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Greenstreet P, Jaki T, Bedding A, Harbron C, Mozgunov P. A multi-arm multi-stage platform design that allows preplanned addition of arms while still controlling the family-wise error. Stat Med 2024; 43:3613-3632. [PMID: 38880949 DOI: 10.1002/sim.10135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 05/26/2024] [Accepted: 05/29/2024] [Indexed: 06/18/2024]
Abstract
There is growing interest in platform trials that allow for adding of new treatment arms as the trial progresses as well as being able to stop treatments part way through the trial for either lack of benefit/futility or for superiority. In some situations, platform trials need to guarantee that error rates are controlled. This paper presents a multi-stage design, that allows additional arms to be added in a platform trial in a preplanned fashion, while still controlling the family-wise error rate, under the assumption of known number and timing of treatments to be added, and no time trends. A method is given to compute the sample size required to achieve a desired level of power and we show how the distribution of the sample size and the expected sample size can be found. We focus on power under the least favorable configuration which is the power of finding the treatment with a clinically relevant effect out of a set of treatments while the rest have an uninteresting treatment effect. A motivating trial is presented which focuses on two settings, with the first being a set number of stages per active treatment arm and the second being a set total number of stages, with treatments that are added later getting fewer stages. Compared to Bonferroni, the savings in the total maximum sample size are modest in a trial with three arms, <1% of the total sample size. However, the savings are more substantial in trials with more arms.
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Affiliation(s)
- Peter Greenstreet
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
- Exeter Clinical Trials Unit, University of Exeter, Exeter, UK
| | - Thomas Jaki
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- University of Regensburg, Regensburg, Germany
| | | | | | - Pavel Mozgunov
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
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2
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Dhaenens BAE, Heimann G, Bakker A, Nievo M, Ferner RE, Evans DG, Wolkenstein P, Leubner J, Potratz C, Carton C, Iloeje U, Kirk G, Blakeley JO, Plotkin S, Fisher MJ, Kim A, Driever PH, Azizi AA, Widemann BC, Gross A, Parke T, Legius E, Oostenbrink R. Platform trial design for neurofibromatosis type 1, NF2-related schwannomatosis and non-NF2-related schwannomatosis: A potential model for rare diseases. Neurooncol Pract 2024; 11:395-403. [PMID: 39006526 PMCID: PMC11241353 DOI: 10.1093/nop/npae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024] Open
Abstract
Background Neurofibromatosis type 1, NF2-related schwannomatosis and non-NF2-related schwannomatosis (grouped under the abbreviation "NF") are rare hereditary tumor predisposition syndromes. Due to the low prevalence, variability in the range, and severity of manifestations, as well as limited treatment options, these conditions require innovative trial designs to accelerate the development of new treatments. Methods Within European Patient-Centric Clinical Trial Platforms (EU-PEARL), we designed 2 platform-basket trials in NF. The trials were designed by a team of multidisciplinary NF experts and trial methodology experts. Results The trial will consist of an observational and a treatment period. The observational period will serve as a longitudinal natural history study. The platform trial design and randomization to a sequence of available interventions allow for the addition of interventions during the trial. If a drug does not meet the predetermined efficacy endpoint or reveals unacceptable toxicities, participants may stop treatment on that arm and re-enter the observational period, where they can be re-randomized to a different treatment arm if eligible. Intervention-specific eligibility criteria and endpoints are listed in intervention-specific-appendices, allowing the flexibility and adaptability needed for highly variable and rare conditions like NF. Conclusions These innovative platform-basket trials for NF may serve as a model for other rare diseases, as they will enhance the chance of identifying beneficial treatments through optimal learning from a small number of patients. The goal of these trials is to identify beneficial treatments for NF more rapidly and at a lower cost than traditional, single-agent clinical trials.
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Affiliation(s)
- Britt A E Dhaenens
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- ENCORE Expertise Centre for Neurodevelopmental Disorders, Erasmus MC, Rotterdam, The Netherlands
| | - Günter Heimann
- Biostatistics & Pharmacometrics, Novartis Pharma AG, Basel, Switzerland
| | | | - Marco Nievo
- Children's Tumor Foundation, New York, New York, USA
| | - Rosalie E Ferner
- Neurofibromatosis Service, Department of Neurology, Guy's and St. Thomas' NHS Foundation Trust London, Great Maze Pond, London, UK
| | - D Gareth Evans
- Centre for Genomic Medicine, Division of Evolution, Infection and Genomic Sciences, University of Manchester, St Mary's Hospital, Manchester, UK
| | | | - Jonas Leubner
- Department of Pediatric Neurology, Charité Universitätsmedizin Berlin-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Cornelia Potratz
- Department of Pediatric Neurology, Charité Universitätsmedizin Berlin-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | | | - Uchenna Iloeje
- Medical Affairs, SpringWorks Therapeutics, Stamford, Connecticut, USA
| | | | - Jaishri O Blakeley
- Department of Neurology, Neuro-Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Scott Plotkin
- Cancer Center and Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael J Fisher
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - AeRang Kim
- Division of Oncology, Children's National Hospital, Washington DC, District of Columbia, USA
| | - Pablo Hernáiz Driever
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Amedeo A Azizi
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Wien, Austria
| | - Brigitte C Widemann
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Andrea Gross
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | | | - Eric Legius
- Department of Human Genetics, KU Leuven, Leuven, Belgium
- Department of Clinical Genetics, UZ Leuven, Leuven, Belgium
- Full Member of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS), Nijmegen, The Netherlands (E.L., R.O.)
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- ENCORE Expertise Centre for Neurodevelopmental Disorders, Erasmus MC, Rotterdam, The Netherlands
- Full Member of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS), Nijmegen, The Netherlands
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3
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Juffermans NP, Gözden T, Brohi K, Davenport R, Acker JP, Reade MC, Maegele M, Neal MD, Spinella PC. Transforming research to improve therapies for trauma in the twenty-first century. Crit Care 2024; 28:45. [PMID: 38350971 PMCID: PMC10865682 DOI: 10.1186/s13054-024-04805-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 01/11/2024] [Indexed: 02/15/2024] Open
Abstract
Improvements have been made in optimizing initial care of trauma patients, both in prehospital systems as well as in the emergency department, and these have also favorably affected longer term outcomes. However, as specific treatments for bleeding are largely lacking, many patients continue to die from hemorrhage. Also, major knowledge gaps remain on the impact of tissue injury on the host immune and coagulation response, which hampers the development of interventions to treat or prevent organ failure, thrombosis, infections or other complications of trauma. Thereby, trauma remains a challenge for intensivists. This review describes the most pressing research questions in trauma, as well as new approaches to trauma research, with the aim to bring improved therapies to the bedside within the twenty-first century.
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Affiliation(s)
- Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Tarik Gözden
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Jason P Acker
- Canadian Blood Services, Innovation and Portfolio Management, Edmonton, AB, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Michael C Reade
- Medical School, University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Marc Maegele
- Department of Trauma and Orthopedic Surgery Cologne-Merheim Medical Center Institute of Research, Operative Medicine University Witten-Herdecke, Cologne, Germany
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Philip C Spinella
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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4
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Ndambo MK, Pickersgill M, Bunn C, Stewart RC, Umar E, Nyasulu M, McIntosh AM, Manda-Taylor L. Maternal mental health research in Malawi: Community and healthcare provider perspectives on acceptability and ethicality. SSM - MENTAL HEALTH 2023; 3:100213. [PMID: 38045108 PMCID: PMC10311285 DOI: 10.1016/j.ssmmh.2023.100213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 12/05/2023] Open
Abstract
Maternal mental health (MMH) is recognised as globally significant. The prevalence of depression and factors associated with its onset among perinatal women in Malawi has been previously reported, and the need for further research in this domain is underscored. Yet, there is little published scholarship regarding the acceptability and ethicality of MMH research to women and community representatives. The study reported here sought to address this in Malawi by engaging with communities and healthcare providers in the districts where MMH research was being planned. Qualitative data was collected in Lilongwe and Karonga districts through 20 focus group discussions and 40 in-depth interviews with community representatives and healthcare providers from January through April 2021. All focus groups and interviews were audio recorded, transcribed verbatim (in local languages Chichewa and Tumbuka), translated into English, and examined through thematic content analysis. Participants' accounts suggest that biopsychosocial MMH research could be broadly acceptable within the communities sampled, with acceptability framed in part through prior encounters with biomedical and public health research and care in these regions, alongside broader understandings of the import of MMH. Willingness and consent to participate do not depend on specifically biomedical understandings of MMH, but rather on familiarity with individuals regarded as living with mental ill-health. However, the data further suggest some 'therapeutic misconceptions' about MMH research, with implications for how investigations in this area are presented by researchers when recruiting and working with participants. Further studies are needed to explore whether accounts of the acceptability and ethicality of MMH research shift and change during and following research encounters. Such studies will enhance the production of granular recommendations for further augmenting the ethicality of biomedical and public health research and researchers' responsibilities to participants and communities.
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Affiliation(s)
| | - Martyn Pickersgill
- Centre for Biomedicine, Self and Society, Usher Institute, University of Edinburgh, Scotland, United Kingdom
| | - Christopher Bunn
- Malawi Epidemiology Intervention Research Unit, Malawi
- School of Social and Political Sciences, Institute of Health and Wellbeing, University of Glasgow, Scotland, United Kingdom
| | - Robert C. Stewart
- Malawi Epidemiology Intervention Research Unit, Malawi
- Division of Psychiatry, Centre for Clinical Brain Sciences, University of Edinburgh, Scotland, United Kingdom
| | - Eric Umar
- School of Global and Public Health, Kamuzu University of Health Sciences, Malawi
| | | | - Andrew M. McIntosh
- Division of Psychiatry, Centre for Clinical Brain Sciences, University of Edinburgh, Scotland, United Kingdom
| | - Lucinda Manda-Taylor
- School of Global and Public Health, Kamuzu University of Health Sciences, Malawi
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5
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Ng FYC, Tan PL, Sundar G. Improving visual outcomes in patients with rare paediatric eye diseases. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:625-634. [PMID: 38920150 DOI: 10.47102/annals-acadmedsg.202323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Rare paediatric eye diseases (RPEDs) threaten both vision and life. Recently, rare diseases were recognised as a global public health agenda, with children specified as a priority in the World Health Organization's VISION 2020 against avoidable visual loss. Method We conducted a review through a query of online databases (PubMed, Embase and Cochrane Library). Articles related to RPEDs were selected based on relevance by 2 authors, with any disagreements adjudicated by the third author. Results We synthesise the current state of knowledge regarding RPEDs, barriers to their care, and recommendations for the future. RPEDs often result in significant visual loss, profoundly impacting the way children comprehend and participate in the world. These diseases may also reduce life expectancy and even be life-threatening. Barriers to the care of RPEDs include an unclear definition of "rare diseases", missed or delayed diagnosis, inadequate knowledge and expertise in management, and challenging research environments. Conclusion Our findings provide an update on the diagnosis and management of RPEDs, which is of relevance to ophthalmologists, paediatricians, healthcare policymakers and social workers. We propose supportive policies and adequate resource allocation to these diseases, comprehensive and patient-centred care, alongside improved education and training, enhanced research capabilities and continued collaboration across institutions.
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Affiliation(s)
- Faye Yu Ci Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Poh Lin Tan
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gangadhara Sundar
- Orbit & Oculofacial Surgery Service, Department of Ophthalmology, National University Hospital, Singapore
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6
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Agarwal A, Marion J, Nagy P, Robinson M, Walkey A, Sevransky J. How Electronic Medical Record Integration Can Support More Efficient Critical Care Clinical Trials. Crit Care Clin 2023; 39:733-749. [PMID: 37704337 DOI: 10.1016/j.ccc.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Large volumes of data are collected on critically ill patients, and using data science to extract information from the electronic medical record (EMR) and to inform the design of clinical trials represents a new opportunity in critical care research. Using improved methods of phenotyping critical illnesses, subject identification and enrollment, and targeted treatment group assignment alongside newer trial designs such as adaptive platform trials can increase efficiency while lowering costs. Some tools such as the EMR to automate data collection are already in use. Refinement of data science approaches in critical illness research will allow for better clinical trials and, ultimately, improved patient outcomes.
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Affiliation(s)
- Ankita Agarwal
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
| | | | - Paul Nagy
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew Robinson
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan Walkey
- Department of Medicine - Section of Pulmonary, Allergy, Critical Care and Sleep Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jonathan Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA.
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7
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Granholm A, Kaas-Hansen BS, Lange T, Schjørring OL, Andersen LW, Perner A, Jensen AKG, Møller MH. An overview of methodological considerations regarding adaptive stopping, arm dropping, and randomization in clinical trials. J Clin Epidemiol 2023; 153:45-54. [PMID: 36400262 DOI: 10.1016/j.jclinepi.2022.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 10/17/2022] [Accepted: 11/02/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Adaptive features may increase flexibility and efficiency of clinical trials, and improve participants' chances of being allocated to better interventions. Our objective is to provide thorough guidance on key methodological considerations for adaptive clinical trials. METHODS We provide an overview of key methodological considerations for clinical trials employing adaptive stopping, adaptive arm dropping, and response-adaptive randomization. We cover pros and cons of different decisions and provide guidance on using simulation to compare different adaptive trial designs. We focus on Bayesian multi-arm adaptive trials, although the same general considerations apply to frequentist adaptive trials. RESULTS We provide guidance on 1) interventions and possible common control, 2) outcome selection, follow-up duration and model choice, 3) timing of adaptive analyses, 4) decision rules for adaptive stopping and arm dropping, 5) randomization strategies, 6) performance metrics, their prioritization, and arm selection strategies, and 7) simulations, assessment of performance under different scenarios, and reporting. Finally, we provide an example using a newly developed R simulation engine that may be used to evaluate and compare different adaptive trial designs. CONCLUSION This overview may help trialists design better and more transparent adaptive clinical trials and to adequately compare them before initiation.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Benjamin Skov Kaas-Hansen
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Lars W Andersen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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8
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Saraf A, Trippa L, Rahman R. Novel Clinical Trial Designs in Neuro-Oncology. Neurotherapeutics 2022; 19:1844-1854. [PMID: 35969361 PMCID: PMC9723049 DOI: 10.1007/s13311-022-01284-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2022] [Indexed: 12/13/2022] Open
Abstract
Scientific and technologic advances have led to a boon of candidate therapeutics for patients with malignancies of the central nervous system. The path from drug development to clinical use has generally followed a regimented order of sequential clinical trial phases. The recent increase in novel therapies, however, has strained the regulatory process and unearthed limitations of the current system, including significant cost, prolonged development time, and difficulties in testing therapies for rarer tumors. Novel clinical trial designs have emerged to increase efficiencies in clinical trial conduct to better evaluate and bring impactful drugs to patients in a timely manner. In order to better capture meaningful benefits for brain tumor patients, new endpoints to complement or replace traditional endpoints are also an increasingly important consideration. This review will explore the current challenges in the current clinical trial landscape and discuss novel clinical trial concepts, including consideration of limitations and risks of novel trial designs, within the context of neuro-oncology.
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Affiliation(s)
- Anurag Saraf
- Harvard Radiation Oncology Program, Boston, MA, USA
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Lorenzo Trippa
- Department of Data Sciences, Dana-Farber Cancer Institute, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Rifaquat Rahman
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
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9
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Bruce Metadata P, Ainscough K, Hatter L, Braithwaite I, Berry LR, Fitzgerald M, Hills T, Brickell K, Cosgrave D, Semprini A, Morpeth S, Berry S, Doran P, Young P, Beasley R, Nichol A. Prophylaxis in healthcare workers during a pandemic: a model for a multi-centre international randomised controlled trial using Bayesian analyses. Trials 2022; 23:534. [PMID: 35761370 PMCID: PMC9235209 DOI: 10.1186/s13063-022-06402-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 05/12/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has exposed the disproportionate effects of pandemics on frontline workers and the ethical imperative to provide effective prophylaxis. We present a model for a pragmatic randomised controlled trial (RCT) that utilises Bayesian methods to rapidly determine the efficacy or futility of a prophylactic agent. METHODS We initially planned to undertake a multicentre, phase III, parallel-group, open-label RCT, to determine if hydroxychloroquine (HCQ) taken once a week was effective in preventing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in healthcare workers (HCW) aged ≥ 18 years in New Zealand (NZ) and Ireland. Participants were to be randomised 2:1 to either HCQ (800 mg stat then 400 mg weekly) or no prophylaxis. The primary endpoint was time to Nucleic Acid Amplification Test-proven SARS-CoV-2 infection. Secondary outcome variables included mortality, hospitalisation, intensive care unit admissions and length of mechanical ventilation. The trial had no fixed sample size or duration of intervention. Bayesian adaptive analyses were planned to occur fortnightly, commencing with a weakly informative prior for the no prophylaxis group hazard rate and a moderately informative prior on the intervention log hazard ratio centred on 'no effect'. Stopping for expected success would be executed if the intervention had a greater than 0.975 posterior probability of reducing the risk of SARS-CoV-2 infection by more than 10%. Final success would be declared if, after completion of 8 weeks of follow-up (reflecting the long half-life of HCQ), the prophylaxis had at least a 0.95 posterior probability of reducing the risk of SARS-CoV-2 infection by more than 10%. Futility would be declared if HCQ was shown to have less than a 0.10 posterior probability of reducing acquisition of SARS-CoV-2 infection by more than 20%. DISCUSSION This study did not begin recruitment due to the marked reduction in COVID-19 cases in NZ and concerns regarding the efficacy and risks of HCQ treatment in COVID-19. Nonetheless, the model presented can be easily adapted for other potential prophylactic agents and pathogens, and pre-established collaborative models like this should be shared and incorporated into future pandemic preparedness planning. TRIAL REGISTRATION The decision not to proceed with the study was made before trial registration occurred.
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Affiliation(s)
- Pepa Bruce Metadata
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand
| | - Kate Ainscough
- grid.7886.10000 0001 0768 2743University College Dublin - Clinical Research Centre at St. Vincent’s University Hospital, Dublin, Ireland
| | - Lee Hatter
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand
| | - Irene Braithwaite
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand
| | | | | | - Thomas Hills
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand ,grid.414057.30000 0001 0042 379XAuckland District Health Board, Auckland, New Zealand
| | - Kathy Brickell
- grid.7886.10000 0001 0768 2743University College Dublin - Clinical Research Centre at St. Vincent’s University Hospital, Dublin, Ireland
| | - David Cosgrave
- grid.6142.10000 0004 0488 0789National University of Ireland, Galway, Ireland ,grid.412440.70000 0004 0617 9371University Hospital Galway, Galway, Ireland
| | - Alex Semprini
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand
| | - Susan Morpeth
- grid.413188.70000 0001 0098 1855Counties Manukau District Health Board, Auckland, New Zealand
| | | | - Peter Doran
- grid.7886.10000 0001 0768 2743University College Dublin - Clinical Research Centre at St. Vincent’s University Hospital, Dublin, Ireland
| | - Paul Young
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand
| | - Richard Beasley
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand
| | - Alistair Nichol
- grid.7886.10000 0001 0768 2743University College Dublin - Clinical Research Centre at St. Vincent’s University Hospital, Dublin, Ireland ,grid.1002.30000 0004 1936 7857Monash University - Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia ,grid.1623.60000 0004 0432 511XDepartment of Intensive Care, Alfred Hospital, Melbourne, Australia
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10
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Tolles J, Beiling M, Schreiber MA, Del Junco DJ, McMullan JT, Guyette FX, Wang H, Jansen JO, Meurer WJ, Mainali S, Yadav K, Lewis RJ. An adaptive platform trial for evaluating treatments in patients with life-threatening hemorrhage from traumatic injuries: Rationale and proposal. Transfusion 2022; 62 Suppl 1:S231-S241. [PMID: 35732508 DOI: 10.1111/trf.16957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Juliana Tolles
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Berry Consultants, LLC, Austin, Texas, USA
| | - Marissa Beiling
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Martin A Schreiber
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Deborah J Del Junco
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio Fort Sam Houston, San Antonio, Texas, USA.,Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jason T McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Henry Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jan O Jansen
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma & Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - William J Meurer
- Berry Consultants, LLC, Austin, Texas, USA.,Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Kabir Yadav
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Berry Consultants, LLC, Austin, Texas, USA
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11
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Dickert NW, Metz K, Deeds SI, Linke MJ, Mitchell AR, Speight CD, Adeoye OM. Getting the Most out of Consent: Patient-Centered Consent for an Acute Stroke Trial. Ethics Hum Res 2022; 44:33-40. [PMID: 35218601 DOI: 10.1002/eahr.500122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Informed consent for clinical trials in acute stroke is characterized by challenges related to urgency, cognitive impairment, and geographical separation. Context-appropriate approaches are needed for this setting. We conducted a mixed-methods project involving focus groups and interviews as well as collaboration with a patient advisory panel and a central institutional review board (CIRB) to design and implement a patient-driven consent process for a multicenter trial incorporating adaptive randomization. Remote consent was recognized as challenging but acceptable. Adaptive randomization was viewed positively, but significant potential for misunderstanding was appreciated. Collaboration between the patient advisory panel and the CIRB resulted in a shortened, more patient-centered consent form that was approved at all sites with few modifications. An information sheet was developed as a resource for patients and surrogates after enrollment. Collaboration between investigators, patient partners, and a CIRB can facilitate innovation and implementation of patient-centered, context-appropriate consent strategies.
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Affiliation(s)
- Neal W Dickert
- Associate professor in the Department of Medicine at the Emory University School of Medicine and in the Department of Epidemiology at the Emory University Rollins School of Public Health
| | - Kathleen Metz
- Resident in the Department of Emergency Medicine at Emory University School of Medicine
| | - S Iris Deeds
- Project manager in the Department of Emergency Medicine at the Washington University School of Medicine
| | - Michael J Linke
- Adjunct professor and IRB chair at the University of Cincinnati College of Medicine
| | - Andrea R Mitchell
- Senior research administrative coordinator in the Department of Medicine at the Emory University School of Medicine
| | - Candace D Speight
- Data analyst in the Department of Medicine at the Emory University School of Medicine
| | - Opeolu M Adeoye
- Professor and the chair of the Department of Emergency Medicine at the Washington University School of Medicine
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12
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Abstract
Vitamins are essential micronutrients with key roles in many biological pathways relevant to sepsis. Some of these relevant biological mechanisms include antioxidant and anti-inflammatory effects, protein and hormone synthesis, energy generation, and regulation of gene transcription. Moreover, relative vitamin deficiencies in plasma are common during sepsis and vitamin therapy has been associated with improved outcomes in some adult and pediatric studies. High-dose intravenous vitamin C has been the vitamin therapy most extensively studied in adult patients with sepsis and septic shock. This includes three randomized control trials (RCTs) as monotherapy with a total of 219 patients showing significant reduction in organ dysfunction and lower mortality when compared to placebo, and five RCTs as a combination therapy with thiamine and hydrocortisone with a total of 1134 patients showing no difference in clinical outcomes. Likewise, the evidence for the role of other vitamins in sepsis remains mixed. In this narrative review, we present the preclinical, clinical, and safety evidence of the most studied vitamins in sepsis, including vitamin C, thiamine (i.e., vitamin B1), and vitamin D. We also present the relevant evidence of the other vitamins that have been studied in sepsis and critical illness in both children and adults, including vitamins A, B2, B6, B12, and E. IMPACT: Vitamins are key effectors in many biological processes relevant to sepsis. We present the preclinical, clinical, and safety evidence of the most studied vitamins in pediatric sepsis. Designing response-adaptive platform trials may help fill in knowledge gaps regarding vitamin use for critical illness and association with clinical outcomes.
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13
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Clinical Research: From Case Reports to International Multicenter Clinical Trials. Crit Care Med 2021; 49:1866-1882. [PMID: 34387238 DOI: 10.1097/ccm.0000000000005247] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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14
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Park JJH, Ford N, Xavier D, Ashorn P, Grais RF, Bhutta ZA, Goossens H, Thorlund K, Socias ME, Mills EJ. Randomised trials at the level of the individual. LANCET GLOBAL HEALTH 2021; 9:e691-e700. [PMID: 33865474 DOI: 10.1016/s2214-109x(20)30540-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 12/31/2022]
Abstract
In global health research, short-term, small-scale clinical trials with fixed, two-arm trial designs that generally do not allow for major changes throughout the trial are the most common study design. Building on the introductory paper of this Series, this paper discusses data-driven approaches to clinical trial research across several adaptive trial designs, as well as the master protocol framework that can help to harmonise clinical trial research efforts in global health research. We provide a general framework for more efficient trial research, and we discuss the importance of considering different study designs in the planning stage with statistical simulations. We conclude this second Series paper by discussing the methodological and operational complexity of adaptive trial designs and master protocols and the current funding challenges that could limit uptake of these approaches in global health research.
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Affiliation(s)
- Jay J H Park
- Department of Experimental Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Denis Xavier
- Department of Pharmacology and Divison of Clinical Research, St John's Medical College, Bangalore, India
| | - Per Ashorn
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Institute of Global Health and Development, and Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Herman Goossens
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Kristian Thorlund
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Maria Eugenia Socias
- Fundación Huésped, Buenos Aires, Argentina; British Columbia Centre for Substance Use, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; School of Public Health, University of Rwanda, Kigali, Rwanda; Cytel, Vancouver, BC, Canada.
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15
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Burnett T, Mozgunov P, Pallmann P, Villar SS, Wheeler GM, Jaki T. Adding flexibility to clinical trial designs: an example-based guide to the practical use of adaptive designs. BMC Med 2020; 18:352. [PMID: 33208155 PMCID: PMC7677786 DOI: 10.1186/s12916-020-01808-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/07/2020] [Indexed: 12/18/2022] Open
Abstract
Adaptive designs for clinical trials permit alterations to a study in response to accumulating data in order to make trials more flexible, ethical, and efficient. These benefits are achieved while preserving the integrity and validity of the trial, through the pre-specification and proper adjustment for the possible alterations during the course of the trial. Despite much research in the statistical literature highlighting the potential advantages of adaptive designs over traditional fixed designs, the uptake of such methods in clinical research has been slow. One major reason for this is that different adaptations to trial designs, as well as their advantages and limitations, remain unfamiliar to large parts of the clinical community. The aim of this paper is to clarify where adaptive designs can be used to address specific questions of scientific interest; we introduce the main features of adaptive designs and commonly used terminology, highlighting their utility and pitfalls, and illustrate their use through case studies of adaptive trials ranging from early-phase dose escalation to confirmatory phase III studies.
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Affiliation(s)
- Thomas Burnett
- Department of Mathematics and Statistics, Lancaster University, Fylde College, Lancaster, LA1 4YF UK
| | - Pavel Mozgunov
- Department of Mathematics and Statistics, Lancaster University, Fylde College, Lancaster, LA1 4YF UK
| | - Philip Pallmann
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Cardiff, UK
| | - Sofia S. Villar
- MRC Biostatistics Unit, University of Cambridge School of Clinical Medicine, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge, CB2 0SR UK
| | - Graham M. Wheeler
- Cancer Research UK & UCL Cancer Trials Centre, University College London, 90 Tottenham Court Road, London, W1T 4TJ UK
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Fylde College, Lancaster, LA1 4YF UK
- MRC Biostatistics Unit, University of Cambridge School of Clinical Medicine, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge, CB2 0SR UK
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16
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Shumway DA, Motomura A, Griffith KA, Hayman JA, Pierce LJ, Jagsi R. Patient Perceptions in a Nonblinded Randomized Trial of Radiation Therapy Technologies: A Novel Survey Study Exploring Therapeutic Misconception. Int J Radiat Oncol Biol Phys 2020; 108:867-875. [PMID: 32454191 DOI: 10.1016/j.ijrobp.2020.05.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/04/2020] [Accepted: 05/14/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Therapeutic misconception is the tendency for a clinical trial participant to overlook the scientific objective of a clinical trial and instead believe that an experimental intervention is intended for personal therapeutic benefit. We sought to evaluate this tendency in the setting of a clinical trial of a new radiation therapy technology. METHODS Patients with left-sided, node positive breast cancer enrolled in a randomized clinical trial evaluating intensity modulated radiation therapy with deep inspiration breath hold (IMRT-DIBH) versus 3-dimensional conformal radiation therapy (3DCRT). Patients who enrolled completed surveys at baseline, after randomization, and upon completion of radiation therapy to evaluate expectations, satisfaction, and experiences. RESULTS Forty women participated in the survey study, with 20 in each arm. Most participants endorsed the perception that participation in the trial might result in better treatment than the current standard treatment (77%) and more medical attention than being off trial (54%). At baseline, most women (74%) believed that a new treatment technology is superior than an established one. Before randomization, 43% of participants believed IMRT-DIBH would be more effective than standard treatment with 3DCRT, none believed that 3DCRT would be more effective, 23% believed that they would be the same, and 34% did not know. None believed that IMRT-DIBH would cause worse long-term side effects, whereas 37% thought that 3DCRT would. Most (71%) reported that they would choose to be treated with IMRT-DIBH; none would have elected 3DCRT if given a choice. Nearly half (44%) in the 3DCRT arm wished that they had been assigned to the IMRT-DIBH arm; none in the IMRT-DIBH arm expressed a wish for crossover. CONCLUSIONS Most participants reported the perception that trial participation would result in better treatment and more medical attention than off trial, hallmarks of therapeutic misconception. Our observations provide empirical evidence of a fixed belief in the superiority of new technology and highlight the importance of adjusting expectations through informed consent to mitigate therapeutic misconception.
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Affiliation(s)
- Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Amy Motomura
- Center for Law and the Biosciences and Stanford Program in Neuroscience and Society, Stanford Law School, Stanford, California
| | - Kent A Griffith
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
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17
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Abstract
The COVID-19 pandemic has turned our lives upside down. Health services have adapted to the challenges posed by the pandemic at eye-watering speed. Telemedicine has seen a rapid uptake in order for patient–physician encounters to comply with social distancing regulations. Elective surgeries have been put on hold to make room in hospitals for patients with COVID-19 and save valuable personal protective equipment. Many pre-pandemic research projects have been put on hold, and legions of medical researchers are now dedicated to researching COVID-19. Breathe Chief Editor @ClaudiaCDobler on how #COVID19 amplifies flaws in clinical research and practicehttps://bit.ly/3cX0jpO
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Affiliation(s)
- Claudia C Dobler
- Institute for Evidence-Based Healthcare, Bond University, Robina, QLD, Australia.,Dept of Respiratory Medicine, Liverpool Hospital, Sydney, NSW, Australia
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18
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Thompson DA, Iannaccone A, Ali RR, Arshavsky VY, Audo I, Bainbridge JWB, Besirli CG, Birch DG, Branham KE, Cideciyan AV, Daiger SP, Dalkara D, Duncan JL, Fahim AT, Flannery JG, Gattegna R, Heckenlively JR, Heon E, Jayasundera KT, Khan NW, Klassen H, Leroy BP, Molday RS, Musch DC, Pennesi ME, Petersen-Jones SM, Pierce EA, Rao RC, Reh TA, Sahel JA, Sharon D, Sieving PA, Strettoi E, Yang P, Zacks DN. Advancing Clinical Trials for Inherited Retinal Diseases: Recommendations from the Second Monaciano Symposium. Transl Vis Sci Technol 2020; 9:2. [PMID: 32832209 PMCID: PMC7414644 DOI: 10.1167/tvst.9.7.2] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 03/12/2020] [Indexed: 12/18/2022] Open
Abstract
Major advances in the study of inherited retinal diseases (IRDs) have placed efforts to develop treatments for these blinding conditions at the forefront of the emerging field of precision medicine. As a result, the growth of clinical trials for IRDs has increased rapidly over the past decade and is expected to further accelerate as more therapeutic possibilities emerge and qualified participants are identified. Although guided by established principles, these specialized trials, requiring analysis of novel outcome measures and endpoints in small patient populations, present multiple challenges relative to study design and ethical considerations. This position paper reviews recent accomplishments and existing challenges in clinical trials for IRDs and presents a set of recommendations aimed at rapidly advancing future progress. The goal is to stimulate discussions among researchers, funding agencies, industry, and policy makers that will further the design, conduct, and analysis of clinical trials needed to accelerate the approval of effective treatments for IRDs, while promoting advocacy and ensuring patient safety.
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Affiliation(s)
- Debra A Thompson
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alessandro Iannaccone
- Department of Ophthalmology, Duke Eye Center, Duke University Medical Center, Durham, NC, USA
| | - Robin R Ali
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA.,Institute of Ophthalmology, University College London, London, UK
| | - Vadim Y Arshavsky
- Department of Ophthalmology, Duke Eye Center, Duke University Medical Center, Durham, NC, USA
| | - Isabelle Audo
- Sorbonne Université, Institut de la Vision, INSERM, CNRS, Paris, France.,CHNO des Quinze-Vingts, INSERM-DGOS CIC 1423, Paris, France
| | | | - Cagri G Besirli
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Kari E Branham
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Artur V Cideciyan
- Department of Ophthalmology, Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven P Daiger
- Human Genetics Center, School of Public Health, University of Texas Health Science Center Houston, Houston, TX, USA
| | - Deniz Dalkara
- Sorbonne Université, Institut de la Vision, INSERM, CNRS, Paris, France
| | - Jacque L Duncan
- Department of Ophthalmology, University of California-San Francisco, San Francisco, CA, USA
| | - Abigail T Fahim
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - John G Flannery
- Helen Wills Neuroscience Institute, University of California-Berkeley, Berkeley, CA, USA
| | | | - John R Heckenlively
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Elise Heon
- Department of Ophthalmology and Vision Sciences, Hospital for Sick Children, Toronto, Ontario, Canada
| | - K Thiran Jayasundera
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Naheed W Khan
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Henry Klassen
- Gavin Herbert Eye Institute, Stem Cell Research Center, University of California-Irvine, Irvine, CA, USA
| | - Bart P Leroy
- Department of Ophthalmology and Center Medical Genetics, Ghent University Hospital and University, Ghent, Belgium.,Division of Ophthalmology and Center for Cellular and Molecular Therapeutics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert S Molday
- Department of Biochemistry/Molecular Biology, University of British Columbia, Vancouver, British Columbia, Canada
| | - David C Musch
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mark E Pennesi
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science Center, Portland, OR, USA
| | - Simon M Petersen-Jones
- Small Animal Clinical Sciences, Michigan State University, College of Veterinary Medicine, East Lansing, MI, USA
| | - Eric A Pierce
- Ocular Genomics Institute, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Rajesh C Rao
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Thomas A Reh
- Department of Biological Structure, University of Washington, Seattle, WA, USA
| | - Jose A Sahel
- Sorbonne Université, Institut de la Vision, INSERM, CNRS, Paris, France.,CHNO des Quinze-Vingts, INSERM-DGOS CIC 1423, Paris, France.,Fondation Ophtalmologique Rothschild, Paris, France.,Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dror Sharon
- Department of Ophthalmology, Hadassah Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Paul A Sieving
- Department of Ophthalmology and Center for Ocular Regenerative Therapy, University of California-Davis School of Medicine, Sacramento, CA, USA.,National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Enrica Strettoi
- Institute of Neuroscience, National Research Council (CNR), Pisa, Italy
| | - Paul Yang
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science Center, Portland, OR, USA
| | - David N Zacks
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
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19
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Tidwell RSS, Peng SA, Chen M, Liu DD, Yuan Y, Lee JJ. Bayesian clinical trials at The University of Texas MD Anderson Cancer Center: An update. Clin Trials 2019; 16:645-656. [PMID: 31450957 DOI: 10.1177/1740774519871471] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIMS In our 2009 article, we showed that Bayesian methods had established a foothold in developing therapies in our institutional oncology trials. In this article, we will document what has happened since that time. In addition, we will describe barriers to implementing Bayesian clinical trials, as well as our experience overcoming them. METHODS We reviewed MD Anderson Cancer Center clinical trials submitted to the institutional protocol office for scientific and ethical review between January 2009 and December 2013, the same length time period as the previous article. We tabulated Bayesian methods implemented for design or analyses for each trial and then compared these to our previous findings. RESULTS Overall, we identified 1020 trials and found that 283 (28%) had Bayesian components so we designated them as Bayesian trials. Among MD Anderson-only and multicenter trials, 56% and 14%, respectively, were Bayesian, higher rates than our previous study. Bayesian trials were more common in phase I/II trials (34%) than in phase III/IV (6%) trials. Among Bayesian trials, the most commonly used features were for toxicity monitoring (65%), efficacy monitoring (36%), and dose finding (22%). The majority (86%) of Bayesian trials used non-informative priors. A total of 75 (27%) trials applied Bayesian methods for trial design and primary endpoint analysis. Among this latter group, the most commonly used methods were the Bayesian logistic regression model (N = 22), the continual reassessment method (N = 20), and adaptive randomization (N = 16). Median institutional review board approval time from protocol submission was the same 1.4 months for Bayesian and non-Bayesian trials. Since the previous publication, the Biomarker-Integrated Approaches of Targeted Therapy for Lung Cancer Elimination (BATTLE) trial was the first large-scale decision trial combining multiple treatments in a single trial. Since then, two regimens in breast cancer therapy have been identified and published from the cooperative Investigation of Serial Studies to Predict Your Therapeutic Response with Imaging and Molecular Analysis (I-SPY 2), enhancing cooperation among investigators and drug developers across the nation, as well as advancing information needed for personalized medicine. Many software programs and Shiny applications for Bayesian trial design and calculations are available from our website which has had more than 21,000 downloads worldwide since 2004. CONCLUSION Bayesian trials have the increased flexibility in trial design needed for personalized medicine, resulting in more cooperation among researchers working to fight against cancer. Some disadvantages of Bayesian trials remain, but new methods and software are available to improve their function and incorporation into cancer clinical research.
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Affiliation(s)
- Rebecca S Slack Tidwell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Andrew Peng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Minxing Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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20
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Rationale and Design of an Adaptive Phase 2b/3 Clinical Trial of Selepressin for Adults in Septic Shock. Selepressin Evaluation Programme for Sepsis-induced Shock-Adaptive Clinical Trial. Ann Am Thorac Soc 2019; 15:250-257. [PMID: 29388815 DOI: 10.1513/annalsats.201708-669sd] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Septic shock carries substantial morbidity and mortality. The failure of many promising therapies during late-phase clinical trials prompted calls for alternative trial designs. We describe an innovative trial evaluating selepressin, a novel selective vasopressin V1a receptor agonist, for adults with septic shock. SEPSIS-ACT (Selepressin Evaluation Programme for Sepsis-induced Shock-Adaptive Clinical Trial) is a blinded, randomized, placebo-controlled, two-part, adaptive phase 2b/3 trial, evaluating up to four selepressin dosing strategies. The primary outcome is pressor- and ventilator-free days, with a value of zero assigned for death within 30 days. We calculate Bayesian probabilities of final trial success to guide interim decision-making. Part 1 (dose-finding) has an adaptive sample size based on response-adaptive randomization and prespecified rules to determine stopping for futility or selection of the best dosing regimen for Part 2. Part 2 (confirmation) randomizes a minimum of 1,000 patients equally to the selected dosing regimen or placebo. The final estimate of treatment effect compares all selepressin-treated patients with all placebo-treated patients. The sample size of 1,800 provides 91% power to detect an increase of 1.5 pressor- and ventilator-free days with a reduction in mortality of 1.5%. The trial received a Special Protocol Assessment agreement from the U.S. Food and Drug Administration Center for Drug Evaluation and Research and is underway in Europe and the United States. SEPSIS-ACT is an innovative trial that addresses both optimal dose and confirmation of benefit, accelerating the evaluation of selepressin while mitigating risks to patients and sponsor through use of response-adaptive randomization, a novel registration endpoint, prespecified futility stopping rules, and a large sample size. Clinical Trial registered with www.clinicaltrials.gov (NCT02508649).
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21
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Sim J. Outcome-adaptive randomization in clinical trials: issues of participant welfare and autonomy. THEORETICAL MEDICINE AND BIOETHICS 2019; 40:83-101. [PMID: 30778720 PMCID: PMC6478640 DOI: 10.1007/s11017-019-09481-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Outcome-adaptive randomization (OAR) has been proposed as a corrective to certain ethical difficulties inherent in the traditional randomized clinical trial (RCT) using fixed-ratio randomization. In particular, it has been suggested that OAR redresses the balance between individual and collective ethics in favour of the former. In this paper, I examine issues of welfare and autonomy arising in relation to OAR. A central issue in discussions of welfare in OAR is equipoise, and the moral status of OAR is crucially influenced by the way in which this concept is construed. If OAR is based on a model of equipoise that demands strict indifference between competing interventions throughout the trial, such equipoise is disturbed by accruing data favouring one treatment over another; OAR seeks to redress this by weighting randomization to the seemingly superior treatment. However, this is a partial response, as patients continue to be allocated to the inferior therapy. Moreover, it rests upon considerations of aggregate harms and benefits, and does not therefore uphold individual ethics. Issues of fairness also arise, as early and late enrollees are randomized on a different basis. Fixed-ratio randomization represents a fuller and more consistent response to a loss of equipoise, as so construed. With regard to consent, the complexity of OAR poses challenges to adequate disclosure and comprehension. Additionally, OAR does not offer a remedy to the therapeutic misconception-participants' tendency to attribute treatment allocation in an RCT to individual clinical judgments, rather than to scientific considerations-and, if anything, accentuates rather than alleviates this misconception. In relation to these issues, OAR fails to offer ethical advantages over fixed-ratio randomization. More broadly, the ethical basis of OAR can be seen to lie more in collective than in individual ethics, and overall it fares worse in this territory than fixed-ratio randomization.
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Affiliation(s)
- Julius Sim
- Institute for Primary Care and Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.
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22
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Schnadower D, Tarr PI, Casper TC, Gorelick MH, Dean JM, O'Connell KJ, Mahajan P, Levine AC, Bhatt SR, Roskind CG, Powell EC, Rogers AJ, Vance C, Sapien RE, Olsen CS, Metheney M, Dickey VP, Hall-Moore C, Freedman SB. Lactobacillus rhamnosus GG versus Placebo for Acute Gastroenteritis in Children. N Engl J Med 2018; 379:2002-2014. [PMID: 30462938 PMCID: PMC6358014 DOI: 10.1056/nejmoa1802598] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute gastroenteritis develops in millions of children in the United States every year, and treatment with probiotics is common. However, data to support the use of probiotics in this population are limited. METHODS We conducted a prospective, randomized, double-blind trial involving children 3 months to 4 years of age with acute gastroenteritis who presented to one of 10 U.S. pediatric emergency departments. Participants received a 5-day course of Lactobacillus rhamnosus GG at a dose of 1×1010 colony-forming units twice daily or matching placebo. Follow-up surveys were conducted daily for 5 days and again 14 days after enrollment and 1 month after enrollment. The primary outcome was moderate-to-severe gastroenteritis, which was defined as an illness episode with a total score on the modified Vesikari scale of 9 or higher (scores range from 0 to 20, with higher scores indicating more severe disease), within 14 days after enrollment. Secondary outcomes included the duration and frequency of diarrhea and vomiting, the duration of day-care absenteeism, and the rate of household transmission (defined as the development of symptoms of gastroenteritis in previously asymptomatic household contacts). RESULTS Among the 971 participants, 943 (97.1%) completed the trial. The median age was 1.4 years (interquartile range, 0.9 to 2.3), and 513 participants (52.9%) were male. The modified Vesikari scale score for the 14-day period after enrollment was 9 or higher in 55 of 468 participants (11.8%) in the L. rhamnosus GG group and in 60 of 475 participants (12.6%) in the placebo group (relative risk, 0.96; 95% confidence interval, 0.68 to 1.35; P=0.83). There were no significant differences between the L. rhamnosus GG group and the placebo group in the duration of diarrhea (median, 49.7 hours in the L. rhamnosus GG group and 50.9 hours in the placebo group; P=0.26), duration of vomiting (median, 0 hours in both groups; P=0.17), or day-care absenteeism (median, 2 days in both groups; P=0.67) or in the rate of household transmission (10.6% and 14.1% in the two groups, respectively; P=0.16). CONCLUSIONS Among preschool children with acute gastroenteritis, those who received a 5-day course of L. rhamnosus GG did not have better outcomes than those who received placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; ClinicalTrials.gov number, NCT01773967 .).
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Affiliation(s)
- David Schnadower
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Phillip I Tarr
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - T Charles Casper
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Marc H Gorelick
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - J Michael Dean
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Karen J O'Connell
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Prashant Mahajan
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Adam C Levine
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Seema R Bhatt
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Cindy G Roskind
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Elizabeth C Powell
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Alexander J Rogers
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Cheryl Vance
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Robert E Sapien
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Cody S Olsen
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Melissa Metheney
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Viani P Dickey
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Carla Hall-Moore
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Stephen B Freedman
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
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Do trials that report a neutral or negative treatment effect improve the care of critically ill patients? Yes. Intensive Care Med 2018; 44:1985-1988. [PMID: 29947880 DOI: 10.1007/s00134-018-5129-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 03/05/2018] [Indexed: 12/30/2022]
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London AJ. Learning health systems, clinical equipoise and the ethics of response adaptive randomisation. JOURNAL OF MEDICAL ETHICS 2018; 44:409-415. [PMID: 29175968 DOI: 10.1136/medethics-2017-104549] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/06/2017] [Accepted: 11/14/2017] [Indexed: 06/07/2023]
Abstract
To give substance to the rhetoric of 'learning health systems', a variety of novel trial designs are being explored to more seamlessly integrate research with medical practice, reduce study duration and reduce the number of participants allocated to ineffective interventions. Many of these designs rely on response adaptive randomisation (RAR). However, critics charge that RAR is unethical on the grounds that it violates the principle of equipoise. In this paper, I reconstruct critiques of RAR as holding that it is inconsistent with five important ethical principles. I then argue that these criticisms rest on a faulty view of equipoise encouraged by the idea that a RAR study models the beliefs of a single rational agent about the relative merits of the interventions being studied. I outline a view in which RAR models an idealised health system in which diverse communities of fully informed experts shrink or grow as their constituent members update their expert opinions in light of reliable medical evidence. I show how a proper understanding of clinical equipoise can reconcile this conception of RAR with these five ethical principles. This analysis removes an in-principle objection to RAR and sheds important light on the relationship between clinical equipoise and transient diversity in the scientific community.
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Laage T, Loewy JW, Menon S, Miller ER, Pulkstenis E, Kan-Dobrosky N, Coffey C. Ethical Considerations in Adaptive Design Clinical Trials. Ther Innov Regul Sci 2017; 51:190-199. [DOI: 10.1177/2168479016667766] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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26
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Heltshe SL, Cogen J, Ramos KJ, Goss CH. Cystic Fibrosis: The Dawn of a New Therapeutic Era. Am J Respir Crit Care Med 2017; 195:979-984. [PMID: 27710011 DOI: 10.1164/rccm.201606-1250pp] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sonya L Heltshe
- 1 Division of Pediatric Pulmonology, Department of Pediatrics, and.,2 Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Jonathan Cogen
- 1 Division of Pediatric Pulmonology, Department of Pediatrics, and
| | - Kathleen J Ramos
- 3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington; and
| | - Christopher H Goss
- 1 Division of Pediatric Pulmonology, Department of Pediatrics, and.,3 Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington; and.,2 Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
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27
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Villar SS, Bowden J, Wason J. Response-adaptive designs for binary responses: How to offer patient benefit while being robust to time trends? Pharm Stat 2017; 17:182-197. [PMID: 29266692 PMCID: PMC5877788 DOI: 10.1002/pst.1845] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/27/2017] [Accepted: 11/07/2017] [Indexed: 12/15/2022]
Abstract
Response‐adaptive randomisation (RAR) can considerably improve the chances of a successful treatment outcome for patients in a clinical trial by skewing the allocation probability towards better performing treatments as data accumulates. There is considerable interest in using RAR designs in drug development for rare diseases, where traditional designs are not either feasible or ethically questionable. In this paper, we discuss and address a major criticism levelled at RAR: namely, type I error inflation due to an unknown time trend over the course of the trial. The most common cause of this phenomenon is changes in the characteristics of recruited patients—referred to as patient drift. This is a realistic concern for clinical trials in rare diseases due to their lengthly accrual rate. We compute the type I error inflation as a function of the time trend magnitude to determine in which contexts the problem is most exacerbated. We then assess the ability of different correction methods to preserve type I error in these contexts and their performance in terms of other operating characteristics, including patient benefit and power. We make recommendations as to which correction methods are most suitable in the rare disease context for several RAR rules, differentiating between the 2‐armed and the multi‐armed case. We further propose a RAR design for multi‐armed clinical trials, which is computationally efficient and robust to several time trends considered.
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Affiliation(s)
- Sofía S Villar
- MRC Biostatistics Unit, Cambridge Institute of Public Health, Cambridge, UK
| | - Jack Bowden
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - James Wason
- MRC Biostatistics Unit, Cambridge Institute of Public Health, Cambridge, UK
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28
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Tsuchida RE, Meurer WJ. More questions than answers - ALS interventions for out of hospital cardiac arrest. Am J Emerg Med 2017; 36:498-500. [PMID: 29217179 DOI: 10.1016/j.ajem.2017.11.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/27/2017] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ryan E Tsuchida
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States.
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States; Department of Neurology, University of Michigan, Ann Arbor, MI, United States; Stroke Program, University of Michigan, Ann Arbor, MI, United States; Michigan Center for Integrative Research on Critical Care, University of Michigan, Ann Arbor, MI, United States; Frankel Cardiovascular Center, University of Michigan, United States.
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29
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Seymour CW, Gomez H, Chang CCH, Clermont G, Kellum JA, Kennedy J, Yende S, Angus DC. Precision medicine for all? Challenges and opportunities for a precision medicine approach to critical illness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:257. [PMID: 29047353 PMCID: PMC5648512 DOI: 10.1186/s13054-017-1836-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 09/06/2017] [Indexed: 01/06/2023]
Abstract
All of medicine aspires to be precise, where a greater understanding of individual data will lead to personalized treatment and improved outcomes. Prompted by specific examples in oncology, the field of critical care may be tempted to envision that complex, acute syndromes could bend to a similar reductionist philosophy-where single mutations could identify and target our critically ill patients for treatment. However, precision medicine faces many challenges in critical care. These include confusion about terminology, uncertainty about how to divide patients into discrete groups, the challenges of multi-morbidity, scale, and the need for timely interventions. This review addresses these challenges and provides a translational roadmap spanning preclinical work to identify putative treatment targets, novel designs for clinical trials, and the integration of the electronic health record to implement precision critical care for all.
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Affiliation(s)
- Christopher W Seymour
- The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, 639 Scaife Hall, Pittsburgh, PA, 15261, USA.
| | - Hernando Gomez
- The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chung-Chou H Chang
- The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gilles Clermont
- The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John A Kellum
- The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jason Kennedy
- The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sachin Yende
- The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Derek C Angus
- The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Ong DSY, van Werkhoven CH, Cremer OL, Thwaites GE, Bonten MJM. Is a randomized trial of a short course of aminoglycoside added to β-lactam antibiotics for empirical treatment in critically ill patients with sepsis justified? Clin Microbiol Infect 2017; 24:95-96. [PMID: 28989114 DOI: 10.1016/j.cmi.2017.09.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 09/23/2017] [Accepted: 09/27/2017] [Indexed: 11/26/2022]
Affiliation(s)
- D S Y Ong
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - C H van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - O L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - M J M Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Schnadower D, Tarr PI, Charles CT, Gorelick MH, Dean MJ, O’Connell KJ, Mahajan P, Chun TH, Bhatt SR, Roskind CG, Powell EC, Rogers AJ, Vance C, Sapien RE, Gao F, Freedman SB. Randomised controlled trial of Lactobacillus rhamnosus (LGG) versus placebo in children presenting to the emergency department with acute gastroenteritis: the PECARN probiotic study protocol. BMJ Open 2017; 7:e018115. [PMID: 28947466 PMCID: PMC5623493 DOI: 10.1136/bmjopen-2017-018115] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Acute gastroenteritis (AGE) is a common and burdensome condition that affects millions of children worldwide each year. Currently available strategies are limited to symptomatic management, treatment and prevention of dehydration and infection control; no disease-modifying interventions exist. Probiotics, defined as live microorganisms beneficial to the host, have shown promise in improving AGE outcomes, but existing studies have sufficient limitations such that the use of probiotics cannot currently be recommended with confidence. Here we present the methods of a large, rigorous, randomised, double-blind placebo-controlled study to assess the effectiveness and side effect profile of Lactobacillus rhamnosus GG (LGG) (ATCC 53103) in children with AGE. METHODS AND ANALYSIS The study is being conducted in 10 US paediatric emergency departments (EDs) within the federally funded Pediatric Emergency Care Applied Research Network, in accordance with current SPIRIT and CONSORT statement recommendations. We will randomise 970 children presenting to participating EDs with AGE to either 5 days of treatment with LGG (1010colony-forming unit twice a day) or placebo between July 2014 to December 2017. The main outcome is the occurrence of moderate-to-severe disease over time, as defined by the Modified Vesikari Scale. We also record adverse events and side effects related to the intervention. We will conduct intention-to-treat analyses and use an enrichment design to restore the statistical power in case the presence of a subpopulation with a substantially low treatment effect is identified. ETHICS AND DISSEMINATION Institutional review board approval has been obtained at all sites, and data and material use agreements have been established between the participating sites. The results of the trial will be published in peer-reviewed journals. A deidentified public data set will be made available after the completion of all study procedures. TRIAL REGISTRATION NUMBER NCT01773967.
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Affiliation(s)
- David Schnadower
- Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Phillip I Tarr
- Division of Gastroenterology and Nutrition, Department of Pediatrics, Washington University, School of Medicine, St. Louis, Missouri, USA
| | - Casper T Charles
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Marc H Gorelick
- Central Administration, Children’s Hospital Minnesota, Minneapolis, Minnesota, USA
| | - Michael J Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Karen J O’Connell
- Division of Emergency Medicine, Children’s National Health System, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Prashant Mahajan
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Michigan Wayne State University, Detroit, Michigan, USA
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas H Chun
- Department of Emergency Medicine and Pediatrics Providence, Hasbro Children’s Hospital and Brown University, Providence, Rhode Island, USA
| | - Seema R Bhatt
- Division of Emergency Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cindy G Roskind
- Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians & Surgeons, New York, New York, USA
| | - Elizabeth C Powell
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alexander J Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Cheryl Vance
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Feng Gao
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Alexander BM, Ba S, Berger MS, Berry DA, Cavenee WK, Chang SM, Cloughesy TF, Jiang T, Khasraw M, Li W, Mittman R, Poste GH, Wen PY, Yung WA, Barker AD. Adaptive Global Innovative Learning Environment for Glioblastoma: GBM AGILE. Clin Cancer Res 2017; 24:737-743. [DOI: 10.1158/1078-0432.ccr-17-0764] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/05/2017] [Accepted: 08/10/2017] [Indexed: 11/16/2022]
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The AREST CF experience in biobanking - More than just tissues, tubes and time. J Cyst Fibros 2017; 16:622-627. [PMID: 28803050 DOI: 10.1016/j.jcf.2017.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 11/24/2022]
Abstract
Research to further improve outcomes for people with CF is dependent upon well characterised, archived and accessible clinical specimens. The recent article by Beekman et al. published in Journal of Cystic Fibrosis summarised a scientific meeting at the 13th ECFS Basic Science Conference. This meeting discussed how well-annotated, clinical biobanks for CF could be established in Europe to meet the needs of therapeutic development. The Australian Respiratory Early Surveillance Team for Cystic Fibrosis (AREST CF) has conducted biobanking of CF research and clinical specimens since the late 1990s and is custodian of the most comprehensive paediatric CF biobank in the world that focuses on the first years of life. This short communication will describe the approach undertaken by AREST CF in establishing a clinical specimen biobank.
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Brown AR, Gajewski BJ, Aaronson LS, Mudaranthakam DP, Hunt SL, Berry SM, Quintana M, Pasnoor M, Dimachkie MM, Jawdat O, Herbelin L, Barohn RJ. A Bayesian comparative effectiveness trial in action: developing a platform for multisite study adaptive randomization. Trials 2016; 17:428. [PMID: 27577191 PMCID: PMC5006258 DOI: 10.1186/s13063-016-1544-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 08/05/2016] [Indexed: 11/18/2022] Open
Abstract
Background In the last few decades, the number of trials using Bayesian methods has grown rapidly. Publications prior to 1990 included only three clinical trials that used Bayesian methods, but that number quickly jumped to 19 in the 1990s and to 99 from 2000 to 2012. While this literature provides many examples of Bayesian Adaptive Designs (BAD), none of the papers that are available walks the reader through the detailed process of conducting a BAD. This paper fills that gap by describing the BAD process used for one comparative effectiveness trial (Patient Assisted Intervention for Neuropathy: Comparison of Treatment in Real Life Situations) that can be generalized for use by others. A BAD was chosen with efficiency in mind. Response-adaptive randomization allows the potential for substantially smaller sample sizes, and can provide faster conclusions about which treatment or treatments are most effective. An Internet-based electronic data capture tool, which features a randomization module, facilitated data capture across study sites and an in-house computation software program was developed to implement the response-adaptive randomization. Results A process for adapting randomization with minimal interruption to study sites was developed. A new randomization table can be generated quickly and can be seamlessly integrated in the data capture tool with minimal interruption to study sites. Conclusion This manuscript is the first to detail the technical process used to evaluate a multisite comparative effectiveness trial using adaptive randomization. An important opportunity for the application of Bayesian trials is in comparative effectiveness trials. The specific case study presented in this paper can be used as a model for conducting future clinical trials using a combination of statistical software and a web-based application. Trial registration ClinicalTrials.gov Identifier: NCT02260388, registered on 6 October 2014
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Affiliation(s)
- Alexandra R Brown
- Department of Biostatistics, University of Kansas Medical Center, Mail Stop 1026, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA.
| | - Byron J Gajewski
- Department of Biostatistics, University of Kansas Medical Center, Mail Stop 1026, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Lauren S Aaronson
- School of Nursing, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Dinesh Pal Mudaranthakam
- Department of Biostatistics, University of Kansas Medical Center, Mail Stop 1026, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Suzanne L Hunt
- Department of Biostatistics, University of Kansas Medical Center, Mail Stop 1026, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Scott M Berry
- Berry Consultants, 4301 Westbank Drive, Suite 140, Bldg B, Austin, TX, 78746, USA
| | - Melanie Quintana
- Berry Consultants, 4301 Westbank Drive, Suite 140, Bldg B, Austin, TX, 78746, USA
| | - Mamatha Pasnoor
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Omar Jawdat
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Laura Herbelin
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, 66160, USA
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Abstract
Background/aims A learning health care system ideally incorporates the ability to adapt to the pace of change, the incorporation of new clinical research paradigms, and leverages electronic health record systems and clinical decision support systems to narrow the divide between research and clinical practice. Methods An adaptive clinical trial can be embedded into the sites and practice of clinical care in a highly pragmatic way to simultaneously generate high-quality data on treatment efficacy and improve the care of patients. This approach can be expanded into a pragmatic platform trial, meaning a trial that is intended to evaluate multiple treatments for a disease or diseases, possibly in combination, and with the available treatments potentially changing over time. This strategy is illustrated using a trial currently being implemented in Europe and funded by the European Union, evaluating three different “domains” of treatments for patients with severe community-acquired pneumonia requiring intensive care. Results Simulation studies demonstrate that this approach has the potential to save lives while identifying the best treatment strategies for this critically ill population. Conclusion Patients are likely to benefit if we can merge clinical trials and decision support into a single continuous learning process.
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Affiliation(s)
- Roger J Lewis
- Department of Emergency Medicine, Harbor–UCLA Medical Center, Torrance, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Los Angeles Biomedical Research Institute, Torrance, CA, USA
- Berry Consultants, LLC, Austin, TX, USA
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Thong IS, Foo MY, Sum MY, Capps B, Lee TS, Ho C, Sim K. Therapeutic Misconception in Psychiatry Research: A Systematic Review. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2016; 14:17-25. [PMID: 26792036 PMCID: PMC4730932 DOI: 10.9758/cpn.2016.14.1.17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/28/2015] [Accepted: 08/29/2015] [Indexed: 11/18/2022]
Abstract
Therapeutic misconception (TM) denotes the phenomenon in which research subjects conflate research purpose, protocols and procedures with clinical treatment. We examined the prevalence, contributory factors, clinical associations, impact, and collated solutions on TM within psychiatric research, and made suggestions going ahead. Literature search for relevant empirical research papers was conducted until February 2015. Eighty-eight reports were extracted, of which 31 were selected, summarised into different headings for discussion of implications and collated solutions of TM. We found variable and high rates of TM (ranging from 12.5% to 86%) in some psychiatry research populations. Contributory factors to TM included perceived medical roles of researchers, media, research setting and subject factors. Greater TM in affective, neurodevelopmental and psychotic spectrum conditions were associated with demographic variables (such as lower education, increased age), clinical factors (such as poor insight, cognitive deficits, increased symptoms, poorer self-rated quality of health), and social functioning (such as decreased independence). Inattention to TM may lead to frustration, negative impression and abandonment of participation in psychiatry research. Strategies such as the employment of a neutral educator during the informed consent process and education modules may be effective in addressing TM. Further research is warranted to examine the different TM facets, specific clinical correlates and more effective management strategies.
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Affiliation(s)
- Ivan Sk Thong
- The College of Arts and Sciences, University at Buffalo, Buffalo, New York, USA
| | - Meng Yee Foo
- The College of Arts and Sciences, University at Buffalo, Buffalo, New York, USA
| | - Min Yi Sum
- Research Division, Institute of Mental Health, Singapore, Singapore
| | - Benjamin Capps
- Department of Bioethics, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Tih-Shih Lee
- Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Calvin Ho
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kang Sim
- Research Division, Institute of Mental Health, Singapore, Singapore.,Department of General Psychiatry, Institute of Mental Health, Singapore, Singapore
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Mayer-Hamblett N, Boyle M, VanDevanter D. Advancing clinical development pathways for new CFTR modulators in cystic fibrosis. Thorax 2016; 71:454-61. [PMID: 26903594 PMCID: PMC4853537 DOI: 10.1136/thoraxjnl-2015-208123] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 01/20/2016] [Indexed: 01/15/2023]
Abstract
Cystic fibrosis (CF) is a life-shortening genetic disease affecting approximately 70,000 individuals worldwide. Until recently, drug development efforts have emphasised therapies treating downstream signs and symptoms resulting from the underlying CF biological defect: reduced function of the CF transmembrane conductance regulator (CFTR) protein. The current CF drug development landscape has expanded to include therapies that enhance CFTR function by either restoring wild-type CFTR protein expression or increasing (modulating) the function of mutant CFTR proteins in cells. To date, two systemic small-molecule CFTR modulators have been evaluated in pivotal clinical trials in individuals with CF and specific mutant CFTR genotypes that have led to regulatory review and/or approval. Advances in the discovery of CFTR modulators as a promising new class of therapies have been impressive, yet work remains to develop highly effective, disease-modifying modulators for individuals of all CF genotypes. The objectives of this review are to outline the challenges and opportunities in drug development created by systemic genotype-specific CFTR modulators, highlight the advantages of sweat chloride as an established biomarker of CFTR activity to streamline early-phase development and summarise options for later phase clinical trial designs that respond to the adoption of approved genotype-specific modulators into standard of care. An optimal development framework will be needed to move the most promising therapies efficiently through the drug development pipeline and ultimately deliver efficacious and safe therapies to all individuals with CF.
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Affiliation(s)
- Nicole Mayer-Hamblett
- Department of Pediatrics and Biostatistics, University of Washington, Seattle, Washington, USA Seattle Children's Hospital, Seattle, Washington, USA
| | - Michael Boyle
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA John Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Donald VanDevanter
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Richert L, Lhomme E, Fagard C, Lévy Y, Chêne G, Thiébaut R. Recent developments in clinical trial designs for HIV vaccine research. Hum Vaccin Immunother 2016; 11:1022-9. [PMID: 25751670 DOI: 10.1080/21645515.2015.1011974] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
HIV vaccine strategies are expected to be a crucial component for controlling the HIV epidemic. Despite the large spectrum of potential candidate vaccines for both prophylactic and therapeutic use, the overall development process of an efficacious HIV vaccine strategy is lengthy. The design of clinical trials and the progression of a candidate strategy through the different clinical development stages remain methodologically challenging, mainly due to the lack of validated correlates of protection. In this review, we describe recent advances in clinical trial designs to increase the efficiency of the clinical development of candidate HIV vaccine strategies. The methodological aspects of the designs for early- (phase I and II) and later -stage (phase IIB and III) development are discussed, taking into account the specificities of both prophylactic and therapeutic HIV vaccine development.
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Thielman NM, Cunningham CK, Woods C, Petzold E, Sprenz M, Russell J. Ebola clinical trials: Five lessons learned and a way forward. Clin Trials 2016; 13:83-6. [PMID: 26768559 DOI: 10.1177/1740774515619897] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | | | | | - James Russell
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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Gobat NH, Gal M, Francis NA, Hood K, Watkins A, Turner J, Moore R, Webb SAR, Butler CC, Nichol A. Key stakeholder perceptions about consent to participate in acute illness research: a rapid, systematic review to inform epi/pandemic research preparedness. Trials 2015; 16:591. [PMID: 26715077 PMCID: PMC4693405 DOI: 10.1186/s13063-015-1110-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/08/2015] [Indexed: 12/14/2022] Open
Abstract
Background A rigorous research response is required to inform clinical and public health decision-making during an epi/pandemic. However, the ethical conduct of such research, which often involves critically ill patients, may be complicated by the diminished capacity to consent and an imperative to initiate trial therapies within short time frames. Alternative approaches to taking prospective informed consent may therefore be used. We aimed to rapidly review evidence on key stakeholder (patients, their proxy decision-makers, clinicians and regulators) views concerning the acceptability of various approaches for obtaining consent relevant to pandemic-related acute illness research. Methods We conducted a rapid evidence review, using the Internet, database and hand-searching for English language empirical publications from 1996 to 2014 on stakeholder opinions of consent models (prospective informed, third-party, deferred, or waived) used in acute illness research. We excluded research on consent to treatment, screening, or other such procedures, non-emergency research and secondary studies. Papers were categorised, and data summarised using narrative synthesis. Results We screened 689 citations, reviewed 104 full-text articles and included 52. Just one paper related specifically to pandemic research. In other emergency research contexts potential research participants, clinicians and research staff found third-party, deferred, and waived consent to be acceptable as a means to feasibly conduct such research. Acceptability to potential participants was motivated by altruism, trust in the medical community, and perceived value in medical research and decreased as the perceived risks associated with participation increased. Discrepancies were observed in the acceptability of the concept and application or experience of alternative consent models. Patients accepted clinicians acting as proxy-decision makers, with preference for two decision makers as invasiveness of interventions increased. Research regulators were more cautious when approving studies conducted with alternative consent models; however, their views were generally under-represented. Conclusions Third-party, deferred, and waived consent models are broadly acceptable to potential participants, clinicians and/or researchers for emergency research. Further consultation with key stakeholders, particularly with regulators, and studies focused specifically on epi/pandemic research, are required. We highlight gaps and recommendations to inform set-up and protocol development for pandemic research and institutional review board processes. PROSPERO protocol registration number CRD42014014000 Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1110-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nina H Gobat
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Neaudd Meirionnydd, Heath Park Campus, Cardiff, Wales, CF14 4YS, UK.
| | - Micaela Gal
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Neaudd Meirionnydd, Heath Park Campus, Cardiff, Wales, CF14 4YS, UK.
| | - Nick A Francis
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Neaudd Meirionnydd, Heath Park Campus, Cardiff, Wales, CF14 4YS, UK.
| | - Kerenza Hood
- College of Biomedical and Life Sciences, Cardiff University, Cardiff, Wales, UK.
| | - Angela Watkins
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Neaudd Meirionnydd, Heath Park Campus, Cardiff, Wales, CF14 4YS, UK.
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Affiliation(s)
- Caroline Kistin
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts2Boston University School of Medicine, Boston, Massachusetts
| | - Michael Silverstein
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts2Boston University School of Medicine, Boston, Massachusetts
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Adaptive design of confirmatory trials: Advances and challenges. Contemp Clin Trials 2015; 45:93-102. [PMID: 26079372 DOI: 10.1016/j.cct.2015.06.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 06/05/2015] [Accepted: 06/10/2015] [Indexed: 11/23/2022]
Abstract
The past decade witnessed major developments in innovative designs of confirmatory clinical trials, and adaptive designs represent the most active area of these developments. We give an overview of the developments and associated statistical methods in several classes of adaptive designs of confirmatory trials. We also discuss their statistical difficulties and implementation challenges, and show how these problems are connected to other branches of mainstream Statistics, which we then apply to resolve the difficulties and bypass the bottlenecks in the development of adaptive designs for the next decade.
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Legocki LJ, Meurer WJ, Frederiksen S, Lewis RJ, Durkalski VL, Berry DA, Barsan WG, Fetters MD. Clinical trialist perspectives on the ethics of adaptive clinical trials: a mixed-methods analysis. BMC Med Ethics 2015; 16:27. [PMID: 25933921 PMCID: PMC4424427 DOI: 10.1186/s12910-015-0022-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 04/23/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND In an adaptive clinical trial (ACT), key trial characteristics may be altered during the course of the trial according to predefined rules in response to information that accumulates within the trial itself. In addition to having distinguishing scientific features, adaptive trials also may involve ethical considerations that differ from more traditional randomized trials. Better understanding of clinical trial experts' views about the ethical aspects of adaptive designs could assist those planning ACTs. Our aim was to elucidate the opinions of clinical trial experts regarding their beliefs about ethical aspects of ACTs. METHODS We used a convergent, mixed-methods design employing a 22-item ACTs beliefs survey with visual analog scales and open-ended questions and mini-focus groups. We developed a coding scheme to conduct thematic searches of textual data, depicted responses to visual analog scales on box-plot diagrams, and integrated findings thematically. Fifty-three clinical trial experts from four constituent groups participated: academic biostatisticians (n = 5); consultant biostatisticians (n = 6); academic clinicians (n = 22); and other stakeholders including patient advocacy, National Institutes of Health, and U.S. Food and Drug Administration representatives (n = 20). RESULTS The respondents recognized potential ethical benefits of ACTs, including a higher probability of receiving an effective intervention for participants, optimizing resource utilization, and accelerating treatment discovery. Ethical challenges voiced include developing procedures so trial participants can make informed decisions about taking part in ACTs and plausible, though unlikely risks of research personnel altering enrollment patterns. CONCLUSIONS Clinical trial experts recognize ethical advantages but also pose potential ethical challenges of ACTs. The four constituencies differ in their weighing of ACT ethical considerations based on their professional vantage points. These data suggest further discussion about the ethics of ACTs is needed to facilitate ACT planning, design and conduct, and ultimately better allow planners to weigh ethical implications of competing trial designs.
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Affiliation(s)
- Laurie J Legocki
- Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48109, USA.
| | - William J Meurer
- Departments of Emergency Medicine and Neurology, University of Michigan, Ann Arbor, MI, USA.
| | - Shirley Frederiksen
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, CA, USA.
- Los Angeles Biomedical Research Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
- Berry Consultants, Austin, TX, USA.
| | - Valerie L Durkalski
- Division of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - Donald A Berry
- Department of Biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
- Berry Consultants, Austin, TX, USA.
| | - William G Barsan
- Los Angeles Biomedical Research Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Michael D Fetters
- Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48109, USA.
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Abstract
Most patients needing intensive care cannot give informed consent to participation in research. This includes the most acutely and severely ill, with the highest mortality and morbidity where research has the greatest potential to improve patient outcomes. In these circumstances consent is usually sought from a substitute decision maker, but while survivors of intensive care believe substitute decision makers will look after their interests, evidence suggests substitute decision makers are poorly equipped for this task. Various models have been suggested for research without patient informed consent when intervention is urgent and cannot wait until first person consent is possible, including a waiver of consent if conditions are met. A nationally consistent model is proposed for Australia with a robust process for initial waiver of consent followed by first person consent to further research-related procedures or ongoing follow-up when this can be competently provided.
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Affiliation(s)
- G. J. Dobb
- Intensive Care Unit, Royal Perth Hospital and Clinical Professor, School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia
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Abstract
Randomization is firmly established as a cornerstone of clinical trial methodology. Yet, the ethics of randomization continues to generate controversy. The default, and most efficient, allocation scheme randomizes patients equally (1:1) across all arms of study. However, many randomized trials are using outcome-adaptive allocation schemes, which dynamically adjust the allocation ratio in favor of the better performing treatment arm. Advocates of outcome-adaptive allocation contend that it better accommodates clinical equipoise and promotes informed consent, since such trials limit patient-subject exposure to sub-optimal care. In this essay, we argue that this purported ethical advantage of outcome-adaptive allocation does not stand up to careful scrutiny in the setting of two-armed studies and/or early-phase research.
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Affiliation(s)
- Spencer Phillips Hey
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada
| | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, QC, Canada
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Tehranisa JS, Meurer WJ. Can response-adaptive randomization increase participation in acute stroke trials? Stroke 2014; 45:2131-3. [PMID: 24916909 DOI: 10.1161/strokeaha.114.005418] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE A response-adaptive randomization (RAR) trial design actively adjusts the ratio of participants assigned to each trial arm, favoring the better performing treatment by using outcome data from participants already in the trial. Compared with a standard clinical trial, an RAR study design has the potential to improve patient participation in acute stroke trials. METHODS This cross-sectional randomized survey included adult emergency department patients, age≥18, without symptoms of stroke or other critical illness. A standardized protocol was used, and subjects were randomized to either an RAR or standard hypothetical acute stroke trial. After viewing the video describing the hypothetical trial (http://youtu.be/cKIWduCaPZc), reviewing the consent form, and having questions answered, subjects indicated whether they would consent to the trial. A multivariable logistic regression model was fitted to estimate the impact of RAR while controlling for demographic factors and patient understanding of the design. RESULTS A total of 418 subjects (210 standard and 208 RAR) were enrolled. All baseline characteristics were balanced between groups. There was significantly higher participation in the RAR trial (67.3%) versus the standard trial (54.5%), absolute increase: 12.8% (95% confidence interval, 3.7-22.2). The RAR group had a higher odds ratio of agreeing to research (odds ratio, 1.89; 95% confidence interval, 1.2-2.9) while adjusting for patient level factors. Trial designs were generally well understood by the participants. CONCLUSIONS The hypothetical RAR trial attracted more research participation than standard randomization. RAR has the potential to increase recruitment and offer benefit to future trial participants.
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Affiliation(s)
- Jason S Tehranisa
- From the University of Michigan Medical School, Ann Arbor (J.S.T.); and Department of Emergency Medicine (W.J.M.) and Department of Neurology (W.J.M.), University of Michigan Health System, Ann Arbor
| | - William J Meurer
- From the University of Michigan Medical School, Ann Arbor (J.S.T.); and Department of Emergency Medicine (W.J.M.) and Department of Neurology (W.J.M.), University of Michigan Health System, Ann Arbor.
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Abstract
PURPOSE OF REVIEW Influenza pandemics occur intermittently and represent an existential global infectious diseases threat. The purpose of this review is to describe clinical and research preparedness for future pandemics. RECENT FINDINGS Pandemic influenza typically results in large numbers of individuals with life-threatening pneumonia requiring treatment in ICUs. Clinical preparedness of ICUs relates to planning to provide increased 'surge' capacity to meet increased demand and requires consideration of staffing, equipment and consumables, bed-space availability and management systems. Research preparedness is also necessary, as timely clinical research has the potential to change the trajectory of a pandemic. The clinical research response during the 2009 H1N1 influenza pandemic was suboptimal. SUMMARY Better planning is necessary to optimize both clinical and research responses to future pandemics.
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Bryant J, Skolarus LE, Smith B, Adelman EE, Meurer WJ. The accuracy of surrogate decision makers: informed consent in hypothetical acute stroke scenarios. BMC Emerg Med 2013; 13:18. [PMID: 24219014 PMCID: PMC4225766 DOI: 10.1186/1471-227x-13-18] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 11/05/2013] [Indexed: 11/10/2022] Open
Abstract
Background Over one third of stroke patients have cognitive or language deficits such that they require surrogate consent for acute stroke treatment or enrollment into acute stroke trials. Little is known about the agreement of stroke patients and surrogates in this time-sensitive decision-making process. We sought to determine patient and surrogate agreement in 4 hypothetical acute stroke scenarios. Methods We performed face to face interviews with ED patients at an academic teaching hospital from June to August 2011. Patients and the surrogates they designated were asked to make decisions regarding 4 hypothetical stroke scenarios: 2 were treatment decisions; 2 involved enrollment into a clinical trial. Percent agreement was calculated as measures of surrogate predictive ability. Results A total of 200 patient/surrogate pairs were interviewed. Overall patient/surrogate percent agreement was 76.5%. Agreement for clinical scenarios ranged from 87% to 96% but dropped to 49%-74% for research scenarios. Conclusions Surrogates accurately predict patient preferences for standard acute stroke treatments. However, the accuracy decreases when predicting research participation suggesting that the degree of surrogate agreement is dependent on the type of decision being made. Further research is needed to more thoroughly characterize surrogate decision-making in acute stroke situations.
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Affiliation(s)
- Jessica Bryant
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA.
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Affiliation(s)
- Christopher W Seymour
- Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Campbell G. Similarities and Differences of Bayesian Designs and Adaptive Designs for Medical Devices: A Regulatory View. Stat Biopharm Res 2013. [DOI: 10.1080/19466315.2013.846873] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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