-1PV was shown to exert pronounced anti-neoplastic effects in pre-clinical models of pancreatic cancer, the drug appears to be a promising candidate for treatment of this malignancy.

METHODS

ParvOryx02 is a non-controlled, single arm, open label, dose-escalating, single center trial. In total seven patients with pancreatic cancer showing at least one hepatic metastasis are to be treated with escalating doses of ParvOryx according to the following schedule: i) 40% of the total dose infused intravenously in equal fractions on four consecutive days, ii) 60% of the total dose injected on a single occasion directly into the hepatic metastasis at varying intervals after intravenous infusions. The main eligibility criteria are: age ≥ 18 years, disease progression despite first-line chemotherapy, and at least one hepatic metastasis. Since it is the second trial within the drug development program, the study primarily explores safety and tolerability after further dose escalation of ParvOryx. The secondary objectives are related to the evaluation of certain aspects of anti-tumor activity and clinical efficacy of the drug.

DISCUSSION

This trial strongly contributes to the clinical development program of ParvOryx. The individual hazards for patients included in the current study and the environmental risks are addressed and counteracted adequately. Besides information on safety and tolerability of the treatment after further dose escalation, thorough evaluations of pharmacokinetics and intratumoral spread as well as proof-of-concept (PoC) in pancreatic cancer will be gained in the course of the trial.

TRIAL REGISTRATION

ClinicalTrials.gov-ID: NCT02653313 , Registration date: Dec. 4th, 2015.

Development of a computer-interpretable clinical guideline model for decision support in the differential diagnosis of hyponatremia

INTRODUCTION

Hyponatremia is the most common type of electrolyte imbalance, occurring when serum sodium is below threshold levels, typically 135mmol/L. Electrolyte balance has been identified as one of the most challenging subjects for medical students, but also as one of the most relevant areas to learn about according to physicians and researchers. We present a computer-interpretable guideline (CIG) model that will be used for medical training to learn how to improve the diagnosis of hyponatremia applying an expert consensus document (ECDs).

METHODS

We used the PROForma set of tools to develop the model, using an iterative process involving two knowledge engineers (a computer science Ph.D. and a preventive medicine specialist) and two expert endocrinologists. We also carried out an initial validation of the model and a qualitative post-analysis from the results of a retrospective study (N=65 patients), comparing the consensus diagnosis of two experts with the output of the tool.

RESULTS

The model includes over two-hundred "for", "against" and "neutral" arguments that are selectively triggered depending on the input value of more than forty patient-state variables. We share the methodology followed for the development process and the initial validation results, that achieved a high ratio of 61/65 agreements with the consensus diagnosis, having a kappa value of K=0.86 for overall agreement and K=0.80 for first-ranked agreement.

CONCLUSION

Hospital care professionals involved in the project showed high expectations of using this tool for training, but the process to follow for a successful diagnosis and application is not trivial, as reported in this manuscript. Secondary benefits of using these tools are associated to improving research knowledge and existing clinical practice guidelines (CPGs) or ECDs. Beyond point-of-care clinical decision support, knowledge-based decision support systems are very attractive as a training tool, to help selected professionals to better understand difficult diseases that are underdiagnosed and/or incorrectly managed.

A new prescription model for regional citrate anticoagulation in therapeutic plasma exchanges

Background

Regional citrate anticoagulation (RCA) is proposed for various extracorporeal purification techniques to overcome the risk of bleeding that might result from systemic anticoagulation. Yet, no individualized treatment protocol has been proposed for therapeutic plasma exchange (TPE) so far. The objective of this study was to assess the determinants of blood citrate concentration needed and to develop an individualized RCA protocol useful for clinical practice.

Methods

The study population included 14 patients who underwent a total of 47 TPE sessions. Citrate was infused pre-plasmafilter. Post-plasmafilter and systemic plasma ionized calcium concentrations were measured at standardized time intervals. An algorithm was proposed for the supplementation of calcium. During the discovery phase, citrate was infused at a fixed starting rate, and adapted accordingly to obtained post-plasmafilter ionized calcium levels. Using a mathematical approach, an algorithm was thereafter developed for individualized prescriptions of citrate.

Results

Pre-treatment values of hematocrit and plasma ionized calcium were the main determinants of the required rate of citrate infusion. These can be integrated into a final equation enabling to individualize the prescription. A prefilter ionized calcium concentration between 0.24 and 0.33 mmol/l prevented coagulation of the extracorporeal circuit. Significant hypocalcemia occurred in 8.5% of treatments. There were no significant acid–base disturbances.

Conclusion

We propose a new protocol, which enables for the first time to individualize the prescription of regional citrate anticoagulation during TPE, in an efficient manner. The immediately obtained regional anticoagulation protects against both the risk of coagulation of the membrane and the exposure to an excess of citrate.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-017-0494-9) contains supplementary material, which is available to authorized users.

Effect of TENS Versus Placebo on Walking Capacity in Patients With Lumbar Spinal Stenosis: A Protocol for a Randomized Controlled Trial

Background

Lumbar spinal stenosis (LSS) is a growing health problem and a leading cause of disability and loss of independence in older adults. It is usually caused by age-related degenerative narrowing of the spinal canals leading to compression and ischemia of the spinal nerves and symptoms of neurogenic claudication. Limited walking ability is the dominant functional impairment caused by LSS. Animal studies suggest increased blood flow to the spinal nerves and spinal cord with superficial paraspinal electrical stimulation. The purpose of this study is to assess the effectiveness of paraspinal transcutaneous electrical nerve stimulation (TENS) applied while walking on walking ability in patients with LSS.

Methods/Design

We propose to conduct a 2-arm double-blinded (participant and assessor) randomized controlled trial. We will recruit individuals who have limited walking ability due to degenerative LSS from hospital specialists, community physicians, and chiropractors located in the city of Toronto, Canada. Eligible consenting participants will be randomly assigned to either paraspinal TENS or placebo paraspinal TENS applied while walking. The primary outcome will be walking distance measured during a single self-paced walking test. We will calculate the differences in proportions among participants in both groups who achieve at least a 30% improvement in walking distance from baseline using Pearson χ² test with 95% confidence intervals.

Discussion

Effective nonoperative interventions for LSS are unknown. Interventions that can improve blood flow to the spinal nerves while walking may increase walking ability in this population. Transcutaneous electrical nerve stimulation is a low-cost intervention that may have the potential to achieve this objective. To our knowledge, this study will be the first clinical trial to assess the effects of TENS on walking ability of patients with LSS.

Trial Registration

ClinicalTrials.gov ID: NCT02592642

Comparison between passive vision-based system and a wearable inertial-based system for estimating temporal gait parameters related to the GAITRite electronic walkway

Quantitative gait analysis allows clinicians to assess the inherent gait variability over time which is a functional marker to aid in the diagnosis of disabilities or diseases such as frailty, the onset of cognitive decline and neurodegenerative diseases, among others. However, despite the accuracy achieved by the current specialized systems there are constraints that limit quantitative gait analysis, for instance, the cost of the equipment, the limited access for many people and the lack of solutions to consistently monitor gait on a continuous basis. In this paper, two low-cost systems for quantitative gait analysis are presented, a wearable inertial system that relies on two wireless acceleration sensors mounted on the ankles; and a passive vision-based system that externally estimates the measurements through a structured light sensor and 3D point-cloud processing. Both systems are compared with a reference clinical instrument using an experimental protocol focused on the feasibility of estimating temporal gait parameters over two groups of healthy adults (five elders and five young subjects) under controlled conditions. The error of each system regarding the ground truth is computed. Inter-group and intra-group analyses are also conducted to transversely compare the performance between both technologies, and of these technologies with respect to the reference system. The comparison under controlled conditions is required as a previous stage towards the adaptation of both solutions to be incorporated into Ambient Assisted Living environments and to provide continuous in-home gait monitoring as part of the future work.

Fast versus slow weight loss: development process and rationale behind the dietary interventions for the TEMPO Diet Trial

Objective and methods

Finding effective solutions to curb the obesity epidemic is a great global public health challenge. The need for long‐term follow‐up necessitates weight loss trials conducted in real‐world settings, outside the confines of tightly controlled laboratory or clinic conditions. Given the complexity of eating behaviour and the food supply, this makes the process of designing a practical dietary intervention that stands up to scientific rigor difficult. Detailed information about the dietary intervention itself, as well as the process of developing the final intervention and its underlying rationale, is rarely reported in scientific weight management publications but is valuable and essential for translating research into practice. Thus, this paper describes the design process and underlying rationale behind the dietary interventions in an exemplar weight loss trial – the TEMPO Diet Trial (Type of Energy Manipulation for Promoting optimal metabolic health and body composition in Obesity). This trial assesses the long‐term effects of fast versus slow weight loss on adiposity, fat free mass, muscle strength and bone density in women with obesity (body mass index 30–40 kg m⁻²) that are 45–65 years of age, postmenopausal and sedentary.

Results and conclusions

This paper is intended as a resource for researchers and/or clinicians to illustrate how theoretical values based on a hypothesis can be translated into a dietary weight loss intervention to be used in free‐living women of varying sizes.

Interforaminal hemorrhage during anterior mandibular implant placement: An overview

Implant surgery in mandibular anterior region may turn from an easy minor surgery into a complicated one for the surgeon, due to inadequate knowledge of the anatomy of the surgical area and/or ignorance toward the required surgical protocol. Hence, the purpose of this article is to present an overview on the: (a) Incidence of massive bleeding and its consequences after implant placement in mandibular anterior region. (b) Its etiology, the precautionary measures to be taken to avoid such an incidence in clinical practice and management of such a hemorrhage if at all happens. An inclusion criterion for selection of article was defined, and an electronic Medline search through different database using different keywords and manual search in journals and books was executed. Relevant articles were selected based upon inclusion criteria to form the valid protocols for implant surgery in the anterior mandible. Further, from the selected articles, 21 articles describing case reports were summarized separately in a table to alert the dental surgeons about the morbidity they could come across while operating in this region. If all the required adequate measures for diagnosis and treatment planning are taken and appropriate surgical protocol is followed, mandibular anterior region is no doubt a preferable area for implant placement.

Standardizing data exchange for clinical research protocols and case report forms: An assessment of the suitability of the Clinical Data Interchange Standards Consortium (CDISC) Operational Data Model (ODM)

Efficient communication of a clinical study protocol and case report forms during all stages of a human clinical study is important for many stakeholders. An electronic and structured study representation format that can be used throughout the whole study life-span can improve such communication and potentially lower total study costs. The most relevant standard for representing clinical study data, applicable to unregulated as well as regulated studies, is the Operational Data Model (ODM) in development since 1999 by the Clinical Data Interchange Standards Consortium (CDISC). ODM's initial objective was exchange of case report forms data but it is increasingly utilized in other contexts. An ODM extension called Study Design Model, introduced in 2011, provides additional protocol representation elements. Using a case study approach, we evaluated ODM's ability to capture all necessary protocol elements during a complete clinical study lifecycle in the Intramural Research Program of the National Institutes of Health. ODM offers the advantage of a single format for institutions that deal with hundreds or thousands of concurrent clinical studies and maintain a data warehouse for these studies. For each study stage, we present a list of gaps in the ODM standard and identify necessary vendor or institutional extensions that can compensate for such gaps. The current version of ODM (1.3.2) has only partial support for study protocol and study registration data mainly because it is outside the original development goal. ODM provides comprehensive support for representation of case report forms (in both the design stage and with patient level data). Inclusion of requirements of observational, non-regulated or investigator-initiated studies (outside Food and Drug Administration (FDA) regulation) can further improve future revisions of the standard.

Effects of a protocol-based management of type A aortic dissections

BACKGROUND

Ascending aortic dissections (AADs) require prompt diagnosis and surgical treatment. We present the results of implementing a multidisciplinary aortic dissection protocol on the outcomes of AAD treatment at a nonteaching hospital.

METHODS

From January 2002-December 2013, 54 patients with the diagnosis of AAD were treated at our institution. Thirty-seven (68.5%) were male with a mean age of 62.3 y. Cardiogenic shock was present in 25.9% of patients. An AAD protocol, focused on educating physicians on presenting signs and symptoms, adequate triaging, and the need for immediate surgical intervention, was implemented, alongside the standardization of surgical treatment. We divided the cohort into two eras, based on AAD program's implementation in 2006, to better assess the impact of this protocol.

RESULTS

Patients from the early era had significantly longer time from Emergency Department to the operating room, more postoperative occurrence of prolonged ventilation, and a longer postoperative hospital stay at 8.7 ± 8 versus 3.1 ± 2.6 h (P = 0.002), 63% versus 18% (P = 0.002), and 63% versus 18% (P = 0.002), respectively. The overall mortality for the cohort was 9.3%, decreasing from 12.5% before 2006 to 7.9% after 2006.

CONCLUSIONS

The implementation of a multidisciplinary aortic dissection protocol has resulted in faster diagnosis and transport of AAD cases from the emergency room to the operating room, improving outcomes. Our data support the concept that nonteaching institutions can deliver excellent care to patients with acute aortic emergencies.

Provider perspectives on the use of indwelling urinary catheters in older adults in emergency department settings: developing a novel clinical protocol

BACKGROUND

Indwelling urinary catheters (IUCs) are commonly placed in older adult (aged ≥ 65 years) patients in emergency department (ED) settings, often for inappropriate indications. The aim of our qualitative study was to explore ED provider knowledge, attitudes, and practice patterns surrounding use of IUCs in older adult patients in the ED setting, to better guide development of a clinical protocol.

METHODS

We conducted 4 focus groups with 38 participants at a large academic medical center. Each focus group was conducted with a single ED provider type: attending physicians, residents, physician assistants, or nurses. Focus groups used a semistructured format, ranging in duration from 23-33 minutes. The sessions were audiorecorded, fully transcribed, and data were coded and analyzed to identify themes.

RESULTS

Participants reported believing that IUCs are overutilized in ED settings, confirming that IUCs are infrequently removed once placed and often inserted for staff convenience. Participants reported that current clinical decision making about IUC placement varies widely; yet all acknowledged the known risks for patient safety and willingness to adopt a clinical protocol to standardize practice. Focus groups were a critical component for the development of a user-friendly protocol, identifying 10 key elements for successful implementation and 11 potential barriers.

CONCLUSIONS

An evidence-based clinical protocol guiding ED providers in appropriate placement and management of IUCs in older adults would be welcomed.

The utility of the surgical safety checklist for wound patients

The purpose of this study was to determine the frequency of changes in patient care resulting from the use of a surgical safety checklist. Data were retrospectively obtained from 233 patients. The number and types of changes made to the patients' intra-operative management, based on the use of the checklist, were recorded. The number of patients whose management was modified as a result of the checklist was 113 (48%) out of 233. The total number of changes made was 132, and 18 patients had more than one modification made to their care plan. Further stratification was identified: among the 132 changes made, antibiotics were held or administered in 73 (55%), changes related to anaemia involving type and screen or transfusion occurred in 27 (20%), modifications made regarding anti-coagulation occurred in 8 (7%), beta-blockers were held in 2 (2%), an allergy was identified in 7 (5%), modifications made to the surgical procedure were 3 (2%) and a category labelled 'other' encompassed 9 (7%) changes. The surgical safety checklist is a standardised form of team communication that leads to modifications of the patient care plan in a large percentage of cases. The ever-increasing complexity of medicine means that patients are at greater risk of oversight and harm without the use of a checklist.

Putting Research Findings into Clinical Practice: Feasibility of integrated evidence-based care pathways in otorhinolaryngology head and neck surgery at Sultan Qaboos University Hospital, Oman

OBJECTIVES

A perception exists that clinicians in Oman are reluctant to adopt evidence-based practice (EBP). This pilot study was undertaken to study the feasibility of using EBP pathways at the point of care in otorhinolaryngology head and neck surgery. The ultimate aim was to facilitate EBP with the probability of developing a new system for implementing research findings/translational research at the clinical point of care.

METHODS

A cross-sectional prospective questionnaire pilot survey of clinicians at Sultan Qaboos University Hospital (SQUH), Oman, a tertiary care medical centre, was undertaken. Respondents included 135 physicians and surgeons with between 3 months and 25 years of clinical experience and included personnel ranging from interns to senior consultants, in areas ranging from primary care to specialist care.

RESULTS

Of those polled, 90% (95% confidence interval (CI) 85-95%) either strongly agreed or agreed that evidence-based practice protocols (EBPP) could help in decision making. A total of 87.4% of participants (95% CI 81.8-93%) either strongly agreed or agreed that EBPPs can improve clinical outcomes; 91.8% of participants (95% CI 87.2-96.4%) would use and apply EBPP in day-to-day care if they were available at the point of care and embedded in the hospital information system.

CONCLUSIONS

The perception that clinicians at SQUH are reluctant to adopt EBP is incorrect. The introduction of EBP pathways is very feasible at the primary care level. Institutional support for embedding EBP in hospital information systems is needed as well as further outcome research to assess the improvement in quality of care.