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Genc C, Tulgar S, Unal M, Genc AS, Kehribar L, Erdivanli B, Vermeylen K, Koksal E. The minimum effective concentration (MEC90) of bupivacaine for an ultrasound-guided suprainguinal fascia iliaca compartment block for analgesia in knee surgery: a dose-finding study. Korean J Anesthesiol 2024; 77:364-373. [PMID: 38480982 PMCID: PMC11150113 DOI: 10.4097/kja.23710] [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: 10/04/2023] [Revised: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND In recent years, the suprainguinal fascia iliaca compartment block (SFICB) has become more common in clinical practice. This assessor-blinded dose-finding study aimed to determine the minimum effective concentration (MEC90, MEC95) of bupivacaine for a single-injection SFICB in patients undergoing arthroscopic anterior cruciate ligament repair. METHODS This prospective study was conducted at a tertiary hospital (postoperative recovery room and ward). The SFICB was performed as a postsurgical intervention after spinal anesthesia. Seventy patients were allocated using the biased-coin design up-and-down sequential method. The ultrasound-guided SFICB was performed using different bupivacaine concentrations, and standard multimodal analgesia was administered to all patients. Block success was defined as the absence of pain or presence of only tactile sensation during the pinprick test conducted on the anterior and lateral regions of the mid-thigh six hours postoperatively. RESULTS According to isotonic regression and bootstrap CIs, the MEC90 value of bupivacaine for a successful SFICB was 0.123% (95% CI [0.098, 0.191]) and the MEC95 value was 0.188% (95% CI [0.113, 0.223]). CONCLUSIONS Our study showed that the MEC90 and MEC95 values for bupivacaine administered via an SFICB for analgesia were 0.123% and 0.188%, respectively. One advantage of using lower concentrations of bupivacaine is the associated reduction in quadriceps weakness.
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Affiliation(s)
- Caner Genc
- Department of Anesthesiology and Reanimation, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Serkan Tulgar
- Department of Anesthesiology and Reanimation, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Murat Unal
- Department of Anesthesiology and Reanimation, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Ahmet Serhat Genc
- Department of Orthopedics and Traumatology, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Lokman Kehribar
- Department of Orthopedics and Traumatology, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Basar Erdivanli
- Department of Anesthesiology and Reanimation, Recep Tayyip Erdogan University Faculty of Medicine, Rize, Turkey
| | - Kris Vermeylen
- Department of Anesthesia, AZ Turnhout, Turnhout, Belgium
| | - Ersin Koksal
- Department of Anesthesiology and Reanimation, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
- Department of Anesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
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Tan HS, Fuller ME, Barney EZ, Diomede OI, Landreth RA, Pham T, Rubright SM, Ernst L, Habib AS. The 90% effective dose of intrathecal hyperbaric bupivacaine for Cesarean delivery under combined spinal-epidural anesthesia in parturients with super obesity: an up-down sequential allocation study. Can J Anaesth 2024; 71:570-578. [PMID: 38438681 DOI: 10.1007/s12630-024-02705-5] [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: 07/25/2023] [Revised: 10/04/2023] [Accepted: 11/04/2023] [Indexed: 03/06/2024] Open
Abstract
PURPOSE To determine the 90% effective dose (ED90) of intrathecal hyperbaric bupivacaine for Cesarean delivery under combined spinal-epidural anesthesia (CSE) in parturients with super obesity (body mass index [BMI] ≥ 50 kg·m-2). METHODS We enrolled parturients with BMI ≥ 50 kg·m-2 with term, singleton vertex pregnancies undergoing elective Cesarean delivery under CSE. An independent statistician generated the 0.75% hyperbaric bupivacaine dosing regimen in increments of 0.75 mg using a biased-coin up-down sequential allocation technique. This was combined with 15 μg fentanyl, 150 μg morphine, and normal saline to a volume of 2.05 mL. The initial and maximum doses were 9.75 mg and 12 mg, respectively. Participants, clinical team, and outcome assessors were blinded to the dose. The primary outcome was block success, defined as T6 block to pinprick within ten minutes and no intraoperative analgesic supplementation within 90 min of spinal injection. We determined the ED90 using logistic regression. RESULTS We enrolled 45 parturients and included 42 in the analysis. All doses achieved a T6 level within ten minutes, and the primary outcome occurred in 0/1 (0%) of the 9.75-mg doses, 2/3 (67%) of the 10.5-mg doses, 21/27 (78%) of the 11.25-mg doses, and 11/11 (100%) of the 12-mg doses. The ED90 of hyperbaric bupivacaine was 11.56 mg (95% confidence interval, 11.16 to 11.99). Four parturients (9.5%) had sensory level higher than T2, but none was symptomatic or required general anesthesia. CONCLUSION The estimated ED90 of hyperbaric bupivacaine with fentanyl and morphine in parturients with super obesity undergoing Cesarean delivery under CSE was approximately 11.5 mg. STUDY REGISTRATION ClinicalTrials.gov (NCT03781388); first submitted 18 December 2018.
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Affiliation(s)
- Hon Sen Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore, Singapore
| | - Matthew E Fuller
- Department of Anesthesiology, Duke University Medical Center, Duke University, Durham, NC, USA
| | - Emily Z Barney
- Department of Anesthesiology, Duke University Medical Center, Duke University, Durham, NC, USA
| | - Olga I Diomede
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, OR, USA
| | - Riley A Landreth
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, USA
| | - Trung Pham
- Associated Anesthesiologists Inc., Tulsa, OK, USA
| | | | - Liliane Ernst
- Division of Women's Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Ashraf S Habib
- Division of Women's Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
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Mohta M, Kumari S, Malhotra RK, Tyagi A, Agarwal R. Calculation of effective dose of phenylephrine bolus for treatment of post-spinal hypotension in pre-eclamptic patients undergoing caesarean section - a non-randomised controlled trial. Int J Obstet Anesth 2023; 56:103929. [PMID: 37826881 DOI: 10.1016/j.ijoa.2023.103929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 08/10/2023] [Accepted: 09/03/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Patients with pre-eclampsia require smaller vasopressor doses compared with those with normotension for management of post-spinal hypotension during caesarean section. However, the literature has little evidence as to the phenylephrine dose required for patients with pre-eclampsia. METHODS Fifty patients, with either pre-eclampsia or normotension, and developing post-spinal hypotension during caesarean section under spinal anaesthesia, were studied. Women in both groups did not receive prophylactic vasopressors. The first patient in each group received phenylephrine 50 µg to treat the first episode of hypotension, defined as fall of systolic blood pressure ≥20% from baseline or an absolute value <100 mmHg. If hypotension was corrected within one minute it was considered a 'success'. The doses for the subsequent patients were determined by responses to all previous patients, according to a variation of Narayana's rule for the up-down sequential allocation method. RESULTS The 95% effective dose (ED95) and 50% effective dose (ED50) of phenylephrine was 41.7 µg (95% CI 33.8 to 49.6 µg) and 29.1 µg (95% CI 26.0 to 32.2 µg) respectively in the pre-eclampsia group, and 64.9 µg (95% CI 54.1 to 75.7 µg) and 47.3 µg (95% CI 39.7 to 54.9 µg) respectively in the normotensive group. The proportionate reduction in phenylephrine dose ranged from 33% (95% CI 18 to 44%) to 40% (95% CI 19 to 52%). CONCLUSION Patients with pre-eclampsia may need a 33% to 40% reduction in the first phenylephrine bolus dose, compared with patients with normotension, for the treatment of the first episode of post-spinal hypotension.
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Affiliation(s)
- M Mohta
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
| | - S Kumari
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - R K Malhotra
- Cancer Registry, Dr. BRAIRCH, All India Institute of Medical Sciences, Delhi, India
| | - A Tyagi
- Department of Anaesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
| | - R Agarwal
- Department of Obstetrics and Gynaecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
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Cao R, Li X, Yang J, Deng L, Cui Y. The minimum effective concentration (MEC90) of ropivacaine for ultrasound-guided quadratus lumborum block for analgesia after cesarean delivery: a dose finding study. BMC Anesthesiol 2022; 22:410. [PMID: 36581811 PMCID: PMC9798625 DOI: 10.1186/s12871-022-01954-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/21/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Quadratus lumborum block was recently proposed as an alternative technique for post-cesarean delivery analgesia. However, there is not a definite optimum concentration of local anesthetics. A biased coin design up-and-down method was used to explore the minimum effective concentration of ropivacaine in quadratus lumborum block for satisfactory analgesia after cesarean delivery. METHODS Fifty-six patients weighing 60-80 kg after cesarean section and with ages between 18 and 40 years were recruited. For the posterior quadratus lumborum block, a volume of 25 ml of the assigned concentration of ropivacaine was injected bilaterally. The concentration administered to each patient depended on the response to the previous dose. The first patient received 0.25%. If a successful block was observed, the next patient was randomized to receive the same ropivacaine concentration (with a probability of 0.89) or 0.025% less (with a probability of 0.11). After any block failure, the concentration was always increased by 0.025% for the next. The study ended when 45 successful blocks were obtained. We defined effective quadratus lumborum block as a resting visual analog score ≤ 3 and the absence of a need for rescue anesthetics. RESULTS The 90% minimum effective concentration of ropivacaine was 0.335% (95% CI 0.306 to 0.375%), and the 99% minimum effective concentration was 0.371% (95% CI 0.355 to 0.375%). The sufentanil consumption was 11 (11,13) and 24 (22,27) μg at 12 and 24 hours after quadratus lumborum block, respectively. CONCLUSIONS The optimum dosage of ropivacaine is a 25 ml volume of 0.335% for quadratus lumborum block after cesarean delivery. TRIAL REGISTRATION The study was registered in the Chinese Clinical Trial Registry (No. ChiCTR2000040415 ).
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Affiliation(s)
- Rong Cao
- grid.489962.80000 0004 7868 473XDepartment of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women’s and Children’s Central Hospital, Chengdu, 610091 China
| | - Xuehan Li
- grid.412901.f0000 0004 1770 1022Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Jing Yang
- grid.489962.80000 0004 7868 473XDepartment of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women’s and Children’s Central Hospital, Chengdu, 610091 China
| | - Lingmei Deng
- grid.489962.80000 0004 7868 473XDepartment of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women’s and Children’s Central Hospital, Chengdu, 610091 China
| | - Yu Cui
- grid.489962.80000 0004 7868 473XDepartment of Anesthesiology, The Affiliated Hospital, School of Medicine, UESTC Chengdu Women’s and Children’s Central Hospital, Chengdu, 610091 China
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Li C, Sun H, Cheng C, Tang L, Pan H. A software tool for both the maximum tolerated dose and the optimal biological dose finding trials in early phase designs. Contemp Clin Trials Commun 2022; 30:100990. [PMID: 36203850 PMCID: PMC9529556 DOI: 10.1016/j.conctc.2022.100990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/14/2022] [Accepted: 08/29/2022] [Indexed: 10/25/2022] Open
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Wang S, Sayour E, Lee JH. Evaluation of phase I clinical trial designs for combinational agents along with guidance based on simulation studies. J Appl Stat 2022. [DOI: 10.1080/02664763.2022.2105827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Shu Wang
- Division of Quantitative Sciences, UF Health, Gainesville, FL, USA
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Elias Sayour
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Ji-Hyun Lee
- Division of Quantitative Sciences, UF Health, Gainesville, FL, USA
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
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Abstract
SUMMARY For the task of estimating a target benchmark dose such as the ED50 (the dose that would be effective for half the population), an adaptive dose-finding design is more effective than the standard approach of treating equal numbers of patients at a set of equally spaced doses. Up-and-down is the most popular family of dose-finding designs and is in common use in anesthesiology. Despite its widespread use, many aspects of up-and-down are not well known, implementation is often misguided, and standard, up-to-date reference material about the design is very limited. This article provides an overview of up-and-down properties, recent methodologic developments, and practical recommendations, illustrated with the help of simulated examples. Additional reference material is offered in the Supplemental Digital Content.
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Hao PP, Tian T, Hu B, Liu WC, Chen YG, Jiang TY, Xue FS. Long-term high-risk drinking does not change effective doses of propofol for successful insertion of gastroscope in Chinese male patients. BMC Anesthesiol 2022; 22:183. [PMID: 35710328 PMCID: PMC9202194 DOI: 10.1186/s12871-022-01725-2] [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] [Received: 11/30/2021] [Accepted: 06/09/2022] [Indexed: 11/12/2022] Open
Abstract
Background Available literature indicates that long-term drinkers demand a higher dose of propofol for induction of anesthesia than non-drinkers. However, there is no study having assessed the influence of long-term high-risk drinking (LTHRD) on the effective doses of propofol for successful insertion of gastroscope with sedation. This study was designed to compare the effective doses of propofol for successful insertion of gastroscope between LTHRD and non-drinking (ND) Chinese male patients. Methods Thirty-one LTHRD patients and 29 ND male patients undergoing elective gastroscopy with propofol sedation were enrolled. The modified Dixon’s up-and-down method was applied to determine the calculated median effective dose (ED50) of propofol for successful insertion of gastroscope. Furthermore, the isotonic regression analysis was used to establish the dose–response curve of propofol and assess the effective doses of propofol where 50% (ED50) and 95% (ED95) of gastroscope insertions were successful. Results The calculated ED50 of propofol for successful insertion of gastroscope was 1.55 ± 0.10 mg/kg and 1.44 ± 0.11 mg/kg in the LTHRD and ND patients. The isotonic regression analysis further showed that ED50 and ED95 of propofol for successful insertion of gastroscope was 1.50 mg/kg (95%CI, 1.40–1.63) and 1.80 mg/kg (95%CI, 1.74–1.90) in the LTHRD patients, respectively; 1.40 mg/kg (95% CI, 1.27–1.57) and 1.60 mg/kg (95%CI, 1.56–1.65) in the ND patients. The ED50 of propofol for successful insertion of gastroscope was not significantly different between LTHRD and ND patients. Conclusions This study demonstrates that the difference in the estimated ED50 of propofol for successful insertion of gastroscope between LTHRD and ND Chinese male patients was not statistically significant. Trial registration The study was registered on November 28, 2020 (ChiCTR2000040382) in the Chinese Clinical Trial Registry. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01725-2.
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Affiliation(s)
- Pei-Pei Hao
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, NO. 95 Yong-An Road, Xi-Cheng District, Beijing, 100050, People's Republic of China
| | - Tian Tian
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, NO. 95 Yong-An Road, Xi-Cheng District, Beijing, 100050, People's Republic of China
| | - Bin Hu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, NO. 95 Yong-An Road, Xi-Cheng District, Beijing, 100050, People's Republic of China
| | - Wei-Chao Liu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, NO. 95 Yong-An Road, Xi-Cheng District, Beijing, 100050, People's Republic of China
| | - Ying-Gui Chen
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, NO. 95 Yong-An Road, Xi-Cheng District, Beijing, 100050, People's Republic of China
| | - Tian-Yu Jiang
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, NO. 95 Yong-An Road, Xi-Cheng District, Beijing, 100050, People's Republic of China
| | - Fu-Shan Xue
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, NO. 95 Yong-An Road, Xi-Cheng District, Beijing, 100050, People's Republic of China.
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Li X, Li J, Zhang P, Deng H, Yang M, He H, Wang R. The minimum effective concentration (MEC90) of ropivacaine for ultrasound-guided caudal block in anorectal surgery. A dose finding study. PLoS One 2021; 16:e0257283. [PMID: 34534232 PMCID: PMC8448308 DOI: 10.1371/journal.pone.0257283] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 07/13/2021] [Indexed: 02/05/2023] Open
Abstract
Background Caudal epidural block (CEB) provides reliable anesthesia for adults undergoing anorectal surgery. Despite the widely utilization, the minimum effective concentration for 90% patients (MEC90) of ropivacaine for CEB remains unknown. Objective To estimate MEC of ropivacaine for CEB in anorectal surgery. Design A prospective dose-finding study using biased coin design up-and-down sequential method. Setting Operating room and postoperative recovery area of Chengdu Shangjin Nanfu Hospital, from October 2019 to January 2020. Patients 50 males and 51 females scheduled for anorectal surgery. Interventions We conducted two independent biased coin design up-and down trials by genders. The concentration of ropivacaine administered to the first patient of male and female were 0.25% with fixed volume of 14ml for male and 12ml for female patients based on our previous study. In case of failure, the concentration was increased by 0.05% in the next subject. Otherwise, the next subject was randomized to a concentration 0.05% less with a probability of 0.11, or the same concentration with a probability of 0.89. Success was defined as complete sensory blockade of perineal area 15 min after the block evidenced by the presence of a lax anal sphincter and pain-free surgery. Main outcome measures The MEC of ropivacaine to achieve a successful CEB in 90%(MEC90) of the patients. Results The MEC90 of ropivacaine for CEB were estimated to be 0.35% (95% CI 0.29 to 0.4%) for male and 0.353% (95%CI 0.22 to 0.4%) for female. By extrapolation to MEC in 99% of subjects (MEC99) and pooled adjacent violators algorithm (PAVA) adjusted responses, it would be optimal to choose 0.4% ropivacaine with a volume of 14ml for male and 12ml for female. Conclusions A concentration of 0.35% ropivacaine with a volume of 14ml provided a successful CEB in 90% of the male patients, while 0.353% ropivacaine with a volume of 12ml provided a successful CEB in 90% of the female patients. A concentration of 0.4% and a volume of 14ml for male and 12 ml for female would be successful in 99% of the patients. Trial registration Chictr.org.cn identifier: No. ChiCTR 1900024315.
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Affiliation(s)
- Xuehan Li
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jun Li
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Pei Zhang
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Huifei Deng
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Mingan Yang
- Division of Biostatistics & Epidemiology, School of Public Health, San Diego State University, San Diego, CA, United States of America
| | - Hongbo He
- Benign Coloproctological Diseases Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Rurong Wang
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- * E-mail:
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Affiliation(s)
- Nancy Flournoy
- Department of Statistics University of Missouri Columbia MO USA
| | - José Moler
- Departamento de Estadística, Informática y Matemáticas Universidad Pública de Navarra, Campus Arrosadia s/n Pamplona 31006 Spain
| | - Fernando Plo
- Department of Statistical Methods Universidad de Zaragoza Pedro Cerbuna, 12 Zaragoza 50009 Spain
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Zhu H, Chen Y, Huang S, Sun X. Interaction of Analgesic Effects of Dezocine and Sufentanil for Relief of Postoperative Pain: A Pilot Study. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:4717-4724. [PMID: 33177808 PMCID: PMC7650029 DOI: 10.2147/dddt.s270478] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/19/2020] [Indexed: 12/12/2022]
Abstract
Purpose The combination of dezocine and sufentanil is often used for postoperative analgesia in China and other areas, but the interaction of both two drugs is still unclear. The purpose of this study was to evaluate the interaction of the analgesic effects of dezocine and sufentanil in the patients after gynecological laparoscopic surgery. Patients and Methods We conducted a prospective, randomized, double-blinded clinical trial. A total of 150 patients were divided into 5 groups (30 in each group) in the post-anesthesia care unit, namely, dezocine group (Group D), sufentanil group (Group S) and dezocine mixed sufentanil groups (Group DS1-3). In group D and S, the initial dose of dezocine or sufentanil was 5mg and 5μg intravenously, respectively. In Group DS1, the initial dose was dezocine 5mg × 3/4 and sufentanil 5μg × 1/4. In Group DS2, the initial dose was dezocine 5mg × 1/2 and sufentanil 5μg × 1/2. In Group DS3, the initial dose was dezocine 5mg × 1/4 and sufentanil 5μg × 3/4. Results The median effective dose (ED50) of dezocine and sufentanil alone was 3.92 (95% confidence interval (CI) 3.01~4.64) mg and 3.71 (95% CI 2.78~4.39) μg, respectively. The isobolographic analysis showed that the combination of dezocine and sufentanil at 1:3, 1:1 or 3:1 appeared in the additive line. Conclusion In conclusion, when simultaneously administered intravenously, combined dezocine and sufentanil produce an additive effect for relieving the acute nociception after gynecological laparoscopic surgery.
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Affiliation(s)
- He Zhu
- Department of Anesthesiology, Tianjin Central Hospital of Gynecology and Obstetrics, Tianjin 300199, People's Republic of China
| | - Yaobing Chen
- Department of Anesthesiology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200093, People's Republic of China
| | - Shaoqiang Huang
- Department of Anesthesiology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200093, People's Republic of China
| | - Xingfeng Sun
- Department of Anesthesiology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200093, People's Republic of China
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Zhou Y, Li R, Yan F, Lee JJ, Yuan Y. A comparative study of Bayesian optimal interval (BOIN) design with interval 3+3 (i3+3) design for phase I oncology dose-finding trials. Stat Biopharm Res 2020; 13:147-155. [PMID: 34249223 PMCID: PMC8261789 DOI: 10.1080/19466315.2020.1811147] [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: 02/11/2020] [Revised: 06/16/2020] [Accepted: 08/02/2020] [Indexed: 10/23/2022]
Abstract
Bayesian optimal interval (BOIN) design is a model-assisted phase I dose-finding design to find the maximum tolerated dose (MTD). The hallmark of the BOIN design is its concise decision rule - making the decision of dose escalation and de-escalation by simply comparing the observed dose-limiting toxicity (DLT) rate at the current dose with a pair of optimal dose escalation and de-escalation boundaries. The interval 3+3 (i3+3) design is a recently proposed algorithm-based dose-finding design based on a similar decision rule with some modifications. The similarity in the appearance of the two designs has caused confusions among practitioners. In this article, we demystify the i3+3 design by elucidating its links with the BOIN design and compare their similarities and differences, as well as pros and cons. We perform comprehensive simulation studies to compare the operating characteristics of the two designs. Our results show that, compared to the algorithm-based i3+3 design, which are characterized by ad hoc and often scientifically and logically incoherent decision rules, the mode-assisted BOIN design is not only simpler, but also statistically more rigorous with better operating characteristics, thus providing a better design choice for phase I oncology trials.
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Affiliation(s)
- Yanhong Zhou
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ruobing Li
- The Center for Drug Evaluation, Beijing, China
| | | | - J. Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Phase I Study of Ficlatuzumab and Cetuximab in Cetuximab-Resistant, Recurrent/Metastatic Head and Neck Cancer. Cancers (Basel) 2020; 12:cancers12061537. [PMID: 32545260 PMCID: PMC7352434 DOI: 10.3390/cancers12061537] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 12/18/2022] Open
Abstract
Cetuximab, an anti-EGFR monoclonal antibody (mAb), is approved for advanced head and neck squamous cell carcinoma (HNSCC) but benefits a minority. An established tumor-intrinsic resistance mechanism is cross-talk between the EGFR and hepatocyte growth factor (HGF)/cMet pathways. Dual pathway inhibition may overcome cetuximab resistance. This Phase I study evaluated the combination of cetuximab and ficlatuzumab, an anti-HGF mAb, in patients with recurrent/metastatic HNSCC. The primary objective was to establish the recommended Phase II dose (RP2D). Secondary objectives included overall response rate (ORR), progression-free survival (PFS), and overall survival (OS). Mechanistic tumor-intrinsic and immune biomarkers were explored. Thirteen patients enrolled with no dose-limiting toxicities observed at any dose tier. Three evaluable patients were treated at Tier 1 and nine at Tier 2, which was determined to be the RP2D (cetuximab 500 mg/m2 and ficlatuzumab 20 mg/kg every 2 weeks). Median PFS and OS were 5.4 (90% CI = 1.9–11.4) and 8.9 (90% CI = 2.7–15.2) months, respectively, with a confirmed ORR of 2 of 12 (17%; 90% CI = 6–40%). High circulating soluble cMet levels correlated with poor survival. An increase in peripheral T cells, particularly the CD8+ subset, was associated with treatment response whereas progression was associated with expansion of a distinct myeloid population. This well-tolerated combination demonstrated promising activity in cetuximab-resistant, advanced HNSCC.
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Keyboard design for phase I drug-combination trials. Contemp Clin Trials 2020; 92:105972. [DOI: 10.1016/j.cct.2020.105972] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 02/24/2020] [Accepted: 03/01/2020] [Indexed: 11/24/2022]
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15
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Mohta M, Dubey M, Malhotra R, Tyagi A. Comparison of the potency of phenylephrine and norepinephrine bolus doses used to treat post-spinal hypotension during elective caesarean section. Int J Obstet Anesth 2019; 38:25-31. [DOI: 10.1016/j.ijoa.2018.12.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/11/2018] [Accepted: 12/06/2018] [Indexed: 11/30/2022]
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16
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Liu L, Qian J, Shen B, Xiao F, Shen H. Intrathecal dexmedetomidine can decrease the 95% effective dose of bupivacaine in spinal anesthesia for cesarean section: A prospective, double-blinded, randomized study. Medicine (Baltimore) 2019; 98:e14666. [PMID: 30817591 PMCID: PMC6831281 DOI: 10.1097/md.0000000000014666] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Dexmedetomidine (Dex), as an adjuvant, has been reported to prolong the duration of spinal analgesia when adding to local anesthetic. We hypothesized that Dex could enhance the efficiency of intrathecal bupivacaine for spinal anesthesia in cesarean section. The aim of his study is to test our hypothesis that 5 μg Dex could enhance the efficiency of intrathecal bupivacaine and reduce the dose requirement of spinal bupivacaine for patients undergoing cesarean section. METHODS Ninety patients with ASA I or II, who underwent cesarean section, were randomized into 2 groups: group D (bupivacaine + 5 μg Dex) and group C (bupivacaine + the same volume of saline). The subsequent dose of spinal bupivacaine was determined by the improved up-down allocation method. The initial dose of bupivacaine in the 2 groups was 4 mg, and the subsequent dose for the following patient was depended on the probability of the current dose. ED95 of spinal bupivacaine was calculated using logistic regression model. RESULTS The ED95 and 95% confidence intervals (95% CI) of spinal hyperbaric bupivacaine in group D and group C were 7.4 mg (95% CI, 5.6-12.4 mg) and 11.0 mg (95% CI, 4.4-56.8 mg), respectively. The duration of sensory block was 120.5 ± 37.0 minutes in Dex group and 70.5 ± 34.5 minutes in Control group, respectively (P < .05). The duration of analgesia was 230.5 ± 40.5 minutes in Dex group and 145.1 ± 28.5 minutes in Control group, respectively (P < .001). The consumption of postoperative rescued sufentanil was significantly lower in Dex group than in the Control group (56.3 ± 9.4 vs 65.9 ± 10.7 μg). There was not significantly different in the patient satisfaction of analgesia, incidence of side effects, neonatal outcomes and neurological deficit between the 2 groups. CONCLUSION Intrathecal 5 μg Dex enhances the efficacy of spinal bupivacaine by 24% in patients undergoing cesarean section with spinal anesthesia. No additional side effect was observed by adding spinal Dex.
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Affiliation(s)
| | | | | | | | - Huaxiang Shen
- Department of Obstetrics, Jiaxing University Affiliated Women and Children Hospital, Jiaxing City, China
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17
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Xia F, Chang X, Zhang Y, Wang L, Xiao F. The effect of intrathecal dexmedetomidine on the dose requirement of hyperbaric bupivacaine in spinal anaesthesia for caesarean section: a prospective, double-blinded, randomized study. BMC Anesthesiol 2018; 18:74. [PMID: 29935528 PMCID: PMC6015661 DOI: 10.1186/s12871-018-0528-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 05/25/2018] [Indexed: 11/10/2022] Open
Abstract
Background Studies have shown that dexmedetomidine (Dex) can prolong the duration of analgesia when added to local anaesthetic as an adjuvant in a central or peripheral nerve block. We hypothesized that intrathecal Dex can reduce the ED95 of spinal hyperbaric bupivacaine. Therefore, we conducted this prospective, double-blinded, randomized study to verify our hypothesis. Methods Ninety patients were allocated into the Dexmedetomidine group (received bupivacaine + 5 mcg dexmedetomidine) and the Control group (received bupivacaine + the same volume of saline) using a double-blinded and randomized method. The first patient in each group received 5 mg of IT hyperbaric bupivacaine, and the next dose for the following patient was determined by the probability of successful anaesthesia of the previous neighbouring dose. An improved up-down sequence allocated method combined with probit analysis was used to determine the ED95 of intrathecal hyperbaric bupivacaine for the two groups. Results The ED95 and 95% confidence intervals (95% CI) of IT hyperbaric bupivacaine of the Dex group and Control group were 8.4 mg (95% CI, 6.5~ 13.8 mg) and 12.1 mg (95% CI, 8.3~ 312.8 mg), respectively. The duration of sensory block was longer in the Dex group than in the Control group (110.3 ± 35.3 vs 67.5 ± 26.2). The duration of analgesia was also longer in the Dex group than in the Control group (224.9 ± 45.4 vs 155.1 ± 31.6). The consumption of postoperative rescued sufentanil was significantly higher in the Control group than in the Dex group. Conclusion Intrathecal 5 mcg dexmedetomidine potentiated hyperbaric bupivacaine antinociception by 31% in spinal anaesthesia for patients undergoing caesarean section. Trial registration We registered this study in a Chinese Clinical Trial Registry (ChiCTR) centre on Nov 1st 2016 and received the registration number: ChiCTR-IPR-16009699.
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Affiliation(s)
- Feng Xia
- Department of Anaesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, Zhejiang, China
| | - Xiangyang Chang
- Department of Anaesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, Zhejiang, China
| | - Yinfa Zhang
- Department of Anaesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, Zhejiang, China
| | - Lizhong Wang
- Department of Anaesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, Zhejiang, China.
| | - Fei Xiao
- Department of Anaesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, Zhejiang, China.
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18
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Zhou H, Murray TA, Pan H, Yuan Y. Comparative review of novel model-assisted designs for phase I clinical trials. Stat Med 2018; 37:2208-2222. [DOI: 10.1002/sim.7674] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 03/03/2018] [Accepted: 03/05/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Heng Zhou
- Department of Biostatistics; The University of Texas MD Anderson Cancer Center; Houston TX USA
| | - Thomas A. Murray
- Department of Biostatistics; The University of Minnesota; Minneapolis MN USA
| | - Haitao Pan
- Department of Biostatistics; St. Jude Children's Research Hospital; Memphis TN USA
| | - Ying Yuan
- Department of Biostatistics; The University of Texas MD Anderson Cancer Center; Houston TX USA
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19
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Oron AP, Flournoy N. Centered Isotonic Regression: Point and Interval Estimation for Dose–Response Studies. Stat Biopharm Res 2017. [DOI: 10.1080/19466315.2017.1286256] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Assaf P. Oron
- Children's Core for Biomedical Statistics, Seattle Children's Research Institute, Seattle, WA
| | - Nancy Flournoy
- Department of Statistics, University of Missouri, Columbia, MO
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20
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Cunanan KM, Koopmeiners JS. Hierarchical models for sharing information across populations in phase I dose-escalation studies. Stat Methods Med Res 2017; 27:3447-3459. [DOI: 10.1177/0962280217703812] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The primary goal of a phase I clinical trial in oncology is to evaluate the safety of a novel treatment and identify the maximum tolerated dose, defined as the maximum dose with a toxicity rate below some pre-specified threshold. Researchers are often interested in evaluating the performance of a novel treatment in multiple patient populations, which may require multiple phase I trials if the treatment is to be used with background standard-of-care that varies by population. An alternate approach is to run parallel trials but combine the data through a hierarchical model that allows for a different maximum tolerated dose in each population but shares information across populations to achieve a more accurate estimate of the maximum tolerated dose. In this manuscript, we discuss hierarchical extensions of three commonly used models for the dose–toxicity relationship in phase I oncology trials. We then propose three dose-finding guidelines for phase I oncology trials using hierarchical modeling. The proposed guidelines allow us to fully realize the benefits of hierarchical modeling while achieving a similar toxicity profile to standard phase I designs. Finally, we evaluate the operating characteristics of a phase I clinical trial using the proposed hierarchical models and dose-finding guidelines by simulation. Our simulation results suggest that incorporating hierarchical modeling in phase I dose-escalation studies will increase the probability of correctly identifying the maximum tolerated dose and the number of patients treated at the maximum tolerated dose, while decreasing the rate of dose-limiting toxicities and number of patients treated above the maximum tolerated dose, in most cases.
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Affiliation(s)
- Kristen M Cunanan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph S Koopmeiners
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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21
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Tarhini AA, Rafique I, Floros T, Tran P, Gooding WE, Villaruz LC, Burns TF, Friedland DM, Petro DP, Farooqui M, Gomez-Garcia J, Gaither-Davis A, Dacic S, Argiris A, Socinski MA, Stabile LP, Siegfried JM. Phase 1/2 study of rilotumumab (AMG 102), a hepatocyte growth factor inhibitor, and erlotinib in patients with advanced non-small cell lung cancer. Cancer 2017; 123:2936-2944. [PMID: 28472537 DOI: 10.1002/cncr.30717] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 01/09/2017] [Accepted: 01/11/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Activation of the mesenchymal-epidermal transition factor (MET) tyrosine kinase and its ligand, hepatocyte growth factor (HGF), is implicated in resistance to epidermal growth factor receptor (EGFR) inhibitors. In this phase 1/2 trial, rilotumumab (an anti-HGF antibody) combined with erlotinib was evaluated in patients with metastatic, previously treated non-small cell lung cancer. METHODS In phase 1, a dose de-escalation design was adopted with rilotumumab starting at 15 mg/kg intravenously every 3 weeks and oral erlotinib 150 mg daily. In phase 2, the disease control rate (DCR) (according to Response Evaluation Criteria in Solid Tumors) of the combination was evaluated using a Simon 2-stage design. The biomarkers examined included 10 plasma-circulating molecules associated with the EGFR and MET pathways. RESULTS Without indications for de-escalation, the recommended phase 2 dose was dose level 0. Overall, 45 response-evaluable patients were enrolled (13 with squamous carcinoma, 32 with adenocarcinoma; 2 had confirmed EGFR mutations, 33 had confirmed wild-type [WT] EGFR, and 7 had KRAS mutations). The DCR for all patients was 60% (90% confidence interval [CI], 47.1%-71.3%). Median progression-free survival was 2.6 months (90% CI, 1.4-2.7 months), and median overall survival was 6.6 months (90% CI, 5.6-8.9 months). Among patients with WT EGFR, the DCR was 60.6% (90% CI, 46.3%-73.3%), median progression-free survival was 2.6 months (90% CI, 1.4-2.7 months), and median overall survival was 7.0 months (90% CI, 5.6-13.4 months). Elevated baseline levels of neuregulin 1 were associated with longer progression-free survival (hazard ratio, 0.41; 95% CI, 0.19-0.87), whereas elevated amphiregulin levels were associated with more rapid progression (hazard ratio, 2.14; 95% CI, 1.48-3.08). CONCLUSIONS Combined rilotumumab and erlotinib had an acceptable safety profile, and the DCR met the prespecified criteria for success. In the EGFR WT group, the DCR exceeded published reports for erlotinib alone. High circulating levels of neuregulin 1 may indicate sensitivity to this combination. Cancer 2017;123:2936-44. © 2017 American Cancer Society.
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Affiliation(s)
- Ahmad A Tarhini
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,University of Pittsburgh Medical Center and Cancer Institute, Pittsburgh, Pennsylvania
| | - Imran Rafique
- University of Pittsburgh Medical Center and Cancer Institute, Pittsburgh, Pennsylvania
| | - Theofanis Floros
- Department of Medicine, Athens Naval & Veterans Hospital, Athens, Greece
| | - Phu Tran
- University of Pittsburgh Medical Center and Cancer Institute, Pittsburgh, Pennsylvania
| | - William E Gooding
- University of Pittsburgh Medical Center and Cancer Institute, Pittsburgh, Pennsylvania
| | - Liza C Villaruz
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,University of Pittsburgh Medical Center and Cancer Institute, Pittsburgh, Pennsylvania
| | - Timothy F Burns
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,University of Pittsburgh Medical Center and Cancer Institute, Pittsburgh, Pennsylvania.,Department of Medicine, Athens Naval & Veterans Hospital, Athens, Greece
| | - David M Friedland
- University of Pittsburgh Medical Center and Cancer Institute, Pittsburgh, Pennsylvania
| | - Daniel P Petro
- University of Pittsburgh Medical Center and Cancer Institute, Pittsburgh, Pennsylvania
| | - Mariya Farooqui
- Department of Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Jose Gomez-Garcia
- Department of Pharmacology, University of Minnesota, Minneapolis, Minnesota
| | - Autumn Gaither-Davis
- University of Pittsburgh Medical Center and Cancer Institute, Pittsburgh, Pennsylvania.,Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sanja Dacic
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,University of Pittsburgh Medical Center and Cancer Institute, Pittsburgh, Pennsylvania
| | - Athanassios Argiris
- University of Pittsburgh Medical Center and Cancer Institute, Pittsburgh, Pennsylvania
| | - Mark A Socinski
- University of Pittsburgh Medical Center and Cancer Institute, Pittsburgh, Pennsylvania
| | - Laura P Stabile
- University of Pittsburgh Medical Center and Cancer Institute, Pittsburgh, Pennsylvania.,Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jill M Siegfried
- Department of Pharmacology, University of Minnesota, Minneapolis, Minnesota
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22
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Choi S, Wang JJ, Awad IT, McHardy P, Safa B, McCartney CJ. The minimal effective volume (MEAV 95) for interscalene brachial plexus block for surgical anesthesia under sedation: A prospective observational dose finding study. Can J Pain 2017; 1:8-13. [PMID: 35005337 PMCID: PMC8730609 DOI: 10.1080/24740527.2017.1304805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background: Interscalene brachial plexus (ISB) block is routinely used to provide anesthesia and analgesia for shoulder surgery. Traditional local anesthetic volumes for ISB result in near universal ipsilateral phrenic nerve paresis potentially including oxygenation and ventilation. Aims: The purpose of this study was to determine the lowest minimal effective anesthetic volume in 95% of patients (MEAV 95) of ropivacaine 0.75% for ISB that provides surgical anesthesia for arthroscopic shoulder surgery. Methods: Prospective observational cohort study in patients undergoing arthroscopic shoulder surgery under ISB (C6 level) with sedation. The dose finding protocol used the Narayana rule for up/down sequential allocation to estimate the MEAV 95 of ropivacaine 0.75%. Successful ISB was defined as complete absence of pinprick sensation in the C5 and C6 dermatomes 30 min postblock. Secondary outcomes assessed included ability to complete surgery with propofol sedation, change in slow vital capacity, room air oxygen saturation postblock, block duration, ISB complications, and numeric rating scale for pain immediately after surgery. Results: The study was stopped early due to futility. Among 225 participants approached, 54 consented to participate. The MEAV 95 for ultrasound-guided ISB of ropivacaine 0.75% for shoulder surgery was unable to be accurately estimated. Local anesthetic volumes between 5 and 20 ml did not influence any of the predefined secondary outcomes. Conclusions: The MEAV 95 (at 30 min) of ropivacaine 0.75% for ultrasound-guided ISB exceeds the local anesthetic volumes that consistently produces hemidiaphragmatic impairment. ISB cannot be guaranteed to provide surgical anesthesia at 30 min without the potential for concomitant phrenic nerve block.
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Affiliation(s)
- Stephen Choi
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jane J. Wang
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Imad T. Awad
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Paul McHardy
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ben Safa
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Colin J. McCartney
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ontario, Canada
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23
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Systematic comparison of the statistical operating characteristics of various Phase I oncology designs. Contemp Clin Trials Commun 2016; 5:34-48. [PMID: 29740620 PMCID: PMC5936704 DOI: 10.1016/j.conctc.2016.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 11/16/2016] [Accepted: 11/22/2016] [Indexed: 11/21/2022] Open
Abstract
Dose finding Phase I oncology designs can be broadly categorized as rule based, such as the 3 + 3 and the accelerated titration designs, or model based, such as the CRM and Eff-Tox designs. This paper systematically reviews and compares through simulations several statistical operating characteristics, including the accuracy of maximum tolerated dose (MTD) selection, the percentage of patients assigned to the MTD, over-dosing, under-dosing, and the trial dose-limiting toxicity (DLT) rate, of eleven rule-based and model-based Phase I oncology designs that target or pre-specify a DLT rate of ∼0.2, for three sets of true DLT probabilities. These DLT probabilities are generated at common dosages from specific linear, logistic, and log-logistic dose-toxicity curves. We find that all the designs examined select the MTD much more accurately when there is a clear separation between the true DLT rate at the MTD and the rates at the dose level immediately above and below it, such as for the DLT rates generated using the chosen logistic dose-toxicity curve; the separations in these true DLT rates depend, in turn, not only on the functional form of the dose-toxicity curve but also on the investigated dose levels and the parameter set-up. The model based mTPI, TEQR, BOIN, CRM and EWOC designs perform well and assign the greatest percentages of patients to the MTD, and also have a reasonably high probability of picking the true MTD across the three dose-toxicity curves examined. Among the rule-based designs studied, the 5 + 5 a design picks the MTD as accurately as the model based designs for the true DLT rates generated using the chosen log-logistic and linear dose-toxicity curves, but requires enrolling a higher number of patients than the other designs. We also find that it is critical to pick a design that is aligned with the true DLT rate of interest. Further, we note that Phase I trials are very small in general and hence may not provide accurate estimates of the MTD. Thus our work provides a map for planning Phase I oncology trials or developing new ones.
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24
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Yuan Y, Hess KR, Hilsenbeck SG, Gilbert MR. Bayesian Optimal Interval Design: A Simple and Well-Performing Design for Phase I Oncology Trials. Clin Cancer Res 2016; 22:4291-301. [PMID: 27407096 DOI: 10.1158/1078-0432.ccr-16-0592] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 06/02/2016] [Indexed: 11/16/2022]
Abstract
Despite more than two decades of publications that offer more innovative model-based designs, the classical 3 + 3 design remains the most dominant phase I trial design in practice. In this article, we introduce a new trial design, the Bayesian optimal interval (BOIN) design. The BOIN design is easy to implement in a way similar to the 3 + 3 design, but is more flexible for choosing the target toxicity rate and cohort size and yields a substantially better performance that is comparable with that of more complex model-based designs. The BOIN design contains the 3 + 3 design and the accelerated titration design as special cases, thus linking it to established phase I approaches. A numerical study shows that the BOIN design generally outperforms the 3 + 3 design and the modified toxicity probability interval (mTPI) design. The BOIN design is more likely than the 3 + 3 design to correctly select the MTD and allocate more patients to the MTD. Compared with the mTPI design, the BOIN design has a substantially lower risk of overdosing patients and generally a higher probability of correctly selecting the MTD. User-friendly software is freely available to facilitate the application of the BOIN design. Clin Cancer Res; 22(17); 4291-301. ©2016 AACR.
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Affiliation(s)
- Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Kenneth R Hess
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Mark R Gilbert
- Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
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Riviere MK, Yuan Y, Jourdan JH, Dubois F, Zohar S. Phase I/II dose-finding design for molecularly targeted agent: Plateau determination using adaptive randomization. Stat Methods Med Res 2016; 27:466-479. [DOI: 10.1177/0962280216631763] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Conventionally, phase I dose-finding trials aim to determine the maximum tolerated dose of a new drug under the assumption that both toxicity and efficacy monotonically increase with the dose. This paradigm, however, is not suitable for some molecularly targeted agents, such as monoclonal antibodies, for which efficacy often increases initially with the dose and then plateaus. For molecularly targeted agents, the goal is to find the optimal dose, defined as the lowest safe dose that achieves the highest efficacy. We develop a Bayesian phase I/II dose-finding design to find the optimal dose. We employ a logistic model with a plateau parameter to capture the increasing-then-plateau feature of the dose–efficacy relationship. We take the weighted likelihood approach to accommodate for the case where efficacy is possibly late-onset. Based on observed data, we continuously update the posterior estimates of toxicity and efficacy probabilities and adaptively assign patients to the optimal dose. The simulation studies show that the proposed design has good operating characteristics. This method is going to be applied in more than two phase I clinical trials as no other method is available for this specific setting. We also provide an R package dfmta that can be downloaded from CRAN website.
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Affiliation(s)
- Marie-Karelle Riviere
- INSERM, U1138, Team 22, Centre de Recherche des Cordeliers, Université Paris 5, Université Paris 6, France
- IRIS (Institut de Recherches Internationales Servier), Suresnes, France
| | - Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Frédéric Dubois
- IRIS (Institut de Recherches Internationales Servier), Suresnes, France
| | - Sarah Zohar
- INSERM, U1138, Team 22, Centre de Recherche des Cordeliers, Université Paris 5, Université Paris 6, France
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26
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Ivanova A, Wang Y, Foster MC. The rapid enrollment design for Phase I clinical trials. Stat Med 2016; 35:2516-24. [PMID: 26833922 DOI: 10.1002/sim.6886] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 01/01/2016] [Accepted: 01/05/2016] [Indexed: 11/10/2022]
Abstract
We propose a dose-finding design for Phase I oncology trials where each new patient is assigned to the dose most likely to be the target dose given observed data. The main model assumption is that the dose-toxicity curve is non-decreasing. This method is beneficial when it is desirable to assign a patient to a dose as soon as the patient is enrolled into a study. To prevent assignments to doses with limited toxicity information in fast accruing trials we propose a conservative rule that assigns temporary fractional toxicities to patients still in follow-up. We also recommend always using a safety rule in any fast accruing dose-finding trial. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599-7420, U.S.A
| | - Yunfei Wang
- Departments of Pediatrics and Biostatistics, George Washington University and Children's National Medical Center, Washington DC, 20010, U.S.A
| | - Matthew C Foster
- University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC, 27599, U.S.A
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27
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Sun Z, Braun TM. A two-dimensional biased coin design for dual-agent dose-finding trials. Clin Trials 2015; 12:596-607. [DOI: 10.1177/1740774515592404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Given the limited efficacy observed with single agents, there is growing interest in Phase I clinical trial designs that allow for identification of the maximum tolerated combination of two agents. Purpose: Existing parametric designs may suffer from over- or under-parameterization. Thus, we have designed a nonparametric approach that can be easily understood and implemented for combination trials. Methods: We propose a two-stage adaptive biased coin design that extends existing methods for single-agent trials to dual-agent dose-finding trials. The basic idea of our design is to divide the entire trial into two stages and apply the biased coin design, with modification, in each stage. Results: We compare the operating characteristics of our design to four competing parametric approaches via simulation in several numerical examples. Under all simulation scenarios we have examined, our method performs well in terms of identification of the maximum tolerated combination and allocation of patients relative to the performance of its competitors. Limitations: In our design, stopping rule criteria and the distribution of the total sample size among the two stages are context-dependent, and both need careful consideration before adopting our design in practice. Efficacy is not a part of the dose-assignment algorithm, nor used to define the maximum tolerated combination. Conclusion: Our design inherits the favorable statistical properties of the biased coin design, is competitive with existing designs, and promotes patient safety by limiting patient exposure to toxic combinations whenever possible.
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Affiliation(s)
- Zhichao Sun
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Thomas M Braun
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Wang Y, Ivanova A. Dose finding with continuous outcome in phase I oncology trials. Pharm Stat 2014; 14:102-7. [PMID: 25408518 DOI: 10.1002/pst.1662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 10/07/2014] [Accepted: 10/28/2014] [Indexed: 11/10/2022]
Abstract
The goal of a phase I clinical trial in oncology is to find a dose with acceptable dose-limiting toxicity rate. Often, when a cytostatic drug is investigated or when the maximum tolerated dose is defined using a toxicity score, the main endpoint in a phase I trial is continuous. We propose a new method to use in a dose-finding trial with continuous endpoints. The new method selects the right dose on par with other methods and provides more flexibility in assigning patients to doses in the course of the trial when the rate of accrual is fast relative to the follow-up time.
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Affiliation(s)
- Yunfei Wang
- Department of Biostatistics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599-7420, USA
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Riviere MK, Yuan Y, Dubois F, Zohar S. A Bayesian dose-finding design for drug combination clinical trials based on the logistic model. Pharm Stat 2014; 13:247-57. [PMID: 24828456 DOI: 10.1002/pst.1621] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 04/03/2014] [Accepted: 04/09/2014] [Indexed: 02/03/2023]
Abstract
In early phase dose-finding cancer studies, the objective is to determine the maximum tolerated dose, defined as the highest dose with an acceptable dose-limiting toxicity rate. Finding this dose for drug-combination trials is complicated because of drug-drug interactions, and many trial designs have been proposed to address this issue. These designs rely on complicated statistical models that typically are not familiar to clinicians, and are rarely used in practice. The aim of this paper is to propose a Bayesian dose-finding design for drug combination trials based on standard logistic regression. Under the proposed design, we continuously update the posterior estimates of the model parameters to make the decisions of dose assignment and early stopping. Simulation studies show that the proposed design is competitive and outperforms some existing designs. We also extend our design to handle delayed toxicities.
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Affiliation(s)
- Marie-Karelle Riviere
- INSERM, UMRS 1138, Equipe 22, Centre de Recherche des Cordeliers, Université Paris 5, Université Paris 6, Paris, France; IRIS (Institut de Recherches Internationales Servier), Suresnes, France
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Riviere MK, Dubois F, Zohar S. Competing designs for drug combination in phase I dose-finding clinical trials. Stat Med 2014; 34:1-12. [DOI: 10.1002/sim.6094] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 12/20/2013] [Accepted: 12/23/2013] [Indexed: 11/11/2022]
Affiliation(s)
- M.-K. Riviere
- INSERM, U1138, Equipe 22, Centre de Recherche des Cordeliers; Université Paris 5, Université Paris 6; Paris France
- IRIS (Institut de Recherches Internationales Servier); Suresnes France
| | - F. Dubois
- IRIS (Institut de Recherches Internationales Servier); Suresnes France
| | - S. Zohar
- INSERM, U1138, Equipe 22, Centre de Recherche des Cordeliers; Université Paris 5, Université Paris 6; Paris France
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Sverdlov O, Wong WK, Ryeznik Y. Adaptive clinical trial designs for phase I cancer studies. STATISTICS SURVEYS 2014. [DOI: 10.1214/14-ss106] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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33
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Liu S, Cai C, Ning J. Up-and-down designs for phase I clinical trials. Contemp Clin Trials 2013; 36:218-27. [PMID: 23856381 DOI: 10.1016/j.cct.2013.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 07/02/2013] [Accepted: 07/03/2013] [Indexed: 11/30/2022]
Abstract
Various up-and-down designs have been proposed to improve the operating characteristics of the traditional "3 + 3" design, but they have been of limited use in practice. A major impediment to the adoption of the improved up-and-down designs is a lack of general guidance and a comprehensive assessment of the operating characteristics of these designs under practical clinical settings. To fill this gap, we review six up-and-down designs: the "3 + 3" design, accelerated titration design, biased coin design, k-in-a-row design, group up-and-down design and cumulative group up-and-down design. We conduct comprehensive simulation studies to evaluate their operating characteristics under various practical settings, and compare their performance to a theoretical optimal bound of nonparametric designs. The results show that the cumulative group up-and-down design has the best overall performance in terms of selecting the maximum tolerated dose (MTD), assigning patients to the MTD and patient safety. Its performance is generally close to the upper bound of nonparametric designs, but improvement seems possible in some cases.
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Affiliation(s)
- Suyu Liu
- Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, USA.
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Sloan AE, Ahluwalia MS, Valerio-Pascua J, Manjila S, Torchia MG, Jones SE, Sunshine JL, Phillips M, Griswold MA, Clampitt M, Brewer C, Jochum J, McGraw MV, Diorio D, Ditz G, Barnett GH. Results of the NeuroBlate System first-in-humans Phase I clinical trial for recurrent glioblastoma: clinical article. J Neurosurg 2013; 118:1202-19. [PMID: 23560574 DOI: 10.3171/2013.1.jns1291] [Citation(s) in RCA: 156] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Laser interstitial thermal therapy has been used as an ablative treatment for glioma; however, its development was limited due to technical issues. The NeuroBlate System incorporates several technological advances to overcome these drawbacks. The authors report a Phase I, thermal dose-escalation trial assessing the safety and efficacy of NeuroBlate in recurrent glioblastoma multiforme (rGBM). METHODS Adults with suspected supratentorial rGBM of 15- to 40-mm dimension and a Karnofsky Performance Status score of ≥ 60 were eligible. After confirmatory biopsy, treatment was delivered using a rigid, gas-cooled, side-firing laser probe. Treatment was monitored using real-time MRI thermometry, and proprietary software providing predictive thermal damage feedback was used by the surgeon, along with control of probe rotation and depth, to tailor tissue coagulation. An external data safety monitoring board determined if toxicity at lower levels justified dose escalation. RESULTS Ten patients were treated at the Case Comprehensive Cancer Center (Cleveland Clinic and University Hospitals-Case Medical Center). Their average age was 55 years (range 34-69 years) and the median preoperative Karnofsky Performance Status score was 80 (range 70-90). The mean tumor volume was 6.8 ± 5 cm(3) (range 2.6-19 cm(3)), the percentage of tumor treated was 78% ± 12% (range 57%-90%), and the conformality index was 1.21 ± 0.33 (range 1.00-2.04). Treatment-related necrosis was evident on MRI studies at 24 and 48 hours. The median survival was 316 days (range 62-767 days). Three patients improved neurologically, 6 remained stable, and 1 worsened. Steroid-responsive treatment-related edema occurred in all patients but one. Three had Grade 3 adverse events at the highest dose. CONCLUSIONS NeuroBlate represents new technology for delivering laser interstitial thermal therapy, allowing controlled thermal ablation of deep hemispheric rGBM. CLINICAL TRIAL REGISTRATION NO.: NCT00747253 ( ClinicalTrials.gov ).
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Affiliation(s)
- Andrew E Sloan
- Brain Tumor & Neuro-Oncology Center and Department of Neurosurgery, University Hospitals Case Medical Center, Seidman Cancer Center, Cleveland, Ohio, USA
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Falcão L, Perez M, de Castro I, Yamashita A, Tardelli M, Amaral J. Minimum effective volume of 0.5% bupivacaine with epinephrine in ultrasound-guided interscalene brachial plexus block. Br J Anaesth 2013. [DOI: 10.1093/bja/aes419] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
Background Novel dose-finding designs for Phase I cancer clinical trials, using estimation to assign the best estimated Maximum Tolerated Dose (MTD) at each point in the experiment, most prominently via Bayesian techniques, have been widely discussed and promoted since 1990. Purpose To examine the small-sample behavior of these ‘Bayesian Phase I’ designs, and also of non-Bayesian designs sharing the same main ‘Long-Memory’ traits of using likelihood estimation and assigning the estimated MTD to the next patient. Methods Data from several recently published experiments are presented and discussed, and Long-Memory designs’ operating principles are explained. Simulation studies compare the small-sample behavior of Long-Memory designs with short-memory ‘Up-and-Down’ designs. Results In simulation, Long-Memory and Up-and-Down designs achieved similar success rates in finding the MTD. However, for all Long-Memory designs examined, the number n* of cohorts treated at the true MTD was highly variable between simulated experiments drawn from the same toxicity-threshold distribution. Further investigation using the same set of thresholds in permuted order indicates that this Long-Memory behavior is driven by sensitivity to the order in which participants enter the experiment. This sensitivity is related to Long-Memory designs’ ‘winner-takes-all’ dose-assignment rule, which grants the early cohorts a disproportionately large influence, and causes many experiments to settle early on a specific dose. Additionally for the Bayesian Long-Memory designs, the prior-predictive distribution over the dose levels has a substantial impact upon MTD-finding performance, long into the experiment. Limitations While the numerical evidence for Long-Memory designs’ order sensitivity is broad, and plausible explanations for it are provided, we do not present a theoretical proof of the phenomenon. Conclusions Method developers, analysts, and practitioners should be aware of Long-Memory designs’ order sensitivity and related phenomena. In particular, they should be informed that settling on a single dose does not guarantee that this dose is the MTD. Presently, Up-and-Down designs offer a simpler and more robust alternative for the sample sizes of 10–40 patients used in most Phase I trials. Future designs might benefit from combining the two approaches. We also suggest that the field’s paradigm change from dose-selection to dose-estimation.
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Affiliation(s)
- Assaf P Oron
- Core for Biomedical Statistics, Seattle Children’s Research Institute, Seattle, WA, USA
- Professional and Continuing Education, University of Washington, Seattle, WA, USA
| | - Peter D Hoff
- Departments of Statistics and Biostatistics, University of Washington, Seattle, WA, USA
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Das I, Mukhopadhyay S, Xu H. Individualized Dosing for Multiple Ordered Groups of Patients. JOURNAL OF STATISTICAL THEORY AND PRACTICE 2013. [DOI: 10.1080/15598608.2013.756348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Toledo P. What’s new in obstetric anesthesia: the 2011 Gerard W. Ostheimer lecture. Int J Obstet Anesth 2012; 21:68-74. [DOI: 10.1016/j.ijoa.2011.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 11/07/2011] [Indexed: 01/22/2023]
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Azriel D, Mandel M, Rinott Y. The treatment versus experimentation dilemma in dose finding studies. J Stat Plan Inference 2011. [DOI: 10.1016/j.jspi.2011.03.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Daimon T, Zohar S, O'Quigley J. Posterior maximization and averaging for Bayesian working model choice in the continual reassessment method. Stat Med 2011; 30:1563-73. [PMID: 21351288 DOI: 10.1002/sim.4054] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 07/15/2010] [Indexed: 11/08/2022]
Abstract
The continual reassessment method (CRM) is a method for estimating the maximum tolerated dose in a dose-finding study. Traditionally, use is made of a single working model or 'skeleton' idealizing an underlying true dose-toxicity relationship. This working model is chosen either by discussion with investigators or published data, before the beginning of the trial or simply on the basis of operating characteristics. To overcome the arbitrariness of the choice of such a single working model, Yin and Yuan (biJ. Am. Statist. Assoc. 2009; 104:954-968) propose a model averaging over a set of working models. Here, instead of averaging, we investigate some alternative Bayesian model criteria that maximize the posterior distribution. We propose three adaptive model-selecting CRMs using the Bayesian model selection criteria, in which we specify in advance a collection of candidate working models for the dose-toxicity relationship, especially initial guesses of toxicity probabilities, and adaptively select the only one working model among the candidates updated by using the original CRM for each working model, based on the posterior model probability, the posterior predictive loss or the deviance information criteria, during the course of the trial. These approaches were compared via a simulation study with the model averaging approach.
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Affiliation(s)
- T Daimon
- Division of Biostatistics, Hyogo College of Medicine, Hyogo, Japan.
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Wang M, Day R. Adaptive Bayesian design for phase I dose-finding trials using a joint model of response and toxicity. J Biopharm Stat 2010; 20:125-44. [PMID: 20077253 DOI: 10.1080/10543400903280613] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We present a new adaptive Bayesian method for dose-finding in phase I clinical trials based on both response and toxicity. Although clinical responses are usually rare in phase I cancer trials, molecularly targeted therapy may make clinical responses more likely. In addition, biological responses may be common. Thus responses may be frequent enough to help decide how aggressive a phase I escalation should be. The model assumes that response and toxicity events happen depending on respective dose thresholds for the individual, assuming that the thresholds jointly follow a bivariate log-normal distribution or a mixture. The design utilizes prior information about the population threshold distribution as well as accumulated data. The next dose is assigned to maximize a patient-oriented expected utility integrated over the current posterior distribution. The design is evaluated through simulation with population parameters equaling estimates from early Gleevec trials. This exercise provides evidence for the value of the use of the proposed design for future clinical trials.
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Affiliation(s)
- Meihua Wang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh 15261, Pennsylvania, USA.
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Up-down determination of the ED(90) of oxytocin infusions for the prevention of postpartum uterine atony in parturients undergoing Cesarean delivery. Can J Anaesth 2010; 57:578-82. [PMID: 20238255 DOI: 10.1007/s12630-010-9297-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Accepted: 03/03/2010] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Use of the lowest effective dose of oxytocin may reduce side effects. This study was designed to determine the effective dose (ED)(90) of oxytocin infusion for an elective Cesarean delivery (CD) to prevent uterine atony. METHODS The participants were ASA I and II, non-obese, non-labouring adult women undergoing an elective CD at term with a singleton gestation. The spinal anesthetic technique was standardized, and a blinded infusion of oxytocin was administered after delivery. The obstetrician rated the uterine contraction as either satisfactory or unsatisfactory. The initial dose of oxytocin infusion was 0.4 IU.min(-1), and the dose for the next subject was based on the response of the preceding subject as per a biased-coin design up-down sequential method. The ED(90) was calculated using Firth's penalized likelihood estimation. RESULTS Fifty subjects were screened, eight subjects were excluded, and two patients were withdrawn. Seven of the 40 subjects had uterine tone that was judged unsatisfactory by the obstetrician and required additional uterotonic medications. The ED(90), i.e., the dose at which 90% of women were judged to have satisfactory uterine tone, was 0.29 IU.min(-1) (95% confidence interval [CI] 0.15-0.43 IU.min(-1)). DISCUSSION In this study, we found the ED(90) of oxytocin required to prevent uterine atony and postpartum hemorrhage after an elective CD to be 0.29 IU.min(-1)-approximately 15 IU of oxytocin in 1 L of intravenous fluid administered over a one-hour period-(95% CI 0.15-0.43 IU.min(-1)). This oxytocin infusion dose is 30% less than the clinical infusions currently in use. It remains to be seen whether this dosing will be required for higher risk individuals or for labouring parturients undergoing non-elective CD. (Clinical Trial gov. NCT00785395).
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Ivanova A, Liu K, Snyder E, Snavely D. An adaptive design for identifying the dose with the best efficacy/tolerability profile with application to a crossover dose-finding study. Stat Med 2010; 28:2941-51. [PMID: 19731265 DOI: 10.1002/sim.3684] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Proof-of-concept in clinical trials has traditionally focused on the identification of a maximum tolerated dose with the assumption that the higher doses provide better efficacy. However, adverse events associated with a maximum tolerated dose may have a negative effect on efficacy. We present an efficient adaptive dose-finding strategy that concentrates patient assignments at and around the dose which has the best efficacy/tolerability profile based on a utility function. The strategy is applied within the setting of a crossover design. While the strategy may also be applied to parallel studies, a crossover design provides more power for a given sample size for comparisons between the optimal dose versus placebo and/or active control when it is reasonable to assume no carryover effects.
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Affiliation(s)
- Anastasia Ivanova
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7420, USA.
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Advances in Oncology Clinical Research: Statistical and Study Design Methodologies. Lung Cancer 2010. [DOI: 10.1007/978-1-60761-524-8_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Frawley G, Smith K, Ingelmo P. Relative potencies of bupivacaine, levobupivacaine, and ropivacaine for neonatal spinal anaesthesia. Br J Anaesth 2009; 103:731-8. [DOI: 10.1093/bja/aep259] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Zohar S, O'Quigley J. Sensitivity of dose-finding studies to observation errors. Contemp Clin Trials 2009; 30:523-30. [PMID: 19580886 DOI: 10.1016/j.cct.2009.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Revised: 06/12/2009] [Accepted: 06/18/2009] [Indexed: 11/18/2022]
Abstract
The purpose of Phase I designs is to estimate the MTD (maximum tolerated dose, in practice a dose with some given acceptable rate of toxicity) while, at the same time, minimizing the number of patients treated at doses too far removed from the MTD. Our purpose here is to investigate the sensitivity of conclusions from dose-finding designs to recording or observation errors. Certain toxicities may go undetected and, conversely, certain non-toxicities may be incorrectly recorded as dose-limiting toxicities. Recording inaccuracies would be expected to have an influence on final and within trial recommendations and, in this paper, we study in greater depth this question. We focus, in particular on three designs used currently; the standard '3+3' design, the grouped up-and-down design [M. Gezmu, N. Flournoy, Group up-and-down designs for dose finding. Journal of Statistical Planning and Inference 2006; 136 (6): 1749-1764.] and the continual reassessment method (CRM, [J. O'Quigley, M. Pepe, L. Fisher, Continual reassessment method: a practical design for phase 1 clinical trials in cancer. Biometrics 1990; 46 (1): 33-48.]). A non-toxicity incorrectly recorded as a toxicity (error of first kind) has a greater influence in general than the converse (error of second kind). These results are illustrated via figures which suggest that the standard '3+3' design in particular is sensitive to errors of the second kind. Such errors can have a very important impact on drug development in that, if carried through to the Phase 2 and Phase 3 studies, we can significantly increase the probability of failure to detect efficacy as a result of having delivered an inadequate dose.
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Affiliation(s)
- Sarah Zohar
- Inserm CIC 9504, Centre d'Investigations Cliniques, Hôpital Saint-Louis, 75010 Paris, France.
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Le Tourneau C, Lee JJ, Siu LL. Dose escalation methods in phase I cancer clinical trials. J Natl Cancer Inst 2009; 101:708-20. [PMID: 19436029 PMCID: PMC2684552 DOI: 10.1093/jnci/djp079] [Citation(s) in RCA: 575] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Revised: 02/17/2009] [Accepted: 03/04/2009] [Indexed: 12/28/2022] Open
Abstract
Phase I clinical trials are an essential step in the development of anticancer drugs. The main goal of these studies is to establish the recommended dose and/or schedule of new drugs or drug combinations for phase II trials. The guiding principle for dose escalation in phase I trials is to avoid exposing too many patients to subtherapeutic doses while preserving safety and maintaining rapid accrual. Here we review dose escalation methods for phase I trials, including the rule-based and model-based dose escalation methods that have been developed to evaluate new anticancer agents. Toxicity has traditionally been the primary endpoint for phase I trials involving cytotoxic agents. However, with the emergence of molecularly targeted anticancer agents, potential alternative endpoints to delineate optimal biological activity, such as plasma drug concentration and target inhibition in tumor or surrogate tissues, have been proposed along with new trial designs. We also describe specific methods for drug combinations as well as methods that use a time-to-event endpoint or both toxicity and efficacy as endpoints. Finally, we present the advantages and drawbacks of the various dose escalation methods and discuss specific applications of the methods in developmental oncotherapeutics.
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Affiliation(s)
- Christophe Le Tourneau
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
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