Safe and effective gradual reduction (tapering) of opioids in people with chronic non-cancer pain: systematic review of effects, barriers and facilitators and inequalities to inform service design in the NHS
Opioids have been used for pain management for centuries. However, current evidence suggests that the long-term use of opioid therapy is not effective for managing chronic non-cancer pain. People with chronic non-cancer pain may need to increase opioid dose to achieve pain relief which can lead to tolerance and dependency. Some people may also experience increased sensitivity to pain.
People with chronic non-cancer pain taking opioids long-term may need help to reduce their opioid use. This project aims to inform better practice, pathways and service design to support people with chronic pain to reduce their use of opioids and reduce inequalities. We are undertaking an evidence synthesis which includes systematic reviews of the quantitative and qualitative evidence, and the use of an emerging method - qualitative comparative analysis (QCA). The reviews will synthesise evidence on effectiveness, safety and acceptability of interventions to reduce opioid use; barriers to and facilitators of interventions; and inequalities in access to or benefiting from interventions.
Ruaraidh Hill. Rebecca Bresnahan. Rui Duarte. Juliet Hounsome. Michelle Maden.
Reporting guidelines for clinical trial protocols and reports of implantable neurostimulation devices: the SPIRIT-iNeurostim and CONSORT-iNeurostim extensions
The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) statement was produced to ensure that trial protocols were complete and more likely to produce valid results, while the Consolidated Standards of Reporting Trials (CONSORT) initiative was produced to improve the reporting, clarity and transparency of randomised controlled trials (RCTs) after completion. Extensions of the SPIRIT and CONSORT statements are developed to improve the reporting of trials of specific trial designs, data or interventions. SPIRIT and CONSORT extensions have not been developed for clinical trials of implantable neurostimulation devices.
The aim of this project is to develop SPIRIT and CONSORT extensions for clinical trials of implantable neurostimulation devices. We have produced an initial list of candidate items for the SPIRIT-iNeurostim and CONSORT-iNeurostim extensions which we have circulated to experts via a Delphi survey. The experts will vote on which candidate items should be included in the SPIRIT-iNeurostim and/or CONSORT-iNeurostim extensions. The final items for inclusion in each extension will be decided at a consensus meeting.
Rui Duarte.
TAILOR medication synthesis - Optimising a whole-person-centred approach to stopping medicines in older people with multi-morbidity and polypharmacy
We contribute to the Tailor Medication Synthesis project, which aims to provide clinicians and patients with the information they need to make individual decisions about which medicines provide benefit and which they could stop. Doctors and patients alike have described feeling anxious about knowing when and how to stop long term medicines. Uncertainty about the risks involved can prevent people from making decisions. We conducted an extensive scoping review to complement a realist synthesis and patient and professional expert input.A report is being prepared and we will contribute to a stakeholder event and a learning package for professionals.
Health Effects of Liquid and Gaseous Fuel Use for Household Cooking, Heating, and Lighting
In 2014 the World Health Organisation (WHO) published the first WHO Guidelines for Indoor Air Quality: Household Fuel Combustion, which provide recommendations on emission rates for fuels and technologies to protect health and guidance on which fuels should not be used in the home. We are contributing to a review commissoned by the WHO that aims to address gaps in the evidence base regarding the health impacts from the use of liquid and gaseous fuels for cleaner household energy to replace solid fuels and kerosene. The findings of the review will form a database and be reported in peer-reviewed publications, to potentially be used to inform future air quality guidelines and policies supporting rapid transition to clean, efficient and safe household energy fuels and technologies.
Nigel Fleeman. Michelle Maden. Rui Duarte. Rebecca Bresnahan. Katherine Edwards. Angela Boland.
Are cleaner cooking solutions clean enough? A systematic review and meta-analysis of particulate and carbon monoxide concentrations and exposures
Globally, approximately 3 billion primarily cook using inefficient and poorly vented combustion devices, leading to unsafe levels of household air pollution (HAP) in and around the home. Such exposures contribute to nearly 4 million deaths annually (WHO 2018a, 2018b). Characterizing the effectiveness of interventions for reducing HAP concentration and exposure is critical for informing policy and programmatic decision-making on which cooking solutions yield the greatest health benefits.
This review synthesizes evidence of in-field measurements from four cleaner cooking technologies and three clean fuels, using field studies aimed at reducing HAP concentration and personal exposure to health damaging pollutants (particulate matter (PM2.5) and carbon monoxide (CO)). Fifty studies from Africa, Asia, South and Latin America, provided 168 estimates synthesized through meta-analysis.
Nigel Fleeman. Rui Duarte. Michelle Maden.
Care delivery and self‐management strategies for children with epilepsy
Epilepsy is spectrum of disorders in which a person may have seizures (fits) that are unpredictable in frequency. Most seizures are well controlled with medicines and other types of treatments, but epilepsy can cause problems in social, school and work situations, making independent living difficult. People with epilepsy and their families may lack social support or experience social isolation, embarrassment, fear and discrimination, and some parents may also feel guilty. Self-management of epilepsy refers to a wide range of health behaviours and activities that a person can learn and adapt to control their seizures and improve their well-being.
We searched scientific databases for studies in children and adolescents with epilepsy that looked at the effects of self-management of epilepsy. We wanted to look at several outcomes to see how well people and their families generally cope with epilepsy.
Care delivery and self management strategies for adults with epilepsy
This review compared the effectiveness of a range of interventions, including specialist nurses and management strategies, in improving outcomes for adults with epilepsy. We identified seven distinct intervention types, with varying amounts of evidence to support them. While included studies did show some benefit from specialist epilepsy nurses and self management education, other intervention types lack evidence of effectiveness. This is compounded by the poor quality methods of some studies and by the complex nature of the interventions, whose impact may vary according to where they take place. Based on this evidence, it is not possible to advocate any specific intervention type in the care of adults with epilepsy.
Developing resources to support shared decision making for add-on therapies for people with drug-resistant epilepsy
Research dissemination is recognised as an important and essential aspect of research. It ensures that a target audience are aware of the research and can effectively implement its findings. For clinical research, that audience includes patients, clinicians and caregivers, who will use the information to guide their clinical decisions. As part of our NIHR funded (6/114/26) programme, we (Cochrane Epilepsy group) and our collaborators (Epilepsy Action) committed to use research dissemination to engage with stakeholders (our target audience).
We developed a Patient Decision Aid (PDA) to disseminate findings from multiple Cochrane systematic reviews, primarily focused on add-on therapies for drug-resistant epilepsies.
Ruaraidh Hill. Rebecca Bresnahan.
Clinically effective treatments for central nervous system disorders in the NHS, with a focus on epilepsy and Movement Disorders.
Work with Cochrane Epilepsy group, as part of a NIHR funded (6/114/26) programme, to update systematic reviews of add-on therapies for people with drug-resistant epilepsy as well as high-priority systematic reviews of interventions for epilepsy, e.g. ‘Cannabinoids for epilepsy’.
Ruaraidh Hill. Rebecca Bresnahan.
Systematic reviews to examine the clinical effectiveness and tolerability of chemotherapy treatment for older people with cancer
LRiG have been commissioned on behalf of the National Cancer Equity Initiative (NCEI) and the Pharmaceutical Oncology Initiative (POI) to conduct a series of six systematic reviews to explore the effectiveness and tolerability of chemotherapy used to treat older people with: breast cancer, lung cancer, renal cell carcinoma, colorectal cancer, chronic myeloid leukaemia and non-Hodgkin’s lymphoma.
The overall purpose of the reviews is to determine the amount of available evidence and whether older people derive benefit from chemotherapy in terms of survival and/or response to treatment and their tolerance to the treatment. The completed reports are available below.
Breast Cancer Systematic Review
systematic review older people chronic leukaemia
systematic review of chemotherapy old people colorectal
Systematic review of chemotherapy for older people with lung cancer
Enhancing the safety, quality and productivity of perioperative care
LRiG are assisting with several systematic reviews undertaken as part of the NIHR Cochrane Collaboration Programme Grant, Enhancing the safety, quality and productivity of perioperative care. The grant, based at the Royal Lancaster Infirmary and in collaboration with the Cochrane Anaesthesia Review Group, aims to identify clinical questions in perioperative care where there is uncertainty about best practice, to summarise the available evidence in a series of systematic reviews and subsequently disseminate results to clinicians and health policy-makers. LRiG staff are currently working on the following review questions: whether altering the format or media of educational material given to patients before an operation increases their knowledge and reduces their anxiety about the operation; whether the use of nitrous oxide gas in general anaesthesia affects the risk of a patient becoming aware during the anaesthetic; and whether the decision that a patient is fit for surgery differs depending on whether the preoperative evaluation of a patient is performed by a nurse or by a doctor.
A randomised controlled trial of extended brief intervention for alcohol dependent patients in an acute hospital setting (ADPAC)
This is a randomised controlled trial with a primary hypothesis that extended brief interventions (EBI) delivered to alcohol-dependent patients in a hospital setting by an Alcohol Specialist Nurse (ASN) will be effective when compared to usual care in reducing overall alcohol consumption and improving on the standard measures of alcohol dependence. Read more
Contact: Angela Boland (LRiG)
Economic evaluation alongside SLEEPS (Safety profiLe, Efficacy and Equivalence in Paediatric intensive care Sedation)
SLEEPS is a prospective, multi-centre randomised, double blind equivalence study comparing clonidine and midazolam as intravenous sedative agents in critically ill children. A cost-effectiveness analysis was undertaken alongside the trial focusing on the incremental cost per additional case of adequate sedation achieved.
Contact: Angela Boland (LRiG)
Economic evaluation alongside MAGNETIC (MAGnesium NEbuliser Trial In Children)
MAGNETIC is a randomised placebo controlled, double blind multi-centre trial designed to compare nebulised magnesium sulphate with placebo along with standard therapy of nebulised salbutamol and ipratropium. Cost-effectiveness analyses were undertaken focusing on the incremental cost per unit reduction in Asthma Severity Score (ASS) score and incremental cost per quality adjusted life year (QALY) gained.
Contact: Angela Boland (LRiG)
BEA (Multi-frequency Bioimpedance in the Early detection of lymphoedema after Axillary surgery)
BEA is a trial of a new diagnostic technique to assess the extent of swelling which is being compared to conventional perometer measurement. Suitable BEA patients are invited to enrol in the PLACE trial.
Contact: Adrian Bagust (LRiG), Angela Boland (LRiG)
PLACE (Prevention of Lymphoedema After Clearance by External compression)
PLACE is a trial designed to assess the value of compression sleeves, used when moderate swelling is first detected, to prevent the development of full lymphoedema. Suitable BEA patients are invited to enrol in the PLACE trial.
Contact: Adrian Bagust (LRiG) Angela Boland (LRiG)
LiVio (Liverpool Violence Research Group)
The Liverpool Violence (LiVio) Research Group is a multi-disciplinary partnership of academics and clinicians with a commitment to both qualitative and quantitative research approaches and their application to problems of violence and self-harm linked to mental health issues in real-world settings.
Contact: Juliet Hockenhull (LRiG) Richard Whittington (HACCRU)
Clinical and cost effectiveness of interventions for epilepsy in the NHS
To provide evidence about the effectiveness of a range of interventions for epilepsy and, where appropriate, systematic reviews of health economic data or health economic modelling to inform the best use of resources in the NHS. The reviews will cover a range of key topics important to the treatment of patients with epilepsy including anti-epileptic drug (AED) treatment following first seizure, AED withdrawal for those in remission and generic substitution of AEDs. The management of particular quality of life issues (depression, anxiety and memory problems) for patients with epilepsy will be assessed as will the evidence for the teratogenic effects of AEDs.
Contact: Rumona Dickson (LRiG) Janette Greenhalgh (LRiG) Jennifer Pulman (Cochrane Epilepsy Group)
Enhancing the safety, quality and productivity of perioperative care.
LRiG are assisting with several systematic reviews undertaken as part of the NIHR Cochrane Collaboration Programme Grant, Enhancing the safety, quality and productivity of perioperative care. The grant, based at the Royal Lancaster Infirmary and in collaboration with the Cochrane Anaesthesia Review Group, aims to identify clinical questions in perioperative care where there is uncertainty about best practice, to summarise the available evidence in a series of systematic reviews and subsequently disseminate results to clinicians and health policy-makers. LRiG staff are currently working on the following review questions: whether altering the format or media of educational material given to patients before an operation increases their knowledge and reduces their anxiety about the operation; whether the use of nitrous oxide gas in general anaesthesia affects the risk of a patient becoming aware during the anaesthetic; and whether the decision that a patient is fit for surgery differs depending on whether the preoperative evaluation of a patient is performed by a nurse or by a doctor.
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