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Hayward KS, Dalton EJ, Campbell BCV, Khatri P, Dukelow SP, Johns H, Walter S, Yogendrakumar V, Pandian JD, Sacco S, Bernhardt J, Parsons MW, Saver JL, Churilov L. Adaptive Trials in Stroke: Current Use and Future Directions. Neurology 2024; 103:e209876. [PMID: 39325999 DOI: 10.1212/wnl.0000000000209876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024] Open
Abstract
Inclusion of adaptive design features in a clinical trial provides preplanned flexibility to dynamically modify a trial during its conduct while preserving validity and integrity. Adaptive trials are needed to accelerate the conduct of more efficient, informative, and ethical clinical research in the field of neurology. Stroke is a natural candidate for adoption of these innovative approaches to trial design. This Research Methods in Neurology article is informed by a scoping review that identified 45 completed or ongoing adaptive clinical trials in stroke that were appraised: 15 trials had published results with or without a published protocol and 30 ongoing trials (14 trials had a published protocol, and 16 trials were registered only). Interventions spanned acute (n = 28), rehabilitation (n = 8), prevention (n = 8), and rehabilitation and prevention (n = 1). A subsample of these trials was selected to illustrate the utility of adaptive design features and discuss why each adaptive feature was incorporated in the design to best achieve the aim; whether each individual feature was used and whether it resulted in expected efficiencies; and any learnings during preparation, conduct, or reporting. We then discuss the operational, ethical, and regulatory considerations that warrant careful consideration during adaptive trial planning and reflect on the workforce readiness to deliver adaptive trials in practice. We conclude that adaptive trials can be designed, funded, conducted, and published for a wide range of research questions and offer future directions to support adoption of adaptive trial designs in stroke and neurologic research more broadly.
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Affiliation(s)
- Kathryn S Hayward
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Emily J Dalton
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Bruce C V Campbell
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Pooja Khatri
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Sean P Dukelow
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Hannah Johns
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Silke Walter
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Vignan Yogendrakumar
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Jeyaraj D Pandian
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Simona Sacco
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Julie Bernhardt
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Mark W Parsons
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Jeffrey L Saver
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Leonid Churilov
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
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Fantini MC, Fiorino G, Colli A, Laharie D, Armuzzi A, Caprioli FA, Gisbert JP, Kirchgesner J, Macaluso FS, Magro F, Ghosh S. Pragmatic Trial Design to Compare Real-world Effectiveness of Different Treatments for Inflammatory Bowel Diseases: The PRACTICE-IBD European Consensus. J Crohns Colitis 2024; 18:1222-1231. [PMID: 38367197 PMCID: PMC11324339 DOI: 10.1093/ecco-jcc/jjae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/10/2024] [Accepted: 02/15/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND AND AIMS Pragmatic studies designed to test interventions in everyday clinical settings can successfully complement the evidence from registration and explanatory clinical trials. The European consensus project PRACTICE-IBD was developed to identify essential criteria and address key methodological issues needed to design valid, comparative, pragmatic studies in inflammatory bowel diseases [BDs]. METHODS Statements were issued by a panel of 11 European experts in IBD management and trial methodology, on four main topics: [I] study design; [II] eligibility, recruitment and organisation, flexibility; [III] outcomes; [IV] analysis. The consensus process followed a modified Delphi approach, involving two rounds of assessment and rating of the level of agreement [1 to 9; cut-off ≥7 for approval] with the statements by 18 additional European experts in IBD. RESULTS At the first voting round, 25 out of the 26 statements reached a mean score ≥7. Following the discussion that preceded the second round of voting, it was decided to eliminate two statements and to split one into two. At the second voting round, 25 final statements were approved: seven for study design; six for eligibility, recruitment and organisation, flexibility; eight for outcomes; and four for analysis. CONCLUSIONS Pragmatic, randomised, clinical trials can address important questions in IBD clinical practice, and may provide complementary, high-level evidence, as long as they follow a methodologically rigorous approach. These 25 statements intend to offer practical guidance in the design of high-quality, pragmatic, clinical trials that can aid decision making in choosing a management strategy for IBDs.
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Affiliation(s)
- Massimo Claudio Fantini
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Gastroenterology Unit, Azienda Ospedaliero-Universitaria di Cagliari,Italy
| | - Gionata Fiorino
- IBD Unit, Department of Gastroenterology and Digestive Endoscopy, San Camillo-Forlanini, Rome, Italy; Department of Gastroenterology and Digestive Endoscopy, San Raffaele Hospital and Vita-Salute San Raffaele Hospital, Milan, Italy
| | - Agostino Colli
- Department of Transfusion Medicine and Haematology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - David Laharie
- CHU de Bordeaux, Hôpital Haut-Lévêque, Service d’Hépato-gastroentérologie et Oncologie Digestive, Université de Bordeaux, Bordeaux, France
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Flavio Andrea Caprioli
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-Princesa], Universidad Autónoma de Madrid [UAM], Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - Julien Kirchgesner
- INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Sorbonne Université, Department of Gastroenterology, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Fernando Magro
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Porto, Portugal; Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal; Department of Clinical Pharmacology, São João University Hospital Center [CHUSJ], Porto, Portugal; Center for Health Technology and Services Research [CINTESIS], Porto, Portugal
| | - Subrata Ghosh
- College of Medicine and Health, University College Cork, Cork, Ireland
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Arnaldi D, Iranzo A, Nobili F, Postuma RB, Videnovic A. Developing disease-modifying interventions in idiopathic REM sleep behavior disorder and early synucleinopathy. Parkinsonism Relat Disord 2024; 125:107042. [PMID: 38943771 DOI: 10.1016/j.parkreldis.2024.107042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 07/01/2024]
Abstract
Alpha-synucleinopathies are prevalent neurological disorders that cause significant disability, leading to progressive clinical deterioration that is currently managed solely through symptomatic treatment. Efforts to evaluate disease-modifying therapies during the established stage of the disease have not yielded positive outcomes in terms of clinical or imaging efficacy endpoints. However, alpha-synucleinopathies have a long prodromal phase that presents a promising opportunity for intervention with disease-modifying therapies. The presence of polysomnography-confirmed REM sleep behavior disorder (RBD) is the most reliable risk factor for identifying individuals in the prodromal stage of alpha-synucleinopathy. This paper discusses the rationale behind targeting idiopathic/isolated RBD in disease-modifying trials and outlines possible study designs, including strategies for patient stratification, selection of biomarkers to assess disease progression and patient eligibility, as well as the identification of suitable endpoints. Additionally, the potential targets for disease-modifying treatment in alpha-synucleinopathies are summarized.
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Affiliation(s)
- Dario Arnaldi
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy; Neurofisiopatologia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Alex Iranzo
- Neurology Service, Sleep Disorder Centre, Hospital Clinic Barcelona, Universitat de Barcelona, IDIBAPS, CIBERNED: CB06/05/0018-ISCIII, Barcelona, Spain
| | - Flavio Nobili
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
| | - Ronald B Postuma
- Department of Neurology, McGill University, Montreal Neurological Institute, Montreal, Canada; Centre d'Études Avancées en Médecine du Sommeil, Hôpital du Sacré-Cœur de Montréal, Montréal, Canada
| | - Aleksandar Videnovic
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Gordon AC, Alipanah-Lechner N, Bos LD, Dianti J, Diaz JV, Finfer S, Fujii T, Giamarellos-Bourboulis EJ, Goligher EC, Gong MN, Karakike E, Liu VX, Lumlertgul N, Marshall JC, Menon DK, Meyer NJ, Munroe ES, Myatra SN, Ostermann M, Prescott HC, Randolph AG, Schenck EJ, Seymour CW, Shankar-Hari M, Singer M, Smit MR, Tanaka A, Taccone FS, Thompson BT, Torres LK, van der Poll T, Vincent JL, Calfee CS. From ICU Syndromes to ICU Subphenotypes: Consensus Report and Recommendations for Developing Precision Medicine in the ICU. Am J Respir Crit Care Med 2024; 210:155-166. [PMID: 38687499 PMCID: PMC11273306 DOI: 10.1164/rccm.202311-2086so] [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: 11/14/2023] [Accepted: 04/29/2024] [Indexed: 05/02/2024] Open
Abstract
Critical care uses syndromic definitions to describe patient groups for clinical practice and research. There is growing recognition that a "precision medicine" approach is required and that integrated biologic and physiologic data identify reproducible subpopulations that may respond differently to treatment. This article reviews the current state of the field and considers how to successfully transition to a precision medicine approach. To impact clinical care, identification of subpopulations must do more than differentiate prognosis. It must differentiate response to treatment, ideally by defining subgroups with distinct functional or pathobiological mechanisms (endotypes). There are now multiple examples of reproducible subpopulations of sepsis, acute respiratory distress syndrome, and acute kidney or brain injury described using clinical, physiological, and/or biological data. Many of these subpopulations have demonstrated the potential to define differential treatment response, largely in retrospective studies, and that the same treatment-responsive subpopulations may cross multiple clinical syndromes (treatable traits). To bring about a change in clinical practice, a precision medicine approach must be evaluated in prospective clinical studies requiring novel adaptive trial designs. Several such studies are underway, but there are multiple challenges to be tackled. Such subpopulations must be readily identifiable and be applicable to all critically ill populations around the world. Subdividing clinical syndromes into subpopulations will require large patient numbers. Global collaboration of investigators, clinicians, industry, and patients over many years will therefore be required to transition to a precision medicine approach and ultimately realize treatment advances seen in other medical fields.
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Affiliation(s)
| | - Narges Alipanah-Lechner
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | | | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Departamento de Cuidados Intensivos, Centro de Educación Médica e Investigaciones Clínicas, Buenos Aires, Argentina
| | | | - Simon Finfer
- School of Public Health, Imperial College London, London, United Kingdom
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Tomoko Fujii
- Jikei University School of Medicine, Jikei University Hospital, Tokyo, Japan
| | | | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Ng Gong
- Division of Critical Care Medicine and
- Division of Pulmonary Medicine, Department of Medicine and Department of Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Eleni Karakike
- Second Department of Critical Care Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | - Nuttha Lumlertgul
- Excellence Center for Critical Care Nephrology, Division of Nephrology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - John C. Marshall
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David K. Menon
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Nuala J. Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth S. Munroe
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sheila N. Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marlies Ostermann
- King’s College London, Guy’s & St Thomas’ Hospital, London, United Kingdom
| | - Hallie C. Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Anaesthesia and
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Edward J. Schenck
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Christopher W. Seymour
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Manu Shankar-Hari
- Centre for Inflammation Research, Institute of Regeneration and Repair, University of Edinburgh, Edinburgh, United Kingdom
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, United Kingdom
| | | | - Aiko Tanaka
- Department of Intensive Care, University of Fukui Hospital, Yoshida, Fukui, Japan
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Fabio S. Taccone
- Department des Soins Intensifs, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium; and
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lisa K. Torres
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Tom van der Poll
- Center of Experimental and Molecular Medicine, and
- Division of Infectious Diseases, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jean-Louis Vincent
- Department des Soins Intensifs, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium; and
| | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
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Angus DC, Huang AJ, Lewis RJ, Abernethy AP, Califf RM, Landray M, Kass N, Bibbins-Domingo K. The Integration of Clinical Trials With the Practice of Medicine: Repairing a House Divided. JAMA 2024; 332:153-162. [PMID: 38829654 DOI: 10.1001/jama.2024.4088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Importance Optimal health care delivery, both now and in the future, requires a continuous loop of knowledge generation, dissemination, and uptake on how best to provide care, not just determining what interventions work but also how best to ensure they are provided to those who need them. The randomized clinical trial (RCT) is the most rigorous instrument to determine what works in health care. However, major issues with both the clinical trials enterprise and the lack of integration of clinical trials with health care delivery compromise medicine's ability to best serve society. Observations In most resource-rich countries, the clinical trials and health care delivery enterprises function as separate entities, with siloed goals, infrastructure, and incentives. Consequently, RCTs are often poorly relevant and responsive to the needs of patients and those responsible for care delivery. At the same time, health care delivery systems are often disengaged from clinical trials and fail to rapidly incorporate knowledge generated from RCTs into practice. Though longstanding, these issues are more pressing given the lessons learned from the COVID-19 pandemic, heightened awareness of the disproportionate impact of poor access to optimal care on vulnerable populations, and the unprecedented opportunity for improvement offered by the digital revolution in health care. Four major areas must be improved. First, especially in the US, greater clarity is required to ensure appropriate regulation and oversight of implementation science, quality improvement, embedded clinical trials, and learning health systems. Second, greater adoption is required of study designs that improve statistical and logistical efficiency and lower the burden on participants and clinicians, allowing trials to be smarter, safer, and faster. Third, RCTs could be considerably more responsive and efficient if they were better integrated with electronic health records. However, this advance first requires greater adoption of standards and processes designed to ensure health data are adequately reliable and accurate and capable of being transferred responsibly and efficiently across platforms and organizations. Fourth, tackling the problems described above requires alignment of stakeholders in the clinical trials and health care delivery enterprises through financial and nonfinancial incentives, which could be enabled by new legislation. Solutions exist for each of these problems, and there are examples of success for each, but there is a failure to implement at adequate scale. Conclusions and Relevance The gulf between current care and that which could be delivered has arguably never been wider. A key contributor is that the 2 limbs of knowledge generation and implementation-the clinical trials and health care delivery enterprises-operate as a house divided. Better integration of these 2 worlds is key to accelerated improvement in health care delivery.
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Affiliation(s)
- Derek C Angus
- JAMA , Chicago, Illinois
- University of Pittsburgh Schools of the Health Sciences, Pittsburgh, Pennsylvania
| | | | - Roger J Lewis
- JAMA , Chicago, Illinois
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Amy P Abernethy
- Verily Life Sciences, San Francisco, California
- Now with Highlander Health, Dallas, Texas
| | | | - Martin Landray
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Protas, Manchester, United Kingdom
| | - Nancy Kass
- Johns Hopkins University, Baltimore, Maryland
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6
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Curfman G. Integrating Clinical Trials and Practice: A New JAMA Series and Call for Papers. JAMA 2024; 332:111. [PMID: 38829732 DOI: 10.1001/jama.2024.10266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
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7
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Chen Z, Berger JS, Castellucci LA, Farkouh M, Goligher EC, Hade EM, Hunt BJ, Kornblith LZ, Lawler PR, Leifer ES, Lorenzi E, Neal MD, Zarychanski R, Heath A. A comparison of computational algorithms for the Bayesian analysis of clinical trials. Clin Trials 2024:17407745241247334. [PMID: 38752434 DOI: 10.1177/17407745241247334] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
BACKGROUND Clinical trials are increasingly using Bayesian methods for their design and analysis. Inference in Bayesian trials typically uses simulation-based approaches such as Markov Chain Monte Carlo methods. Markov Chain Monte Carlo has high computational cost and can be complex to implement. The Integrated Nested Laplace Approximations algorithm provides approximate Bayesian inference without the need for computationally complex simulations, making it more efficient than Markov Chain Monte Carlo. The practical properties of Integrated Nested Laplace Approximations compared to Markov Chain Monte Carlo have not been considered for clinical trials. Using data from a published clinical trial, we aim to investigate whether Integrated Nested Laplace Approximations is a feasible and accurate alternative to Markov Chain Monte Carlo and provide practical guidance for trialists interested in Bayesian trial design. METHODS Data from an international Bayesian multi-platform adaptive trial that compared therapeutic-dose anticoagulation with heparin to usual care in non-critically ill patients hospitalized for COVID-19 were used to fit Bayesian hierarchical generalized mixed models. Integrated Nested Laplace Approximations was compared to two Markov Chain Monte Carlo algorithms, implemented in the software JAGS and stan, using packages available in the statistical software R. Seven outcomes were analysed: organ-support free days (an ordinal outcome), five binary outcomes related to survival and length of hospital stay, and a time-to-event outcome. The posterior distributions for the treatment and sex effects and the variances for the hierarchical effects of age, site and time period were obtained. We summarized these posteriors by calculating the mean, standard deviations and the 95% equitailed credible intervals and presenting the results graphically. The computation time for each algorithm was recorded. RESULTS The average overlap of the 95% credible interval for the treatment and sex effects estimated using Integrated Nested Laplace Approximations was 96% and 97.6% compared with stan, respectively. The graphical posterior densities for these effects overlapped for all three algorithms. The posterior mean for the variance of the hierarchical effects of age, site and time estimated using Integrated Nested Laplace Approximations are within the 95% credible interval estimated using Markov Chain Monte Carlo but the average overlap of the credible interval is lower, 77%, 85.6% and 91.3%, respectively, for Integrated Nested Laplace Approximations compared to stan. Integrated Nested Laplace Approximations and stan were easily implemented in clear, well-established packages in R, while JAGS required the direct specification of the model. Integrated Nested Laplace Approximations was between 85 and 269 times faster than stan and 26 and 1852 times faster than JAGS. CONCLUSION Integrated Nested Laplace Approximations could reduce the computational complexity of Bayesian analysis in clinical trials as it is easy to implement in R, substantially faster than Markov Chain Monte Carlo methods implemented in JAGS and stan, and provides near identical approximations to the posterior distributions for the treatment effect. Integrated Nested Laplace Approximations was less accurate when estimating the posterior distribution for the variance of hierarchical effects, particularly for the proportional odds model, and future work should determine if the Integrated Nested Laplace Approximations algorithm can be adjusted to improve this estimation.
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Affiliation(s)
- Ziming Chen
- The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | | | | | | | | | | | - Eric S Leifer
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | | | - Matthew D Neal
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Anna Heath
- The Hospital for Sick Children, Toronto, ON, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Statistical Science, University College London, London, UK
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8
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Dennis B, Deane A, Lauzier F, Zytaruk N, Hardie M, Hammond N, Finfer S, Arabi Y, Marshall J, Saunders L, Heels-Ansdell D, Myburgh J, Knowles S, Muscedere J, Ostermann M, Rajbhandari D, English S, Matic K, Venkatesh B, Al Fares A, Guyatt G, Alhazzani W, Mumtaz H, Poole A, Xie F, Thabane L, Hall R, Cook D. Protocol implementation during the COVID-19 pandemic: experiences from a randomized trial of stress ulcer prophylaxis. BMC Med Res Methodol 2024; 24:109. [PMID: 38704520 PMCID: PMC11069460 DOI: 10.1186/s12874-024-02233-2] [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: 06/13/2023] [Accepted: 04/23/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND During the COVID-19 pandemic, many intensive care units (ICUs) halted research to focus on COVID-19-specific studies. OBJECTIVE To describe the conduct of an international randomized trial of stress ulcer prophylaxis (Re-Evaluating the Inhibition of Stress Erosions in the ICU [REVISE]) during the pandemic, addressing enrolment patterns, center engagement, informed consent processes, data collection, a COVID-specific substudy, patient transfers, and data monitoring. METHODS REVISE is a randomized trial among mechanically ventilated patients, comparing pantoprazole 40 mg IV to placebo on the primary efficacy outcome of clinically important upper gastrointestinal bleeding and the primary safety outcome of 90-day mortality. We documented protocol implementation status from March 11th 2020-August 30th 2022. RESULTS The Steering Committee did not change the scientific protocol. From the first enrolment on July 9th 2019 to March 10th 2020 (8 months preceding the pandemic), 267 patients were enrolled in 18 centers. From March 11th 2020-August 30th 2022 (30 months thereafter), 41 new centers joined; 59 were participating by August 30th 2022 which enrolled 2961 patients. During a total of 1235 enrolment-months in the pandemic phase, enrolment paused for 106 (8.6%) months in aggregate (median 3 months, interquartile range 2;6). Protocol implementation involved a shift from the a priori consent model pre-pandemic (188, 58.8%) to the consent to continue model (1615, 54.1%, p < 0.01). In one new center, an opt-out model was approved. The informed consent rate increased slightly (80.7% to 85.0%, p = 0.05). Telephone consent encounters increased (16.6% to 68.2%, p < 0.001). Surge capacity necessitated intra-institutional transfers; receiving centers continued protocol implementation whenever possible. We developed a nested COVID-19 substudy. The Methods Centers continued central statistical monitoring of trial metrics. Site monitoring was initially remote, then in-person when restrictions lifted. CONCLUSION Protocol implementation adaptations during the pandemic included a shift in the consent model, a sustained high consent rate, and launch of a COVID-19 substudy. Recruitment increased as new centers joined, patient transfers were optimized, and monitoring methods were adapted.
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Affiliation(s)
- Brittany Dennis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Adam Deane
- Department of Critical Care Or Medicine, Department of Critical Care Medicine, Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - François Lauzier
- Departments of Anesthesiology, Medicine and Critical Care Medicine, Université Laval, Québec, Canada
| | - Nicole Zytaruk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Research Institute, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Miranda Hardie
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Naomi Hammond
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Simon Finfer
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Yaseen Arabi
- Intensive Care Department, Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - John Marshall
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Lois Saunders
- Division of Critical Care, Research Institute, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - John Myburgh
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Intensive Care Unit, St. George Hospital, Sydney, Australia
| | - Serena Knowles
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Thomas' Hospital, Guy's & St, London, UK
| | - Dorrilyn Rajbhandari
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Shane English
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Karlo Matic
- Division of Critical Care, Research Institute, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Bala Venkatesh
- Critical Care Program, Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Abdulrahman Al Fares
- Departments of Anesthesia, Critical Care Medicine, and Pain Medicine, Al-Amiri Center for Respiratory and Cardiac Failure, Al-Amiri Hospital, Ministry of Health, Kuwait Extracorporeal Life Support Program, Ministry of Health, Kuwait City, Kuwait
| | - Gordon Guyatt
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Research Institute, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Hassan Mumtaz
- Department of Critical Care, Maroof Hospital, Islamabad, Pakistan
| | - Alexis Poole
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
- Centre for Research Excellence in Translating Nutrition Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Research Institute, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Biostatistics Unit, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Richard Hall
- Departments of Anesthesia, Critical Care and Pharmacology, Dalhousie University, Halifax, NS, Canada
| | - Deborah Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
- Division of Critical Care, Research Institute, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.
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Krychtiuk KA, Andersson TL, Bodesheim U, Butler J, Curtis LH, Elkind M, Hernandez AF, Hornik C, Lyman GH, Khatri P, Mbagwu M, Murakami M, Nichols G, Roessig L, Young AQ, Schilsky RL, Pagidipati N. Drug development for major chronic health conditions-aligning with growing public health needs: Proceedings from a multistakeholder think tank. Am Heart J 2024; 270:23-43. [PMID: 38242417 DOI: 10.1016/j.ahj.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/21/2024]
Abstract
The global pharmaceutical industry portfolio is skewed towards cancer and rare diseases due to more predictable development pathways and financial incentives. In contrast, drug development for major chronic health conditions that are responsible for a large part of mortality and disability worldwide is stalled. To examine the processes of novel drug development for common chronic health conditions, a multistakeholder Think Tank meeting, including thought leaders from academia, clinical practice, non-profit healthcare organizations, the pharmaceutical industry, the Food and Drug Administration (FDA), payors as well as investors, was convened in July 2022. Herein, we summarize the proceedings of this meeting, including an overview of the current state of drug development for chronic health conditions and key barriers that were identified. Six major action items were formulated to accelerate drug development for chronic diseases, with a focus on improving the efficiency of clinical trials and rapid implementation of evidence into clinical practice.
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Affiliation(s)
| | | | | | - Javed Butler
- Baylor Scott & White Research Institute, Dallas, TX
| | | | - Mitchell Elkind
- American Heart Association, Dallas, TX; Columbia University, New York, NY
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Griessbach A, Schönenberger CM, Taji Heravi A, Gloy V, Agarwal A, Hallenberger TJ, Schandelmaier S, Janiaud P, Amstutz A, Covino M, Mall D, Speich B, Briel M. Characteristics, Progression, and Output of Randomized Platform Trials: A Systematic Review. JAMA Netw Open 2024; 7:e243109. [PMID: 38506807 PMCID: PMC10955344 DOI: 10.1001/jamanetworkopen.2024.3109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/24/2024] [Indexed: 03/21/2024] Open
Abstract
Importance Platform trials have become increasingly common, and evidence is needed to determine how this trial design is actually applied in current research practice. Objective To determine the characteristics, progression, and output of randomized platform trials. Evidence Review In this systematic review of randomized platform trials, Medline, Embase, Scopus, trial registries, gray literature, and preprint servers were searched, and citation tracking was performed in July 2022. Investigators were contacted in February 2023 to confirm data accuracy and to provide updated information on the status of platform trial arms. Randomized platform trials were eligible if they explicitly planned to add or drop arms. Data were extracted in duplicate from protocols, publications, websites, and registry entries. For each platform trial, design features such as the use of a common control arm, use of nonconcurrent control data, statistical framework, adjustment for multiplicity, and use of additional adaptive design features were collected. Progression and output of each platform trial were determined by the recruitment status of individual arms, the number of arms added or dropped, and the availability of results for each intervention arm. Findings The search identified 127 randomized platform trials with a total of 823 arms; most trials were conducted in the field of oncology (57 [44.9%]) and COVID-19 (45 [35.4%]). After a more than twofold increase in the initiation of new platform trials at the beginning of the COVID-19 pandemic, the number of platform trials has since declined. Platform trial features were often not reported (not reported: nonconcurrent control, 61 of 127 [48.0%]; multiplicity adjustment for arms, 98 of 127 [77.2%]; statistical framework, 37 of 127 [29.1%]). Adaptive design features were only used by half the studies (63 of 127 [49.6%]). Results were available for 65.2% of closed arms (230 of 353). Premature closure of platform trial arms due to recruitment problems was infrequent (5 of 353 [1.4%]). Conclusions and Relevance This systematic review found that platform trials were initiated most frequently during the COVID-19 pandemic and declined thereafter. The reporting of platform features and the availability of results were insufficient. Premature arm closure for poor recruitment was rare.
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Affiliation(s)
- Alexandra Griessbach
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christof Manuel Schönenberger
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ala Taji Heravi
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Viktoria Gloy
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Arnav Agarwal
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Stefan Schandelmaier
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Perrine Janiaud
- Pragmatic Evidence Lab, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alain Amstutz
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Manuela Covino
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - David Mall
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Benjamin Speich
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Matthias Briel
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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11
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Duan XP, Qin BD, Jiao XD, Liu K, Wang Z, Zang YS. New clinical trial design in precision medicine: discovery, development and direction. Signal Transduct Target Ther 2024; 9:57. [PMID: 38438349 PMCID: PMC10912713 DOI: 10.1038/s41392-024-01760-0] [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: 11/30/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 03/06/2024] Open
Abstract
In the era of precision medicine, it has been increasingly recognized that individuals with a certain disease are complex and different from each other. Due to the underestimation of the significant heterogeneity across participants in traditional "one-size-fits-all" trials, patient-centered trials that could provide optimal therapy customization to individuals with specific biomarkers were developed including the basket, umbrella, and platform trial designs under the master protocol framework. In recent years, the successive FDA approval of indications based on biomarker-guided master protocol designs has demonstrated that these new clinical trials are ushering in tremendous opportunities. Despite the rapid increase in the number of basket, umbrella, and platform trials, the current clinical and research understanding of these new trial designs, as compared with traditional trial designs, remains limited. The majority of the research focuses on methodologies, and there is a lack of in-depth insight concerning the underlying biological logic of these new clinical trial designs. Therefore, we provide this comprehensive review of the discovery and development of basket, umbrella, and platform trials and their underlying logic from the perspective of precision medicine. Meanwhile, we discuss future directions on the potential development of these new clinical design in view of the "Precision Pro", "Dynamic Precision", and "Intelligent Precision". This review would assist trial-related researchers to enhance the innovation and feasibility of clinical trial designs by expounding the underlying logic, which be essential to accelerate the progression of precision medicine.
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Affiliation(s)
- Xiao-Peng Duan
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Bao-Dong Qin
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Xiao-Dong Jiao
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Ke Liu
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zhan Wang
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yuan-Sheng Zang
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China.
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12
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The Rise of Adaptive Platform Trials in Critical Care. Am J Respir Crit Care Med 2024; 209:491-496. [PMID: 38271622 PMCID: PMC10919116 DOI: 10.1164/rccm.202401-0101cp] [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: 01/10/2024] [Accepted: 01/25/2024] [Indexed: 01/27/2024] Open
Abstract
As durable learning research systems, adaptive platform trials represent a transformative new approach to accelerating clinical evaluation and discovery in critical care. This Perspective provides a brief introduction to the concept of adaptive platform trials, describes several established and emerging platforms in critical care, and surveys some opportunities and challenges for their implementation and impact.
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13
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Omerovic E, Petrie M, Redfors B, Fremes S, Murphy G, Marquis-Gravel G, Lansky A, Velazquez E, Perera D, Reid C, Smith J, van der Meer P, Lipsic E, Juni P, McMurray J, Bauersachs J, Køber L, Rouleau JL, Doenst T. Pragmatic randomized controlled trials: strengthening the concept through a robust international collaborative network: PRIME-9-Pragmatic Research and Innovation through Multinational Experimentation. Trials 2024; 25:80. [PMID: 38263138 PMCID: PMC10807265 DOI: 10.1186/s13063-024-07935-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 01/15/2024] [Indexed: 01/25/2024] Open
Abstract
In an era focused on value-based healthcare, the quality of healthcare and resource allocation should be underpinned by empirical evidence. Pragmatic clinical trials (pRCTs) are essential in this endeavor, providing randomized controlled trial (RCT) insights that encapsulate real-world effects of interventions. The rising popularity of pRCTs can be attributed to their ability to mirror real-world practices, accommodate larger sample sizes, and provide cost advantages over traditional RCTs. By harmonizing efficacy with effectiveness, pRCTs assist decision-makers in prioritizing interventions that have a substantial public health impact and align with the tenets of value-based health care. An international network for pRCT provides several advantages, including larger and diverse patient populations, access to a broader range of healthcare settings, sharing knowledge and expertise, and overcoming ethical and regulatory barriers. The hypothesis and study design of pRCT answers the decision-maker's questions. pRCT compares clinically relevant alternative interventions, recruits participants from diverse practice settings, and collects data on various health outcomes. They are scarce because the medical products industry typically does not fund pRCT. Prioritizing these studies by expanding the infrastructure to conduct clinical research within the healthcare delivery system and increasing public and private funding for these studies will be necessary to facilitate pRCTs. These changes require more clinical and health policy decision-makers in clinical research priority setting, infrastructure development, and funding. This paper presents a comprehensive overview of pRCTs, emphasizing their importance in evidence-based medicine and the advantages of an international collaborative network for their execution. It details the development of PRIME-9, an international initiative across nine countries to advance pRCTs, and explores various statistical approaches for these trials. The paper underscores the need to overcome current challenges, such as funding limitations and infrastructural constraints, to leverage the full potential of pRCTs in optimizing healthcare quality and resource utilization.
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Affiliation(s)
- Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Bruna Stråket 16, 41345, Gothenburg, Sweden.
| | - Mark Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Bruna Stråket 16, 41345, Gothenburg, Sweden
| | - Stephen Fremes
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Gavin Murphy
- Cardiovascular Research Centre, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | | | - Alexandra Lansky
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Eric Velazquez
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Divaka Perera
- British Heart Foundation Centre of Research Excellence and National Institute for Health and Care Research Biomedical Research Centre at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, UK
| | - Christopher Reid
- Curtin School of Population Health, Faculty of Health Sciences, Curtin University, Kent Street, Bentley, WA, 6102, Australia
| | - Julian Smith
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, VIC, Australia
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, VIC, Australia
| | - Peter van der Meer
- Department of Cardiology, Center for Blistering Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Eric Lipsic
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Peter Juni
- Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, UK
| | - John McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Canada
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Friedrich-Schiller-University Jena, University Hospital, Jena, Germany
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14
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Lombardo G, Couvert C, Kose M, Begum A, Spiertz C, Worrell C, Hasselbaink D, Didden EM, Sforzini L, Todorovic M, Lewi M, Brown M, Vaterkowski M, Gullet N, Amasi-Hartoonian N, Griffon N, Pais R, Rodriguez Navarro S, Kremer A, Maes C, Tan EH, Moinat M, Ferrer JG, Pariante CM, Kalra D, Ammour N, Kalko S. Electronic health records (EHRs) in clinical research and platform trials: Application of the innovative EHR-based methods developed by EU-PEARL. J Biomed Inform 2023; 148:104553. [PMID: 38000766 DOI: 10.1016/j.jbi.2023.104553] [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: 03/28/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE Electronic Health Record (EHR) systems are digital platforms in clinical practice used to collect patients' clinical information related to their health status and represents a useful storage of real-world data. EHRs have a potential role in research studies, in particular, in platform trials. Platform trials are innovative trial designs including multiple trial arms (conducted simultaneously and/or sequentially) on different treatments under a single master protocol. However, the use of EHRs in research comes with important challenges such as incompleteness of records and the need to translate trial eligibility criteria into interoperable queries. In this paper, we aim to review and to describe our proposed innovative methods to tackle some of the most important challenges identified. This work is part of the Innovative Medicines Initiative (IMI) EU Patient-cEntric clinicAl tRial pLatforms (EU-PEARL) project's work package 3 (WP3), whose objective is to deliver tools and guidance for EHR-based protocol feasibility assessment, clinical site selection, and patient pre-screening in platform trials, investing in the building of a data-driven clinical network framework that can execute these complex innovative designs for which feasibility assessments are critically important. METHODS ISO standards and relevant references informed a readiness survey, producing 354 criteria with corresponding questions selected and harmonised through a 7-round scoring process (0-1) in stakeholder meetings, with 85% of consensus being the threshold of acceptance for a criterium/question. ATLAS cohort definition and Cohort Diagnostics were mainly used to create the trial feasibility eligibility (I/E) criteria as executable interoperable queries. RESULTS The WP3/EU-PEARL group developed a readiness survey (eSurvey) for an efficient selection of clinical sites with suitable EHRs, consisting of yes-or-no questions, and a set-up of interoperable proxy queries using physicians' defined trial criteria. Both actions facilitate recruiting trial participants and alignment between study costs/timelines and data-driven recruitment potential. CONCLUSION The eSurvey will help create an archive of clinical sites with mature EHR systems suitable to participate in clinical trials/platform trials, and the interoperable proxy queries of trial eligibility criteria will help identify the number of potential participants. Ultimately, these tools will contribute to the production of EHR-based protocol design.
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Affiliation(s)
- Giulia Lombardo
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, London, UK.
| | - Camille Couvert
- Sanofi R&D, Global Development, Clinical Science & Operations, Chilly-Mazarin, France
| | - Melisa Kose
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, London, UK
| | - Amina Begum
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, London, UK
| | - Cecile Spiertz
- The Janssen Pharmaceutical Companies of Johnson & Johnson, Leiden, The Netherlands
| | - Courtney Worrell
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, London, UK
| | | | - Eva-Maria Didden
- Actelion, a Janssen company of Johnson & Johnson, Allschwil, Basel-Country, Switzerland
| | - Luca Sforzini
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, London, UK
| | - Marija Todorovic
- Johnson & Johnson Clinical Operations (JJCO), Johnson & Johnson company, Belgrade, Serbia
| | - Martine Lewi
- Global Commercial Strategy Organization, the Janssen Pharmaceutical Companies of Johnson & Johnson, Raritan, New Jersey, USA
| | - Mollie Brown
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, London, UK
| | - Morgan Vaterkowski
- Assistance Publique Hôpitaux de Paris, IT Department, Innovation and Data, Paris, France, and EPITA EPITA School of Engineering and Computer Science, Paris, France
| | - Nancy Gullet
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, London, UK
| | - Nare Amasi-Hartoonian
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, London, UK
| | - Nicolas Griffon
- Information Technology Department, AP-HP, Paris, France; LIMICS, Inserm U1142, Sorbonne Université, Paris, France
| | - Raluca Pais
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Institute of Cardiometabolism and Nutrition, INSERM UMRS_938, Paris, France
| | | | - Andreas Kremer
- Information Technology for Translational Medicine, ITTM S.A, House of BioHealth, Esch-sur-Alzette, Luxembourg
| | - Christophe Maes
- The European Institute for Innovation through health data, and Department Public Health and Primary Care, Unit of Medical Informatics and Statistics, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
| | - Eng Hooi Tan
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Maxim Moinat
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Carmine M Pariante
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, London, UK
| | - Dipak Kalra
- The European Institute for Innovation through Health Data and Visiting Professor, University of Ghent, Gent, Belgium
| | - Nadir Ammour
- Sanofi R&D, Global Development, Clinical Science & Operations, Chilly-Mazarin, France
| | - Susana Kalko
- Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.
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15
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Thompson S, Stickland MK, Wilund K, Gyenes GT, Bohm C. Exercise Rehabilitation for People With End-Stage Kidney Disease: Who Will Fill the Gaps? Can J Cardiol 2023; 39:S335-S345. [PMID: 37597748 DOI: 10.1016/j.cjca.2023.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023] Open
Abstract
Exercise rehabilitation is a well established therapy for reducing morbidity and mortality and improving quality of life and function across chronic conditions. People with dialysis-dependent kidney failure have a high burden of comorbidity and symptoms, commonly characterised as fatigue, dyspnoea, and the inability to complete daily activities. Despite more than 30 years of exercise research in people with kidney disease and its established benefit in other chronic diseases, exercise programs are rare in kidney care and are not incorporated into routine management at any stage. In this review, we describe the mechanisms contributing to exercise intolerance in those with end-stage kidney disease and outline the role of exercise rehabilitation in addressing the major challenges to kidney care: cardiovascular disease, symptom burden, and physical frailty. We also draw on existing models of exercise rehabilitation from other chronic conditions to inform the way forward and challenge the status quo of exercise rehabilitation in both practice and research.
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Affiliation(s)
- Stephanie Thompson
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | | | - Kenneth Wilund
- Department of Kinesiology and Community Health, University of Illinois, Urbana, Illinois, USA
| | - Gabor T Gyenes
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Clara Bohm
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Chronic Disease Innovation Centre, Winnipeg, Manitoba, Canada
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16
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Marrie RA, Sormani MP, Apap Mangion S, Bovis F, Cheung WY, Cutter GR, Feys P, Hill MD, Koch MW, McCreary M, Mowry EM, Park JJH, Piehl F, Salter A, Chataway J. Improving the efficiency of clinical trials in multiple sclerosis. Mult Scler 2023; 29:1136-1148. [PMID: 37555492 PMCID: PMC10413792 DOI: 10.1177/13524585231189671] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Phase 3 clinical trials for disease-modifying therapies in relapsing-remitting multiple sclerosis (RRMS) have utilized a limited number of conventional designs with a high degree of success. However, these designs limit the types of questions that can be addressed, and the time and cost required. Moreover, trials involving people with progressive multiple sclerosis (MS) have been less successful. OBJECTIVE The objective of this paper is to discuss complex innovative trial designs, intermediate and composite outcomes and to improve the efficiency of trial design in MS and broaden questions that can be addressed, particularly as applied to progressive MS. METHODS We held an international workshop with experts in clinical trial design. RESULTS Recommendations include increasing the use of complex innovative designs, developing biomarkers to enrich progressive MS trial populations, prioritize intermediate outcomes for further development that target therapeutic mechanisms of action other than peripherally mediated inflammation, investigate acceptability to people with MS of data linkage for studying long-term outcomes of clinical trials, use Bayesian designs to potentially reduce sample sizes required for pediatric trials, and provide sustained funding for platform trials and registries that can support pragmatic trials. CONCLUSION Novel trial designs and further development of intermediate outcomes may improve clinical trial efficiency in MS and address novel therapeutic questions.
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Affiliation(s)
- Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Maria Pia Sormani
- Department of Health Sciences, University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Sean Apap Mangion
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Francesca Bovis
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Winson Y Cheung
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter Feys
- REVAL Rehabilitation Research Center, REVAL, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium/Universitair MS Centrum, UMSC, Hasselt, Belgium
| | - Michael D Hill
- Departments of Clinical Neurosciences, Community Health Sciences, Medicine, and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marcus Werner Koch
- Departments of Clinical Neurosciences, Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Morgan McCreary
- Department of Neurology, Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ellen M Mowry
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jay JH Park
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Amber Salter
- Department of Neurology, Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX, USA
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK/Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
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17
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Li G, Hilgenfeld R, Whitley R, De Clercq E. Therapeutic strategies for COVID-19: progress and lessons learned. Nat Rev Drug Discov 2023; 22:449-475. [PMID: 37076602 PMCID: PMC10113999 DOI: 10.1038/s41573-023-00672-y] [Citation(s) in RCA: 183] [Impact Index Per Article: 183.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 04/21/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has stimulated tremendous efforts to develop therapeutic strategies that target severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and/or human proteins to control viral infection, encompassing hundreds of potential drugs and thousands of patients in clinical trials. So far, a few small-molecule antiviral drugs (nirmatrelvir-ritonavir, remdesivir and molnupiravir) and 11 monoclonal antibodies have been marketed for the treatment of COVID-19, mostly requiring administration within 10 days of symptom onset. In addition, hospitalized patients with severe or critical COVID-19 may benefit from treatment with previously approved immunomodulatory drugs, including glucocorticoids such as dexamethasone, cytokine antagonists such as tocilizumab and Janus kinase inhibitors such as baricitinib. Here, we summarize progress with COVID-19 drug discovery, based on accumulated findings since the pandemic began and a comprehensive list of clinical and preclinical inhibitors with anti-coronavirus activities. We also discuss the lessons learned from COVID-19 and other infectious diseases with regard to drug repurposing strategies, pan-coronavirus drug targets, in vitro assays and animal models, and platform trial design for the development of therapeutics to tackle COVID-19, long COVID and pathogenic coronaviruses in future outbreaks.
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Affiliation(s)
- Guangdi Li
- Xiangya School of Public Health, Central South University; Hunan Children's Hospital, Changsha, China.
| | - Rolf Hilgenfeld
- Institute of Molecular Medicine & German Center for Infection Research (DZIF), University of Lübeck, Lübeck, Germany.
| | - Richard Whitley
- Department of Paediatrics, Microbiology, Medicine and Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Erik De Clercq
- Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium.
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18
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Godoy LC, Farkouh ME, Zarychanski R, Lawler PR. The Impact of COVID-19 Research on the Development of Scalable Frameworks for Efficient Clinical Trials in Cardiovascular Medicine. Can J Cardiol 2023; 39:764-766. [PMID: 36931622 PMCID: PMC10015822 DOI: 10.1016/j.cjca.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023] Open
Affiliation(s)
- Lucas C Godoy
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Clinical Trials and Translation Unit, Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada; Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Michael E Farkouh
- Clinical Trials and Translation Unit, Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada; Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ryan Zarychanski
- University of Manitoba, Winnipeg, Manitoba, Canada; CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Patrick R Lawler
- Clinical Trials and Translation Unit, Peter Munk Cardiac Centre, University of Toronto, Toronto, Ontario, Canada; McGill University Health Centre, McGill University, Montréal, Québec, Canada.
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19
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Stengel D, Wünscher J, Dubs L, Ekkernkamp A, Renkawitz T. [Evidence-based versus expertise-based medicine in orthopedic and trauma surgery : There is nothing more practical than a good theory]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023:10.1007/s00132-023-04382-6. [PMID: 37222750 DOI: 10.1007/s00132-023-04382-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/25/2023]
Abstract
About a quarter of a century after the introduction of the concept and principles of evidence-based medicine (EbM), some healthcare providers are still adamant that these are incompatible with knowledge gained through experience. Across the surgical disciplines, it is often argued EbM underestimates or neglects the importance of intuition and surgical skills. To put it bluntly, these assumptions are wrong and often characterized by a misunderstanding of the methodology of EbM. Even the best controlled trial cannot be properly interpreted or implemented without clinical reasoning; furthermore, clinicians of all disciplines are obligated to provide care according to the current state of scientific knowledge. In an era of revolutionary biomedical developments, exponential increase of research but incremental innovations, they must become familiar with pragmatic tools to appraise the validity and relevance of clinical study results, and to decide whether there is a need to adapt current beliefs and practices based on the new information. We herein use the recent example of a new medical device for the surgical treatment of rotator cuff tears and subacromial impingement syndrome to illustrate how important it is to interpret data in the context of a precise, answerable question and to combine clinical expertise with methodological principles offered by EbM.
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Affiliation(s)
- Dirk Stengel
- BG Kliniken - Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Leipziger Platz 1, 10117, Berlin, Deutschland.
| | - Johannes Wünscher
- BG Kliniken - Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Leipziger Platz 1, 10117, Berlin, Deutschland
| | | | - Axel Ekkernkamp
- BG Kliniken - Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Leipziger Platz 1, 10117, Berlin, Deutschland
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Deutschland
- Klinik und Poliklinik für Unfall‑, Wiederherstellungschirurgie und Rehabilitative Medizin, Universitätsmedizin Greifswald, Greifswald, Deutschland
| | - Tobias Renkawitz
- Orthopädische Universitätsklinik Heidelberg, Ruprecht-Karls-Universität, Heidelberg, Deutschland
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20
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Pitre T, Cheng S, Cusano E, Khan N, Mikhail D, Leung G, Vernooij RWM, Yarnell CJ, Goligher E, Murthy S, Heath A, Mah J, Rochwerg B, Zeraatkar D. Methodology and design of platform trials: a meta-epidemiological study. J Clin Epidemiol 2023; 157:1-12. [PMID: 36893990 PMCID: PMC9991927 DOI: 10.1016/j.jclinepi.2023.02.010] [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: 09/20/2022] [Revised: 01/26/2023] [Accepted: 02/02/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVES Adaptive platforms allow for the evaluation of multiple interventions at a lower cost and have been growing in popularity, especially during the COVID-19 pandemic. The objective of this review is to summarize published platform trials, examine specific methodological design features among these studies, and hopefully aid readers in the evaluation and interpretation of platform trial results. METHODS We performed a systematic review of EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and clinicaltrials.gov from January 2015 to January 2022 for protocols or results of platform trials. Pairs of reviewers, working independently and in duplicate, collected data on trial characteristics of trial registrations, protocols, and publications of platform trials. We reported our results using total numbers and percentages, as well as medians with interquartile range (IQR) when appropriate. RESULTS We identified 15,277 unique search records and screened 14,403 titles and abstracts after duplicates were removed. We identified 98 unique randomized platform trials. Sixteen platform trials were sourced from a systematic review completed in 2019, which included platform trials reported prior to 2015. Most platform trials (n = 67, 68.3%) were registered between 2020 and 2022, coinciding with the COVID-19 pandemic. The included platform trials primarily recruited or plan to recruit patients from North America or Europe, with most subjects being recruited from the United States (n = 39, 39.7%) and the United Kingdom (n = 31, 31.6%). Bayesian methods were used in 28.6% (n = 28) of platform RCTs and frequentist methods in 66.3% (n = 65) of trials, including 1 (1%) that used methods from both paradigms. Out of the twenty-five trials with peer-reviewed publication of results, seven trials used Bayesian methods (28%), and of those, two (8%) used a predefined sample size calculation while the remainder used pre-specified probabilities of futility, harm, or benefit calculated at (pre-specified) intervals to inform decisions about stopping interventions or the entire trial. Seventeen (68%) peer-reviewed publications used frequentist methods. Out of the seven published Bayesian trials, seven (100%) reported thresholds for benefit. The threshold for benefit ranged from 80% to >99%. CONCLUSION We identified and summarized key components of platform trials, including the basics of the methodological and statistical considerations. Ultimately, improving standardization and reporting in platform trials require an understanding of the current landscape. We provide the most updated and rigorous review of platform trials to date.
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Affiliation(s)
- Tyler Pitre
- Division of Internal Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Samantha Cheng
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Ellen Cusano
- Division of Hematology and Hematologic Malignancies, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nadia Khan
- Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - David Mikhail
- Faculty of Health Sciences, McMaster University, Canada
| | - Gareth Leung
- Faculty of Medicine, University of Ottawa, Canada
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Christopher J Yarnell
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; University Health Network and Sinai Health System, Toronto, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Ewan Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Toronto General Hospital Research Institute, Toronto, Canada; Department of Physiology, University of Toronto, Toronto, Canada
| | - Srinivas Murthy
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anna Heath
- Child Health Evaluative Science, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Department of Statistical Science, University College London, London, UK
| | - Jasmine Mah
- Department of medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bram Rochwerg
- Department of Critical Care, Juravinski Hospital, Hamilton, Ontario, Canada; Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dena Zeraatkar
- Department of Anesthesiology, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Lawler PR, Derde LPG, van de Veerdonk FL, McVerry BJ, Huang DT, Berry LR, Lorenzi E, van Kimmenade R, Gommans F, Vaduganathan M, Leaf DE, Baron RM, Kim EY, Frankfurter C, Epelman S, Kwan Y, Grieve R, O'Neill S, Sadique Z, Puskarich M, Marshall JC, Higgins AM, Mouncey PR, Rowan KM, Al-Beidh F, Annane D, Arabi YM, Au C, Beane A, van Bentum-Puijk W, Bonten MJM, Bradbury CA, Brunkhorst FM, Burrell A, Buzgau A, Buxton M, Cecconi M, Cheng AC, Cove M, Detry MA, Estcourt LJ, Ezekowitz J, Fitzgerald M, Gattas D, Godoy LC, Goossens H, Haniffa R, Harrison DA, Hills T, Horvat CM, Ichihara N, Lamontagne F, Linstrum KM, McAuley DF, McGlothlin A, McGuinness SP, McQuilten Z, Murthy S, Nichol AD, Owen DRJ, Parke RL, Parker JC, Pollock KM, Reyes LF, Saito H, Santos MS, Saunders CT, Seymour CW, Shankar-Hari M, Singh V, Turgeon AF, Turner AM, Zarychanski R, Green C, Lewis RJ, Angus DC, Berry S, Gordon AC, McArthur CJ, Webb SA. Effect of Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Initiation on Organ Support-Free Days in Patients Hospitalized With COVID-19: A Randomized Clinical Trial. JAMA 2023; 329:1183-1196. [PMID: 37039790 PMCID: PMC10326520 DOI: 10.1001/jama.2023.4480] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/07/2023] [Indexed: 04/12/2023]
Abstract
IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non-critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support-free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support-free days among critically ill patients was 10 (-1 to 16) in the ACE inhibitor group (n = 231), 8 (-1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support-free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Patrick R Lawler
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
- McGill University Health Centre, Montreal, QC, Canada
| | | | | | | | | | | | | | | | - Frank Gommans
- Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - David E Leaf
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rebecca M Baron
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edy Y Kim
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Slava Epelman
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Yvonne Kwan
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Richard Grieve
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stephen O'Neill
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Zia Sadique
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Paul R Mouncey
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Djillali Annane
- Hospital Raymond Poincaré (Assistance Publique Hôpitaux de Paris), Garches, France
- Université Versailles SQY - Université Paris Saclay, Montigny-le-Bretonneux, France
| | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Carly Au
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Abi Beane
- University of Oxford, Oxford, England
| | | | | | | | | | | | | | - Meredith Buxton
- Global Coalition for Adaptive Research, Larkspur, California
| | | | | | - Matthew Cove
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | | | | | | | | | - David Gattas
- The George Institute for Global Health, Sydney, Australia
| | - Lucas C Godoy
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | | | - Rashan Haniffa
- University of Oxford, Bangkok, Thailand
- National Intensive Care Surveillance (NICST), Colombo, Sri Lanka
| | - David A Harrison
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Thomas Hills
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | | | | | - Daniel F McAuley
- Queen's University Belfast, Belfast, Northern Ireland
- Royal Victoria Hospital, Belfast, Northern Ireland
| | | | - Shay P McGuinness
- Monash University, Melbourne, Australia
- Auckland City Hospital, Auckland, New Zealand
| | | | | | - Alistair D Nichol
- Monash University, Melbourne, Australia
- University College Dublin, Dublin, Ireland
| | - David R J Owen
- Department of Brain Sciences, Imperial College London, London, United Kingdom
- UK Dementia Research Institute of Imperial College London, London, United Kingdom
| | - Rachael L Parke
- Auckland City Hospital, Auckland, New Zealand
- University of Auckland, Auckland, New Zealand
| | | | | | - Luis Felipe Reyes
- Universidad de La Sabana, Chia, Colombia
- Clinica Universidad de La Sabana, Chia, Colombia
| | - Hiroki Saito
- St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | | | | | | | | | | | - Alexis F Turgeon
- Université Laval, Québec City, Canada
- CHU de Québec-Université Laval Research Center, Québec City, Canada
| | - Anne M Turner
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | - Roger J Lewis
- Berry Consultants, Austin, Texas
- Harbor-UCLA Medical Center, Torrance, California
- Statistical Editor, JAMA
| | - Derek C Angus
- University of Pittsburgh, Pittsburgh, Pennsylvania
- Senior Editor, JAMA
| | | | - Anthony C Gordon
- Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, United Kingdom
| | | | - Steve A Webb
- Monash University, Melbourne, Australia
- St John of God Hospital, Subiaco, Australia
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Kho ME, Connolly B. From Strict Bedrest to Early Mobilization. Crit Care Clin 2023; 39:479-502. [DOI: 10.1016/j.ccc.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
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23
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Lawler PR. Models for Evidence Generation During the COVID-19 Pandemic: New Opportunities for Clinical Trials in Cardiovascular Medicine. Circulation 2023; 147:187-189. [PMID: 36649393 PMCID: PMC9842096 DOI: 10.1161/circulationaha.122.061231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Patrick R. Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital; and Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada
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24
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Affiliation(s)
- Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Paul E Sax
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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25
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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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26
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Auener SL, van Dulmen SA, van Kimmenade R, Westert GP, Jeurissen PPJ. Sustainable adoption of noninvasive telemonitoring for chronic heart failure: A qualitative study in the Netherlands. Digit Health 2023; 9:20552076231196998. [PMID: 37654710 PMCID: PMC10467184 DOI: 10.1177/20552076231196998] [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: 04/06/2023] [Accepted: 08/08/2023] [Indexed: 09/02/2023] Open
Abstract
Objective Noninvasive telemonitoring aims to improve healthcare for patients with chronic heart failure (HF) by reducing hospitalizations and improving patient experiences. Yet, sustainable adoption seems to be limited. Therefore, the goal of our study is to gain insight in the processes that support sustainable adoption of telemonitoring for patients with HF. Methods We conducted semi-structured interviews with 25 stakeholders that were involved with the adoption of telemonitoring, such as healthcare professionals, policymakers and healthcare insurers. We analyzed the interviews by using a combination of open-coding and the themes of the Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability framework. Results We found that telemonitoring projects have moved beyond initial pilot phases despite a high level of complexity on multiple topics. The patient selection, the business case, the evidence, the aims of telemonitoring, integration of telemonitoring in the care pathway, reimbursement, and future centralization were items that yielded different and sometimes contradictory opinions. Conclusions This study showed that the sustainable adoption of telemonitoring for HF is a complex endeavor. Different aims and perspectives play an important role in the patient selection, design, evaluations and envisioned futures of telemonitoring. High conviction among participants of the added value that telemonitoring may support further adoption of telemonitoring. Structural evaluations will be needed to guide cyclical improvement and adapt programs to employ telemonitoring in such a manner that it contributes to collectively supported aims.
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Affiliation(s)
- Stefan L. Auener
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Simone A. van Dulmen
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R van Kimmenade
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert P Westert
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Patrick PJ Jeurissen
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Blumer V, Vaduganathan M. A rationale for dedicated trials of combination therapy in heart failure. Eur Heart J Suppl 2022; 24:L49-L52. [PMID: 36545233 PMCID: PMC9762885 DOI: 10.1093/eurheartjsupp/suac116] [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: 12/23/2022]
Abstract
As heart failure (HF) enters a new era with high level of evidence supporting the use of individual drug therapies, we put forth a rationale for the need for dedicated investigation of the safety, tolerability, and practicalities associated with combination medical therapy. Being able to tailor therapies via combination approaches might offer a way to maximize benefits of available therapies and also facilitate compliance. The evidentiary bar to support multi-drug regimens should be raised in HF for a variety of reasons: (1) Pivotal HF randomized controlled trials (RCTs) to date have not traditionally tested and proven safety and efficacy of drug combinations, (2) HF patients have variable disease trajectories, (3) There is hesitancy by clinicians and patients to using multiple drugs and such trials may build confidence in their use, and (4) HF therapies have overlapping side effects. Similar to combination therapies being developed and tested in adjacent fields of medicine, HF care too would greatly benefit from dedicated investigations of combination treatment approaches. Personalizing precision medicine with combination therapies has the potential to further improve outcomes and facilitate optimal implementation of disease-modifying therapies in HF.
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Affiliation(s)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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28
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Tallarico RT, Neto AS, Legrand M. Pragmatic platform trials to improve the outcome of patients with acute kidney injury. Curr Opin Crit Care 2022; 28:622-629. [PMID: 36170383 PMCID: PMC9613599 DOI: 10.1097/mcc.0000000000000990] [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] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW There is an important need for improved diagnostic strategies and treatment among patients with acute kidney injury (AKI). Classical randomized clinical trials have generated relevant results in AKI but are associated with shortcomings, such as high costs and sometimes lack of generalizability. In this minireview, we discuss the value and limits of pragmatic trials and platform trials for AKI research. RECENT FINDINGS The implementation of pragmatic and platform trials in critical care settings has generated relevant clinical evidence impacting clinical practice. Pragmatic and platform designs have recently been applied to patients at risk of AKI and represent a crucial opportunity to advance our understanding of optimized treatment and strategies in patients at risk of AKI or presenting with AKI. Trials embedded in electronic health records can facilitate patient enrollment and data collection. Platform trials have allowed for a more efficient study design. Although both pragmatic and platform trials have several advantages, they also come with the challenges and shortcomings discussed in this review. SUMMARY Pragmatic and platform trials can provide clinical answers in 'real-life' settings, facilitate a significant sample size enrollment at a limited cost, and provide results that can have a faster implementation in clinical practice.
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Affiliation(s)
- Roberta T Tallarico
- Division of Critical Care Medicine, Department of Anesthesia & Perioperative Care, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Ary S Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University
- Department of Intensive Care, Austin Hospital
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Matthieu Legrand
- Division of Critical Care Medicine, Department of Anesthesia & Perioperative Care, University of California, San Francisco (UCSF), San Francisco, California, USA
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 255] [Impact Index Per Article: 127.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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Myles PS, Yeung J, Beattie WS, Ryan EG, Heritier S, McArthur CJ. Platform trials for anaesthesia and perioperative medicine: a narrative review. Br J Anaesth 2022; 130:677-686. [PMID: 36456249 DOI: 10.1016/j.bja.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 11/29/2022] Open
Abstract
Large randomised trials provide the most reliable evidence of effectiveness of new treatments in clinical practice. However, the time and resources required to complete such trials can be daunting. An overarching clinical trial platform focused on a single condition or type of surgery, aiming to compare several treatments, with an option to stop any or add in new treatment options, can provide greater efficiency. This has the potential to accelerate knowledge acquisition and identify effective, ineffective, or harmful treatments faster. The master protocol of the platform defines the study population(s) and standardised procedures. Ineffective or harmful treatments can be discarded or study drug dose modified during the life cycle of the trial. Other adaptive elements that can be modified include eligibility criteria, required sample size for any comparison(s), randomisation assignment ratio, and the addition of other promising treatment options. There are excellent opportunities for anaesthetists to establish platform trials in perioperative medicine. Platform trials are highly efficient, with the potential to provide quicker answers to important clinical questions that lead to improved patient care.
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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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Legrand M, Bagshaw SM, Koyner JL, Schulman IH, Mathis MR, Bernholz J, Coca S, Gallagher M, Gaudry S, Liu KD, Mehta RL, Pirracchio R, Ryan A, Steubl D, Stockbridge N, Erlandsson F, Turan A, Wilson FP, Zarbock A, Bokoch MP, Casey JD, Rossignol P, Harhay MO. Optimizing the Design and Analysis of Future AKI Trials. J Am Soc Nephrol 2022; 33:1459-1470. [PMID: 35831022 PMCID: PMC9342638 DOI: 10.1681/asn.2021121605] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
AKI is a complex clinical syndrome associated with an increased risk of morbidity and mortality, particularly in critically ill and perioperative patient populations. Most AKI clinical trials have been inconclusive, failing to detect clinically important treatment effects at predetermined statistical thresholds. Heterogeneity in the pathobiology, etiology, presentation, and clinical course of AKI remains a key challenge in successfully testing new approaches for AKI prevention and treatment. This article, derived from the "AKI" session of the "Kidney Disease Clinical Trialists" virtual workshop held in October 2021, reviews barriers to and strategies for improving the design and implementation of clinical trials in patients with, or at risk of, developing AKI. The novel approaches to trial design included in this review span adaptive trial designs that increase the knowledge gained from each trial participant; pragmatic trial designs that allow for the efficient enrollment of sufficiently large numbers of patients to detect small, but clinically significant, treatment effects; and platform trial designs that use one trial infrastructure to answer multiple clinical questions simultaneously. This review also covers novel approaches to clinical trial analysis, such as Bayesian analysis and assessing heterogeneity in the response to therapies among trial participants. We also propose a road map and actionable recommendations to facilitate the adoption of the reviewed approaches. We hope that the resulting road map will help guide future clinical trial planning, maximize learning from AKI trials, and reduce the risk of missing important signals of benefit (or harm) from trial interventions.
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Affiliation(s)
- Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California San Francisco, San Francisco, California
- French Clinical Research Infrastructure Network, Investigation Network Initiative Cardiovascular and Renal Trialists, Nancy, France
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Ivonne H Schulman
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Michael R Mathis
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Steven Coca
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Martin Gallagher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Stéphane Gaudry
- French Clinical Research Infrastructure Network, Investigation Network Initiative Cardiovascular and Renal Trialists, Nancy, France
- Département de Réanimation, Medical and surgical intensive care unit, Assistance Publique-Hôpitaux de Paris Hôpital Avicenne, Bobigny, France
- Common and Rare Kidney Diseases, Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMR-S 1155, Paris, France
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, California
| | - Ravindra L Mehta
- Department of Medicine, University of California San Diego, San Diego, California
| | - Romain Pirracchio
- Department of Anesthesia and Perioperative Medicine, University of California San Francisco, San Francisco, California
| | - Abigail Ryan
- Division of Chronic Care Management, Chronic Care Policy Group, Center for Medicare, Center for Medicare and Medicaid Services, Baltimore, Maryland
| | - Dominik Steubl
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Norman Stockbridge
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | - Alparslan Turan
- Department of Anesthesiology, Lerner College of Medicine of Case Western University, Cleveland, Ohio
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - F Perry Wilson
- Section of Nephrology and Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Michael P Bokoch
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California San Francisco, San Francisco, California
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Patrick Rossignol
- French Clinical Research Infrastructure Network, Investigation Network Initiative Cardiovascular and Renal Trialists, Nancy, France
- University of Lorraine, INSERM CIC 1433, Nancy, France
- Nancy CHRU, INSERM U1116, Nancy, French national institute of Health and Medical Research, unit 1116, Nancy, France
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Laboratory, PAIR (Palliative and Advanced Illness Research) Center, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Emerging Clinical Trial Designs May Accelerate Translation in Hematology: Lessons from COVID-19. Blood Adv 2022; 6:4710-4714. [PMID: 35764486 PMCID: PMC9242698 DOI: 10.1182/bloodadvances.2021005963] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/22/2022] [Indexed: 12/15/2022] Open
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Del Junco DJ, Neal MD, Shackelford SA, Spinella PC, Guyette FX, Sperry JL, Lewis RJ, Yadav K. An adaptive platform trial for evaluating treatments in patients with life-threatening hemorrhage from traumatic injuries: Planning and execution. Transfusion 2022; 62 Suppl 1:S242-S254. [PMID: 35748672 DOI: 10.1111/trf.16982] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022]
Affiliation(s)
| | - Matthew D Neal
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Philip C Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason L Sperry
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, 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.,Statistics and Software, Berry Consultants, LLC, Austin, Texas, 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
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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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