Clinical trial registration and reporting: a survey of academic organizations in the United States

BACKGROUND

Many clinical trials conducted by academic organizations are not published, or are not published completely. Following the US Food and Drug Administration Amendments Act of 2007, "The Final Rule" (compliance date April 18, 2017) and a National Institutes of Health policy clarified and expanded trial registration and results reporting requirements. We sought to identify policies, procedures, and resources to support trial registration and reporting at academic organizations.

METHODS

We conducted an online survey from November 21, 2016 to March 1, 2017, before organizations were expected to comply with The Final Rule. We included active Protocol Registration and Results System (PRS) accounts classified by ClinicalTrials.gov as a "University/Organization" in the USA. PRS administrators manage information on ClinicalTrials.gov. We invited one PRS administrator to complete the survey for each organization account, which was the unit of analysis.

RESULTS

Eligible organization accounts (N = 783) included 47,701 records (e.g., studies) in August 2016. Participating organizations (366/783; 47%) included 40,351/47,701 (85%) records. Compared with other organizations, Clinical and Translational Science Award (CTSA) holders, cancer centers, and large organizations were more likely to participate. A minority of accounts have a registration (156/366; 43%) or results reporting policy (129/366; 35%). Of those with policies, 15/156 (11%) and 49/156 (35%) reported that trials must be registered before institutional review board approval is granted or before beginning enrollment, respectively. Few organizations use computer software to monitor compliance (68/366; 19%). One organization had penalized an investigator for non-compliance. Among the 287/366 (78%) accounts reporting that they allocate staff to fulfill ClinicalTrials.gov registration and reporting requirements, the median number of full-time equivalent staff is 0.08 (interquartile range = 0.02-0.25). Because of non-response and social desirability, this could be a "best case" scenario.

CONCLUSIONS

Before the compliance date for The Final Rule, some academic organizations had policies and resources that facilitate clinical trial registration and reporting. Most organizations appear to be unprepared to meet the new requirements. Organizations could enact the following: adopt policies that require trial registration and reporting, allocate resources (e.g., staff, software) to support registration and reporting, and ensure there are consequences for investigators who do not follow standards for clinical research.

Randomised clinical trial: efficacy, safety and dosage of adjunctive allopurinol in azathioprine/mercaptopurine nonresponders (AAA Study)

BACKGROUND

Thiopurine hypermethylation towards 6-methylmercaptopurine (6MMP) instead of 6-thioguanine nucleotides (6TGN) is associated with inefficacy in patients with IBD. Allopurinol reverses such hypermethylation.

AIMS

To prospectively determine efficacy of allopurinol-thiopurine combination and to compare 2 doses of allopurinol.

DESIGN

In a multicentre, double-blind trial, patients with clinically active or steroid-dependent IBD and thiopurine shunting were randomised to 50 or 100 mg/d allopurinol and 25% of their screening thiopurine dose, which was subsequently optimised, aiming for 6TGN of 260-500 pmol/8x10⁸ RBCs. The primary endpoint was steroid-free clinical remission at 24 weeks.

RESULTS

Of 73 patients, 39 (53% [95% CI 42-65]) achieved steroid-free remission, (54% with 50 mg/d and 53% with 100 mg/d). 81% were able to discontinue steroids. Therapeutic 6TGN levels were achieved in both groups. Final thiopurine doses were lower with 100 mg/d allopurinol (P < 0.005). 6MMP: 6TGN ratio decreased from mean 64 to 4 (P < 0.001), being higher with 50 mg/d (6 ± 1.83) than for 100 mg/d ([1 ± 0.16], P = 0.003). Three patients on 50 mg/d failed to sustain low ratios at 24 weeks. Toxicity was minimal; three patients on 50 mg/d allopurinol developed transient leukopenia. Alanine aminotransferase concentrations decreased (P < 0.001) similarly in both arms. Faecal calprotectin levels at study end were lower in patients who achieved the primary endpoint (median 171 [85-541] vs 821[110-5892] ug/g, P = 0.03).

CONCLUSIONS

Low-dose allopurinol-thiopurine combination safely reverses shunting and optimises 6TGN with associated improvement in disease activity. 100 mg/d allopurinol is preferable due to greater metabolite profile stability and lower thiopurine dose without additional toxicity.

Home, No Follow-Up: Are we ignoring the significance of unplanned clinic attendances, re-admission and mortality in the first 12 months post-operatively in over 65 year olds' hip fractures treated with DHS fixation?

INTRODUCTION

80,000 hip fractures are admitted to UK hospitals annually (Royal College of Physicians, 2016). Little is known about 12-month post-operative re-admission, unplanned clinic attendance and mortality. We aimed to determine if there is a role for routine follow-up for certain strata of our hip fracture population treated by Dynamic Hip Screw (DHS) Fixation based on unplanned attendance to clinics and whether it is possible to stratify risk of re-admission, re-operation and mortality within the first 12 months post-operatively.

METHODS

A prospectively collated single centre database of patients >65 years old undergoing DHS fixation for traumatic hip fractures between August 2007 and February 2011 was retrospectively analysed. Pre-operative data regarding patient demographics, mobility, residence and co-morbidities were collected. Post-operative (1, 4, 12 months) place of residence, mobility status, unplanned attendance to an orthopaedic clinic with symptoms relating to the respective limb, re-admission to hospital and mortality was collated. Regression analysis was performed (SPSS, IBM Corporation, version 24). P < 0.05 was considered significant.

RESULTS

648 consecutive patients were identified. Increasing age (p = 0.006) and presence of pressure sores during initial admission (p = 0.0019) increased the frequency of unplanned clinic attendance. No significant predictors of re-admission to hospital were found. Overall mortality was related to increasing age (p = 0.042), male gender (p = 0.004) and ASA grade (p = 0.009).

CONCLUSION

There is no current vogue to follow-up such patients in this post-operative period. We have identified variables that should be sought prior to discharge in this population. 22% of our population had at least one unplanned clinic attendance with a cost implication of approximately £50,132 (£151 per appointment) over the study period and potentially over £1.6 million pounds annually in the U.K.

IMPLICATIONS

Formal follow-up/rehabilitation programs could be offered for those at risk of unplanned clinic attendance. Post-operative orthogeriatric and/or general practitioner follow-up may reduce 12-month mortality in those at risk but validated scoring and risk stratification systems are required to fully justify this.

Evaluation of a novel 5-group classification system of sepsis by vasopressor use and initial serum lactate in the emergency department

Prognostication in sepsis is limited by disease heterogeneity, and measures to risk-stratify patients in the proximal phases of care lack simplicity and accuracy. Hyperlactatemia and vasopressor dependence are easily identifiable risk factors for poor outcomes. This study compares incidence and hospital outcomes in sepsis based on initial serum lactate level and vasopressor use in the emergency department (ED). In a retrospective analysis of a prospectively identified dual-center ED registry, patients with sepsis were categorized by ED vasopressor use and initial serum lactate level. Vasopressor-dependent patients were categorized as dysoxic shock (lactate >4.0 mmol/L) and vasoplegic shock (≤4.0 mmol/L). Patients not requiring vasopressors were categorized as cryptic shock major (lactate >4.0 mmol/L), cryptic shock minor (>2.0 and ≤4.0 mmol/L), and sepsis without lactate elevation (≤2.0 mmol/L). Of 446 patients included, 4.9% (n = 22) presented in dysoxic shock, 11.7% (n = 52) in vasoplegic shock, 12.1% (n = 54) in cryptic shock major, 30.9% (n = 138) in cryptic shock minor, and 40.4% (n = 180) in sepsis without lactate elevation. Group mortality rates at 28 days were 50.0, 21.1, 18.5, 12.3, and 7.2%, respectively. After adjusting for potential confounders, odds ratios for mortality at 28 days were 15.1 for dysoxic shock, 3.6 for vasoplegic shock, 3.8 for cryptic shock major, and 1.9 for cryptic shock minor, when compared to sepsis without lactate elevation. Lactate elevation is associated with increased mortality in both vasopressor dependent and normotensive infected patients presenting to the emergency department (ED). Cryptic shock mortality (normotension + lactate >4 mmol/L) is equivalent to vasoplegic shock mortality (vasopressor requirement + lactate <4 mmol/L) in our population. The odds of normotensive, infected patients decompensating is three to fourfold higher with hyperlactemia. The proposed Sepsis-3 definitions exclude an entire group of high-risk ED patients. A simple classification in the ED by vasopressor requirement and initial lactate level may identify high-risk subgroups of sepsis. This study may inform prognostication and triage decisions in the proximal phases of care.

Improving the Replicability of Psychological Science Through Pedagogy

Replications are important to science, but who will do them? One proposal is that students can conduct replications as part of their training. As a proof of concept for this idea, here we report a series of 11 preregistered replications of findings from the 2015 volume of Psychological Science, all conducted as part of a graduate-level course. As was expected given larger, more systematic prior efforts, the replications typically yielded effects that were smaller than the original ones: The modal outcome was partial support for the original claim. This work documents the challenges facing motivated students as they attempt to replicate previously published results on a first attempt. We describe the workflow and pedagogical methods that were used in the class and discuss implications both for the adoption of this pedagogical model and for replication research more broadly.

Infliximab and adalimumab drug levels in Crohn's disease: contrasting associations with disease activity and influencing factors

BACKGROUND

Discriminative drug level thresholds for disease activity endpoints in patients with Crohn's disease. have been consistently demonstrated with infliximab, but not adalimumab.

AIMS

To identify threshold concentrations for infliximab and adalimumab in Crohn's disease according to different disease endpoints, and factors that influence drug levels.

METHODS

We performed a cross-sectional service evaluation of patients receiving maintenance infliximab or adalimumab for Crohn's disease. Serum drug levels were at trough for infliximab and at any time point for adalimumab. Endpoints included Harvey-Bradshaw index, C-reactive protein and faecal calprotectin. 6-tioguanine nucleotide (TGN) concentrations were measured in patients treated with thiopurines.

RESULTS

A total of 191 patients (96 infliximab, 95 adalimumab) were included. Differences in infliximab levels were observed for clinical (P=.081) and biochemical remission (P=.003) and faecal calprotectin normalisation (P<.0001) with corresponding thresholds identified on ROC analysis of 1.5, 3.4 and 5.7 μg/mL. Adalimumab levels were similar between active disease and remission regardless of the endpoint assessed. Modelling identified that higher infliximab dose, body mass index and colonic disease independently accounted for 31% of the variation in infliximab levels, and weekly dosing, albumin and weight accounted for 23% of variation in adalimumab levels. TGN levels did not correlate with drug levels.

CONCLUSIONS

Infliximab drug levels are associated with the depth of response/remission in patients with Crohn's disease, but no such relationship was observed for adalimumab. More data are needed to explain the variation in drug levels.

Intra-patient variability in adalimumab drug levels within and between cycles in Crohn's disease

BACKGROUND

Whether therapeutic drug monitoring for adalimumab needs to be performed at trough has not been defined.

AIM

To determine intra-patient adalimumab drug-level variation and to identify modulating patient and disease factors.

METHODS

In this prospective observational study, adult patients with Crohn's disease established on maintenance adalimumab had drug levels measured repeatedly according to pre-defined schedules (visit 1: day 4-6, visit 2: day 7-9, trough: day 13-14) across two consecutive fortnightly cycles. Disease activity was assessed using Harvey-Bradshaw Index, C-reactive protein and faecal calprotectin. For this analysis, trough levels ≥4.9 μg/mL were considered therapeutic.

RESULTS

Nineteen patients underwent 111 evaluations. Mean intra-patient drug levels from paired visits between cycles did not differ (visit1 cycle1: 4.81, cycle2: 5.21 μg/mL, P = 0.24, visit2 cycle1: 4.86, cycle2: 4.82, P = 0.91 and trough cycle1: 3.95, cycle2: 3.95, P = 0.99), irrespective of disease activity. Drug levels were stable over the first 9 days (visit 1-2), but declined to trough by a mean 1.06 and 0.89 μg/mL between visit 1 or 2, respectively (P < 0.001). Models using nontemporal factors (smoking, syringe delivery device) and levels at earlier visits accounted for 66-80% of the variance in trough levels. On receiver-operating curve analysis, thresholds identified in the first 9 days that predicted a therapeutic trough level were similar to the trough threshold itself, with high sensitivity but modest specificity.

CONCLUSION

While therapeutic drug monitoring should be performed at trough, a drug level ≥4.9 μg/mL obtained during the first 9 days predicts a therapeutic trough drug level with reasonable confidence.

Using fiberoptic endoscopic evaluation of swallowing to detect laryngeal penetration and aspiration in infants in the neonatal intensive care unit

OBJECTIVE

To evaluate the safety of fiberoptic endoscopic evaluation of swallowing (FEES) and the reliability of both FEES and a videofluoroscopic swallowing study (VFSS) in identifying laryngeal penetration and tracheal aspiration in infants under 3 months old in the neonatal intensive care unit (NICU).

STUDY DESIGN

Twenty-five infants at least 37 weeks postmenstrual age suspected of aspirating were assessed with FEES and VFSS. Complications, autonomic instability and vital signs before endoscope insertion and following FEES were documented. Blinded video recordings were coded by two reviewers to determine reliability.

RESULTS

We found no major complications or significant differences between FEES prefeeding and postfeeding vital signs, including respiratory rate, heart rate or oxygen saturation. FEES interrater reliability was 80% for both penetration and aspiration, compared with 87 and 90%, respectively, for VFSS.

CONCLUSION

FEES is safe and reliable in assessing laryngeal penetration and tracheal aspiration in NICU infants.

Abstract P3-06-05: Receptor-mediated binding of HER2-targeted antibody-liposomal doxorubicin conjugate MM-302 increases liposome binding, nuclear doxorubicin, DNA damage and efficacy relative to untargeted PEGylated liposomal doxorubicin (PLD/Doxil)

This abstract was withdrawn by the authors.

Abstract P4-21-40: In vitro and in vivo activity of HER2-targeted antibody-liposomal doxorubicin conjugate MM-302 in HER2-intermediate tumors

This abstract was withdrawn by the authors.