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Llitjos JF, Carrol ED, Osuchowski MF, Bonneville M, Scicluna BP, Payen D, Randolph AG, Witte S, Rodriguez-Manzano J, François B. Enhancing sepsis biomarker development: key considerations from public and private perspectives. Crit Care 2024; 28:238. [PMID: 39003476 PMCID: PMC11246589 DOI: 10.1186/s13054-024-05032-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 07/10/2024] [Indexed: 07/15/2024] Open
Abstract
Implementation of biomarkers in sepsis and septic shock in emergency situations, remains highly challenging. This viewpoint arose from a public-private 3-day workshop aiming to facilitate the transition of sepsis biomarkers into clinical practice. The authors consist of international academic researchers and clinician-scientists and industry experts who gathered (i) to identify current obstacles impeding biomarker research in sepsis, (ii) to outline the important milestones of the critical path of biomarker development and (iii) to discuss novel avenues in biomarker discovery and implementation. To define more appropriately the potential place of biomarkers in sepsis, a better understanding of sepsis pathophysiology is mandatory, in particular the sepsis patient's trajectory from the early inflammatory onset to the late persisting immunosuppression phase. This time-varying host response urges to develop time-resolved test to characterize persistence of immunological dysfunctions. Furthermore, age-related difference has to be considered between adult and paediatric septic patients. In this context, numerous barriers to biomarker adoption in practice, such as lack of consensus about diagnostic performances, the absence of strict recommendations for sepsis biomarker development, cost and resources implications, methodological validation challenges or limited awareness and education have been identified. Biomarker-guided interventions for sepsis to identify patients that would benefit more from therapy, such as sTREM-1-guided Nangibotide treatment or Adrenomedullin-guided Enibarcimab treatment, appear promising but require further evaluation. Artificial intelligence also has great potential in the sepsis biomarker discovery field through capability to analyse high volume complex data and identify complex multiparametric patient endotypes or trajectories. To conclude, biomarker development in sepsis requires (i) a comprehensive and multidisciplinary approach employing the most advanced analytical tools, (ii) the creation of a platform that collaboratively merges scientific and commercial needs and (iii) the support of an expedited regulatory approval process.
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Affiliation(s)
- Jean-Francois Llitjos
- Open Innovation and Partnerships (OI&P), bioMérieux S.A., Marcy l'Etoile, France.
- Anesthesiology and Critical Care Medicine, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France.
| | - Enitan D Carrol
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection Veterinary and Ecological Sciences, Liverpool, UK
- Department of Paediatric Infectious Diseases and Immunology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Marcin F Osuchowski
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, Vienna, Austria
| | - Marc Bonneville
- Medical and Scientific Affairs, Institut Mérieux, Lyon, France
| | - Brendon P Scicluna
- Department of Applied Biomedical Science, Faculty of Health Sciences, Mater Dei Hospital, University of Malta, Msida, Malta
- Centre for Molecular Medicine and Biobanking, University of Malta, Msida, Malta
| | - Didier Payen
- Paris 7 University Denis Diderot, Paris Sorbonne, Cité, France
| | - Adrienne G Randolph
- Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | | | | | - Bruno François
- Medical-Surgical Intensive Care Unit, Réanimation Polyvalente, Dupuytren University Hospital, CHU de Limoges, 2 Avenue Martin Luther King, 87042, Limoges Cedex, France.
- Inserm CIC 1435, Dupuytren University Hospital, Limoges, France.
- Inserm UMR 1092, Medicine Faculty, University of Limoges, Limoges, France.
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2
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Macdonald S, Fatovich D, Finn J, Litton E. Critical Illness Outside the Intensive Care Unit: Research Challenges in Emergency and Prehospital Settings. Crit Care Clin 2024; 40:609-622. [PMID: 38796231 DOI: 10.1016/j.ccc.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Patients with acute critical illness require prompt interventions, yet high-quality evidence supporting many investigations and treatments is lacking. Clinical research in this setting is challenging due to the need for immediate treatment and the inability of patients to provide informed consent. Attempts to obtain consent from surrogate decision-makers can be intrusive and lead to unacceptable delays to treatment. These problems may be overcome by pragmatic approaches to study design and the use of supervised waivers of consent, which is ethical and appropriate in situations where there is high risk of poor outcome and a paucity of proven effective treatment.
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Affiliation(s)
- Stephen Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Level 6, Rear 54 Murray Street, Perth, WA6000, Australia; Royal Perth Hospital, Victoria Square, Perth, WA6000, Australia; Medical School, University of Western Australia, 35 Stirling Highway, Perth, WA6009, Australia.
| | - Daniel Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Level 6, Rear 54 Murray Street, Perth, WA6000, Australia; Royal Perth Hospital, Victoria Square, Perth, WA6000, Australia; Medical School, University of Western Australia, 35 Stirling Highway, Perth, WA6009, Australia; East Metropolitan Health Service, 10 Murray Street, Perth, WA6000, Australia
| | - Judith Finn
- Prehospital, Resuscitation & Emergency Care Research Unit (PRECRU), Curtin University, Kent Street, Bentley, WA6102, Australia
| | - Edward Litton
- Medical School, University of Western Australia, 35 Stirling Highway, Perth, WA6009, Australia; Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA6150, Australia
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3
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Helms J, Póvoa P, Jaber S. Refining trial design in sepsis management: balancing realism with ideal outcomes. Intensive Care Med 2024; 50:1126-1128. [PMID: 38922427 DOI: 10.1007/s00134-024-07521-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 06/10/2024] [Indexed: 06/27/2024]
Affiliation(s)
- Julie Helms
- Faculté de Médecine, Service de Médecine Intensive-Réanimation, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France.
| | - Pedro Póvoa
- NOVA Medical School, NOVA University of Lisbon, Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
- Department of Intensive Care, Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier Cedex 5, France
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4
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Schenck EJ, Siempos II. Innovation in Enrichment: Is Persistence Enough? Crit Care Med 2024; 52:853-856. [PMID: 38619345 PMCID: PMC11027940 DOI: 10.1097/ccm.0000000000006239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Edward J Schenck
- NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, NY
- Division of Pulmonary & Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Ilias I Siempos
- Division of Pulmonary & Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, NY
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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5
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Grolleau F, Petit F, Gaudry S, Diard É, Quenot JP, Dreyfuss D, Tran VT, Porcher R. Personalizing renal replacement therapy initiation in the intensive care unit: a reinforcement learning-based strategy with external validation on the AKIKI randomized controlled trials. J Am Med Inform Assoc 2024; 31:1074-1083. [PMID: 38452293 PMCID: PMC11031229 DOI: 10.1093/jamia/ocae004] [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: 09/13/2023] [Revised: 12/13/2023] [Accepted: 01/16/2024] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE The timely initiation of renal replacement therapy (RRT) for acute kidney injury (AKI) requires sequential decision-making tailored to individuals' evolving characteristics. To learn and validate optimal strategies for RRT initiation, we used reinforcement learning on clinical data from routine care and randomized controlled trials. MATERIALS AND METHODS We used the MIMIC-III database for development and AKIKI trials for validation. Participants were adult ICU patients with severe AKI receiving mechanical ventilation or catecholamine infusion. We used a doubly robust estimator to learn when to start RRT after the occurrence of severe AKI for three days in a row. We developed a "crude strategy" maximizing the population-level hospital-free days at day 60 (HFD60) and a "stringent strategy" recommending RRT when there is significant evidence of benefit for an individual. For validation, we evaluated the causal effects of implementing our learned strategies versus following current best practices on HFD60. RESULTS We included 3748 patients in the development set and 1068 in the validation set. Through external validation, the crude and stringent strategies yielded an average difference of 13.7 [95% CI -5.3 to 35.7] and 14.9 [95% CI -3.2 to 39.2] HFD60, respectively, compared to current best practices. The stringent strategy led to initiating RRT within 3 days in 14% of patients versus 38% under best practices. DISCUSSION Implementing our strategies could improve the average number of days that ICU patients spend alive and outside the hospital while sparing RRT for many. CONCLUSION We developed and validated a practical and interpretable dynamic decision support system for RRT initiation in the ICU.
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Affiliation(s)
- François Grolleau
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
- Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, F-75004, France
| | - François Petit
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
| | - Stéphane Gaudry
- Service de Réanimation Médico-Chirurgicale, AP-HP, Hôpital Avicenne, Université Sorbonne Paris Nord, Bobigny, 93430, France
- Health Care Simulation Center, UFR SMBH, Sorbonne Paris Cité, Bobigny, 93017, France
- INSERM UMR S1155, Sorbonne Université, CORAKID, Hôpital Tenon, Paris, 75020, France
| | - Élise Diard
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
- Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, F-75004, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, 21000, France
- Lipness Team, INSERM Research Center, LNC-UMR1231 and LabEx LipSTIC, Dijon, 21000, France
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, 21000, France
| | - Didier Dreyfuss
- INSERM UMR S1155, Sorbonne Université, CORAKID, Hôpital Tenon, Paris, 75020, France
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Hôpital Louis Mourier, AP-HP, Université Paris-Cité, Paris, F-75018, France
| | - Viet-Thi Tran
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
- Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, F-75004, France
| | - Raphaël Porcher
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
- Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, F-75004, France
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Granholm A, Lange T, Harhay MO, Jensen AKG, Perner A, Møller MH, Kaas-Hansen BS. Effects of duration of follow-up and lag in data collection on the performance of adaptive clinical trials. Pharm Stat 2024; 23:138-150. [PMID: 37837271 PMCID: PMC10935606 DOI: 10.1002/pst.2342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/07/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023]
Abstract
Different combined outcome-data lags (follow-up durations plus data-collection lags) may affect the performance of adaptive clinical trial designs. We assessed the influence of different outcome-data lags (0-105 days) on the performance of various multi-stage, adaptive trial designs (2/4 arms, with/without a common control, fixed/response-adaptive randomisation) with undesirable binary outcomes according to different inclusion rates (3.33/6.67/10 patients/day) under scenarios with no, small, and large differences. Simulations were conducted under a Bayesian framework, with constant stopping thresholds for superiority/inferiority calibrated to keep type-1 error rates at approximately 5%. We assessed multiple performance metrics, including mean sample sizes, event counts/probabilities, probabilities of conclusiveness, root mean squared errors (RMSEs) of the estimated effect in the selected arms, and RMSEs between the analyses at the time of stopping and the final analyses including data from all randomised patients. Performance metrics generally deteriorated when the proportions of randomised patients with available data were smaller due to longer outcome-data lags or faster inclusion, that is, mean sample sizes, event counts/probabilities, and RMSEs were larger, while the probabilities of conclusiveness were lower. Performance metric impairments with outcome-data lags ≤45 days were relatively smaller compared to those occurring with ≥60 days of lag. For most metrics, the effects of different outcome-data lags and lower proportions of randomised patients with available data were larger than those of different design choices, for example, the use of fixed versus response-adaptive randomisation. Increased outcome-data lag substantially affected the performance of adaptive trial designs. Trialists should consider the effects of outcome-data lags when planning adaptive trials.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care 4131, Copenhagen University
Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health,
University of Copenhagen, Copenhagen, Denmark
| | - Michael O. Harhay
- Clinical Trials Methods and Outcomes Lab, PAIR (Palliative
and Advanced Illness Research) Center, Perelman School of Medicine, University of
Pennsylvania, Philadelphia, USA
- Department of Biostatistics, Epidemiology, and Informatics,
Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health,
University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University
Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University
Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Benjamin Skov Kaas-Hansen
- Department of Intensive Care 4131, Copenhagen University
Hospital – Rigshospitalet, Copenhagen, Denmark
- Section of Biostatistics, Department of Public Health,
University of Copenhagen, Copenhagen, Denmark
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7
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Haines RW, Prowle JR, Day A, Bear DE, Heyland DK, Puthucheary Z. Association between urea trajectory and protein dose in critically ill adults: a secondary exploratory analysis of the effort protein trial (RE-EFFORT). Crit Care 2024; 28:24. [PMID: 38229072 PMCID: PMC10792897 DOI: 10.1186/s13054-024-04799-1] [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: 11/01/2023] [Accepted: 01/04/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Delivering higher doses of protein to mechanically ventilated critically ill patients did not improve patient outcomes and may have caused harm. Longitudinal urea measurements could provide additional information about the treatment effect of higher protein doses. We hypothesised that higher urea values over time could explain the potential harmful treatment effects of higher doses of protein. METHODS We conducted a reanalysis of a randomised controlled trial of higher protein doses in critical illness (EFFORT Protein). We applied Bayesian joint models to estimate the strength of association of urea with 30-day survival and understand the treatment effect of higher protein doses. RESULTS Of the 1301 patients included in EFFORT Protein, 1277 were included in this analysis. There were 344 deaths at 30 days post-randomisation. By day 6, median urea was 2.1 mmol/L higher in the high protein group (95% CI 1.1-3.2), increasing to 3.0 mmol/L (95% CI 1.3-4.7) by day 12. A twofold rise in urea was associated with an increased risk of death at 30 days (hazard ratio 1.34, 95% credible interval 1.21-1.48), following adjustment of baseline characteristics including age, illness severity, renal replacement therapy, and presence of AKI. This association persisted over the duration of 30-day follow-up and in models adjusting for evolution of organ failure over time. CONCLUSIONS The increased risk of death in patients randomised to a higher protein dose in the EFFORT Protein trial was estimated to be mediated by increased urea cycle activity, of which serum urea is a biological signature. Serum urea should be taken into consideration when initiating and continuing protein delivery in critically ill patients. CLINICALTRIALS gov Identifier: NCT03160547 (2017-05-17).
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Affiliation(s)
- Ryan W Haines
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK.
- William Harvey Research Institute, Queen Mary University of London, London, UK.
| | - John R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
- Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK
| | - Andrew Day
- Clinical Evaluation Research Unit, Kingston Health Science Center, Kingston, ON, Canada
| | - Danielle E Bear
- Departments of Critical Care and Nutrition and Dietetics, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Zudin Puthucheary
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
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Kaas-Hansen BS, Granholm A, Sivapalan P, Anthon CT, Schjørring OL, Maagaard M, Kjaer MBN, Mølgaard J, Ellekjaer KL, Fagerberg SK, Lange T, Møller MH, Perner A. Real-world causal evidence for planned predictive enrichment in critical care trials: A scoping review. Acta Anaesthesiol Scand 2024; 68:16-25. [PMID: 37649412 DOI: 10.1111/aas.14321] [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: 07/04/2023] [Revised: 08/01/2023] [Accepted: 08/12/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Randomised clinical trials in critical care are prone to inconclusiveness due, in part, to undue optimism about effect sizes and suboptimal accounting for heterogeneous treatment effects. Although causal evidence from rich real-world critical care can help overcome these challenges by informing predictive enrichment, no overview exists. METHODS We conducted a scoping review, systematically searching 10 general and speciality journals for reports published on or after 1 January 2018, of randomised clinical trials enrolling adult critically ill patients. We collected trial metadata on 22 variables including recruitment period, intervention type and early stopping (including reasons) as well as data on the use of causal evidence from secondary data for planned predictive enrichment. RESULTS We screened 9020 records and included 316 unique RCTs with a total of 268,563 randomised participants. One hundred seventy-three (55%) trials tested drug interventions, 101 (32%) management strategies and 42 (13%) devices. The median duration of enrolment was 2.2 (IQR: 1.3-3.4) years, and 83% of trials randomised less than 1000 participants. Thirty-six trials (11%) were restricted to COVID-19 patients. Of the 55 (17%) trials that stopped early, 23 (42%) used predefined rules; futility, slow enrolment and safety concerns were the commonest stopping reasons. None of the included RCTs had used causal evidence from secondary data for planned predictive enrichment. CONCLUSION Work is needed to harness the rich multiverse of critical care data and establish its utility in critical care RCTs. Such work will likely need to leverage methodology from interventional and analytical epidemiology as well as data science.
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Affiliation(s)
- 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
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Praleene Sivapalan
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Carl Thomas Anthon
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | | | - Jesper Mølgaard
- Department of Anesthesiology, Centre for Cancer and Organ Dysfunction, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Karen Louise Ellekjaer
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Steen Kåre Fagerberg
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Theis Lange
- 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
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Zhang Z, Chen L, Liu X, Yang J, Huang J, Yang Q, Hu Q, Jin K, Celi LA, Hong Y. Exploring disease axes as an alternative to distinct clusters for characterizing sepsis heterogeneity. Intensive Care Med 2023; 49:1349-1359. [PMID: 37792053 DOI: 10.1007/s00134-023-07226-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/05/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE Various studies have analyzed sepsis subtypes, yet the reproducibility of such results remains unclear. This study aimed to determine the reproducibility of sepsis subtypes across multiple cohorts. METHODS The study examined 63,547 sepsis patients from six distinct cohorts who had similar sepsis-related characteristics (vital signs, lactate, sequential organ failure assessment score, bilirubin, serum, urine output, and Glasgow coma scale). Identical cluster analysis techniques were used, employing 27 clustering schemes, and normalized mutual information (NMI), a metric ranging from 0 to 1 with higher values indicating better concordance, was employed to quantify the clustering solutions' reproducibility. Principal component analysis (PCA) was utilized to obtain the disease axis, and its uniformity across cohorts was evaluated through patterns of feature loading and correlation. RESULTS The reproducibility of sepsis clustering subtypes across the various studies was modest (median NMI ranging from 0.08 to 0.54). The top-down transfer learning method (model trained on cohorts with greater severity was transferred to cohorts with lower severity score) had a higher NMI value than the bottom-up approach (median [Q1, Q3]: 0.64 [0.49, 0.78] vs. 0.23 [0.2, 0.31], p < 0.001). The reproducibility was greater when the transfer solution was performed within United States (US) cohorts. The PCA analysis revealed that the correlation pattern between variables was consistent across all cohorts, and the first two disease axes were the "shock axis" and "systemic inflammatory response syndrome (SIRS) axis." CONCLUSIONS Cluster analysis of sepsis patients across various cohorts showed modest reproducibility. Sepsis heterogeneity is better characterized through continuous disease axes that coexist to varying degrees within the same individual instead of mutually exclusive subtypes.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.
| | - Lin Chen
- Neurological Intensive Care Unit, Department of Neurosurgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Xiaoli Liu
- Center for Artificial Intelligence in Medicine, The General Hospital of PLA, Beijing, China
| | - Jie Yang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Jiajie Huang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Qiling Yang
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, No. 250 Changgang East RoadHaizhu District, Guangzhou, Guangdong, China
| | - Qichao Hu
- Key Laboratory of Digital Technology in Medical Diagnostics of Zhejiang Province, Dian Diagnostics Group Co., Ltd., Hangzhou, Zhejiang Province, China
| | - Ketao Jin
- Department of Colorectal Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, 321000, Zhejiang, China
| | - Leo Anthony Celi
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
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10
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Granholm A, Schjørring OL, Jensen AKG, Kaas-Hansen BS, Munch MW, Klitgaard TL, Crescioli E, Kjaer MBN, Strøm T, Lange T, Perner A, Rasmussen BS, Møller MH. Association between days alive without life support/out of hospital and health-related quality of life. Acta Anaesthesiol Scand 2023; 67:762-771. [PMID: 36915265 DOI: 10.1111/aas.14231] [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: 10/18/2022] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Trials in critically ill patients increasingly focus on days alive without life support (DAWOLS) or days alive out of hospital (DAOOH) and health-related quality of life (HRQoL). DAWOLS and DAOOH convey more information than mortality and are simpler and faster to collect than HRQoL. However, whether these outcomes are associated with HRQoL is uncertain. We thus aimed to assess the associations between DAWOLS and DAOOH and long-term HRQoL. METHODS Secondary analysis of the COVID STEROID 2 trial including adults with COVID-19 and severe hypoxaemia and the Handling Oxygenation Targets in the Intensive Care Unit (HOT-ICU) trial including adult intensive care unit patients with acute hypoxaemic respiratory failure. Associations between DAWOLS and DAOOH at day 28 and 90 and long-term HRQoL (after 6 or 12 months) using the EuroQol 5-dimension 5-level survey (EQ VAS and EQ-5D-5L index values) were assessed using flexible models and evaluated using measures of fit and prediction adequacy in both datasets (comprising internal performance and external validation), non-parametric correlation coefficients and graphical presentations. RESULTS We found no strong associations between DAWOLS or DAOOH and HRQoL in survivors at HRQoL-follow-up (615 and 1476 patients, respectively). There was substantial variability in outcomes, and predictions from the best fitted models were poor both internally and externally in the other trial dataset, which also showed inadequate calibration. Moderate associations were found when including non-survivors, although predictions remained uncertain and calibration inadequate. CONCLUSION DAWOLS and DAOOH were poorly associated with HRQoL in adult survivors of severe or critical illness included in the COVID STEROID 2 and HOT-ICU trials.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Olav Lilleholt Schjørring
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, 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
| | - Marie Warrer Munch
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Thomas Lass Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Elena Crescioli
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Maj-Brit Nørregaard Kjaer
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Thomas Strøm
- Department of Anaesthesia and Critical Care Medicine, Odense University Hospital, Odense, Denmark
- Department of Anaesthesia and Critical Care Medicine, Hospital Sønderjylland, University Hospital of Southern Denmark, Odense, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Bodil Steen Rasmussen
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
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11
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Ishaque S, Famularo ST, Saleem AF, Siddiqui NUR, Kazi Z, Parkar S, Hotwani A, Thomas NJ, Thompson JM, Lahni P, Varisco B, Yehya N. Biomarker-Based Risk Stratification in Pediatric Sepsis From a Low-Middle Income Country. Pediatr Crit Care Med 2023; 24:563-573. [PMID: 37092821 PMCID: PMC10317305 DOI: 10.1097/pcc.0000000000003244] [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] [Indexed: 04/25/2023]
Abstract
OBJECTIVES Most biomarker studies of sepsis originate from high-income countries, whereas mortality risk is higher in low- and middle-income countries. The second version of the Pediatric Sepsis Biomarker Risk Model (PERSEVERE-II) has been validated in multiple North American PICUs for prognosis. Given differences in epidemiology, we assessed the performance of PERSEVERE-II in septic children from Pakistan, a low-middle income country. Due to uncertainty regarding how well PERSEVERE-II would perform, we also assessed the utility of other select biomarkers reflecting endotheliopathy, coagulopathy, and lung injury. DESIGN Prospective cohort study. SETTING PICU in Aga Khan University Hospital in Karachi, Pakistan. PATIENTS Children (< 18 yr old) meeting pediatric modifications of adult Sepsis-3 criteria between November 2020 and February 2022 were eligible. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma was collected within 24 hours of admission and biomarkers quantified. The area under the receiver operating characteristic curve for PERSEVERE-II to discriminate 28-day mortality was determined. Additional biomarkers were compared between survivors and nonsurvivors and between subjects with and without acute respiratory distress syndrome. In 86 subjects (20 nonsurvivors, 23%), PERSEVERE-II discriminated mortality (area under the receiver operating characteristic curve, 0.83; 95% CI, 0.72-0.94) and stratified the cohort into low-, medium-, and high-risk of mortality. Biomarkers reflecting endotheliopathy (angiopoietin 2, intracellular adhesion molecule 1) increased across worsening risk strata. Angiopoietin 2, soluble thrombomodulin, and plasminogen activator inhibitor 1 were higher in nonsurvivors, and soluble receptor for advanced glycation end-products and surfactant protein D were higher in children meeting acute respiratory distress syndrome criteria. CONCLUSIONS PERSEVERE-II performs well in septic children from Aga Khan University Hospital, representing the first validation of PERSEVERE-II in a low-middle income country. Patients possessed a biomarker profile comparable to that of sepsis from high-income countries, suggesting that biomarker-based enrichment strategies may be effective in this setting.
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Affiliation(s)
- Sidra Ishaque
- Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi, Pakistan
| | - Stephen Thomas Famularo
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ali Faisal Saleem
- Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi, Pakistan
| | | | - Zaubina Kazi
- Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi, Pakistan
| | - Sadia Parkar
- Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi, Pakistan
| | - Aneeta Hotwani
- Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi, Pakistan
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State University College of Medicine, Hershey, PA
| | - Jill Marie Thompson
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, PA
| | - Patrick Lahni
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Brian Varisco
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- University of Cincinnati College of Medicine, Cincinnati, OH
| | - Nadir Yehya
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Critical Care, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, PA
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Yang P, Dickert NW, Haczku A, Spainhour C, Auld SC. Trend in Clinical Trial Participation During COVID-19: A Secondary Analysis of the I-SPY COVID Clinical Trial. Crit Care Explor 2023; 5:e0930. [PMID: 37346229 PMCID: PMC10281328 DOI: 10.1097/cce.0000000000000930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023] Open
Abstract
To analyze the temporal trend in enrollment rates in a COVID-19 platform trial during the first three waves of the pandemic in the United States. DESIGN Secondary analysis of data from the I-SPY COVID randomized controlled trial (RCT). SETTING Thirty-one hospitals throughout the United States. PATIENTS Patients who were approached, either directly or via a legally authorized representative, for consent and enrollment into the I-SPY COVID RCT. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 1,338 patients approached for the I-SPY COVID trial from July 30, 2020, to February 17, 2022, the number of patients who enrolled (n = 1,063) versus declined participation (n = 275) was used to calculate monthly enrollment rates. Overall, demographic and baseline clinical characteristics were similar between those who enrolled versus declined. Enrollment rates fluctuated over the course of the COVID-19 pandemic, but there were no significant trends over time (Mann-Kendall test, p = 0.21). Enrollment rates were also comparable between vaccinated and unvaccinated patients. In multivariable logistic regression analysis, age, sex, region of residence, COVID-19 severity of illness, and vaccination status were not significantly associated with the decision to decline consent. CONCLUSIONS In this secondary analysis of the I-SPY COVID clinical trial, there was no significant association between the enrollment rate and time period or vaccination status among all eligible patients approached for clinical trial participation. Additional studies are needed to better understand whether the COVID-19 pandemic has altered clinical trial participation and to develop strategies for encouraging participation in future COVID-19 and critical care clinical trials.
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Affiliation(s)
- Philip Yang
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University, Atlanta, GA
| | - Neal W Dickert
- Division of Cardiology, Emory University, Atlanta, GA
- Emory Health Services Research Center, Departments of Medicine & Surgery, Emory University, Atlanta, GA
| | - Angela Haczku
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California Davis, Sacramento, CA
| | - Christine Spainhour
- Emory Critical Care Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Sara C Auld
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University, Atlanta, GA
- Departments of Epidemiology and Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
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Arrigo M, Blet A, Morley-Smith A, Aissaoui N, Baran DA, Bayes-Genis A, Chioncel O, Desch S, Karakas M, Moller JE, Poess J, Price S, Zeymer U, Mebazaa A. Current and future trial design in refractory cardiogenic shock. Eur J Heart Fail 2023; 25:609-615. [PMID: 36987926 DOI: 10.1002/ejhf.2838] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/23/2023] [Accepted: 03/26/2023] [Indexed: 03/30/2023] Open
Affiliation(s)
- Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich Triemli, Zurich, Switzerland
| | - Alice Blet
- Department of Anesthesia and Intensive Care, Croix-Rousse Hospital, North Hospital Group, Hospices Civils de Lyon and CRCL, UMRS Inserm 1052/CNRS 5286, University Claude Bernard Lyon 1, Centre Léon Bérard, Lyon, France
| | - Andrew Morley-Smith
- Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nadia Aissaoui
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris, Hôpital Cochin, AP-HP and Université de Paris, After-ROSC Network, INSERM U970, Paris, France
| | - David A Baran
- Section of Heart Failure, Transplant and MCS, Cleveland Clinic Heart Vascular and Thoracic Institute, Weston, FL, USA
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Universitat Autonoma, Barcelona, Spain
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof. C.C. Iliescu", and University of Medicine Carol Davila, Bucharest, Romania
| | - Steffen Desch
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at the University of Leipzig, Leipzig, Germany
| | - Mahir Karakas
- Department of Intensive Care Medicine, University Medical Center, Hamburg Eppendorf, Hamburg, Germany
| | - Jacob Eifer Moller
- Department of Cardiology, Heart Center, Copenhagen University Hospital Rigshospitalet and Department of Cardiology, Odense University Hospital, Denmark
| | - Janine Poess
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at the University of Leipzig, Leipzig, Germany
| | - Susanna Price
- Royal Brompton & Harefield Hospitals, National Heart & Lung Institute, Imperial College, London, UK
| | - Uwe Zeymer
- Klinikum Ludwigshafen und Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care Medicine, AP-HP, St. Louis and Lariboisière University Hospitals and INSERM UMR-S 942, MASCOT, Université de Paris, Paris, France
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14
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Friedrich JO, Harhay MO, Angus DC, Burns KEA, Cook DJ, Fergusson DA, Finfer S, Hébert P, Rowan K, Rubenfeld G, Marshall JC. Mortality As a Measure of Treatment Effect in Clinical Trials Recruiting Critically Ill Patients. Crit Care Med 2023; 51:222-230. [PMID: 36661450 DOI: 10.1097/ccm.0000000000005721] [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: 01/21/2023]
Abstract
OBJECTIVES All-cause mortality is a common measure of treatment effect in ICU-based randomized clinical trials (RCTs). We sought to understand the performance characteristics of a mortality endpoint by evaluating its temporal course, responsiveness to differential treatment effects, and impact when used as an outcome measure in trials of acute illness. DATA SOURCES We searched OVID Medline for RCTs published from 1990 to 2018. STUDY SELECTION We reviewed RCTs that had randomized greater than or equal to 100 patients, were published in one of five high-impact general medical or eight critical care journals, and reported mortality at two or more distinct time points. We excluded trials recruiting pediatric or neonatal patients and cluster RCTs. DATA EXTRACTION Mortality by randomization group was recorded from the article or estimated from survival curves. Trial impact was assessed by inclusion of results in clinical practice guidelines. DATA SYNTHESIS From 2,592 potentially eligible trials, we included 343 RCTs (228,784 adult patients). While one third of all deaths by 180 days had occurred by day 7, the risk difference between study arms continued to increase until day 60 (p = 0.01) and possibly day 90 (p = 0.07) and remained stable thereafter. The number of deaths at ICU discharge approximated those at 28-30 days (95% [interquartile range [IQR], 86-106%]), and deaths at hospital discharge approximated those at 60 days (99% [IQR, 94-104%]). Only 13 of 43 interventions (30.2%) showing a mortality benefit have been adopted into widespread clinical practice. CONCLUSIONS Our findings provide a conceptual framework for choosing a time horizon and interpreting mortality outcome in trials of acute illness. Differential mortality effects persist for 60 to 90 days following recruitment. Location-based measures approximate time-based measures for trials conducted outside the United States. The documentation of a mortality reduction has had a modest impact on practice.
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Affiliation(s)
- Jan O Friedrich
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Derek C Angus
- CRISMA Centre, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Karen E A Burns
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | | | - Paul Hébert
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Kathy Rowan
- The Intensive Care National Audit and Resource Centre (ICNARC), London, United Kingdom
| | - Gordon Rubenfeld
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - John C Marshall
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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15
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De Jong A, Bignon A, Stephan F, Godet T, Constantin JM, Asehnoune K, Sylvestre A, Sautillet J, Blondonnet R, Ferrandière M, Seguin P, Lasocki S, Rollé A, Fayolle PM, Muller L, Pardo E, Terzi N, Ramin S, Jung B, Abback PS, Guerci P, Sarton B, Rozé H, Dupuis C, Cousson J, Faucher M, Lemiale V, Cholley B, Chanques G, Belafia F, Huguet H, Futier E, Azoulay E, Molinari N, Jaber S, BIGNON ANNE, STEPHAN FRANÇOIS, GODET THOMAS, CONSTANTIN JEANMICHEL, ASEHNOUNE KARIM, SYLVESTRE AUDE, SAUTILLET JULIETTE, BLONDONNET RAIKO, FERRANDIERE MARTINE, SEGUIN PHILIPPE, LASOCKI SIGISMOND, ROLLE AMELIE, FAYOLLE PIERREMARIE, MULLER LAURENT, PARDO EMMANUEL, TERZI NICOLAS, RAMIN SEVERIN, JUNG BORIS, ABBACK PAERSELIM, GUERCI PHILIPPE, SARTON BENJAMINE, ROZE HADRIEN, DUPUIS CLAIRE, COUSSON JOEL, FAUCHER MARION, LEMIALE VIRGINIE, CHOLLEY BERNARD, CHANQUES GERALD, BELAFIA FOUAD, HUGUET HELENA, FUTIER EMMANUEL, GNIADEK CLAUDINE, VONARB AURELIE, PRADES ALBERT, JAILLET CARINE, CAPDEVILA XAVIER, CHARBIT JONATHAN, GENTY THIBAUT, REZAIGUIA-DELCLAUX SAIDA, IMBERT AUDREY, PILORGE CATHERINE, CALYPSO ROMAN, BOUTEAU-DURAND ASTRID, CARLES MICHEL, MEHDAOUI HOSSEN, SOUWEINE BERTRAND, CALVET LAURE, JABAUDON MATTHIEU, RIEU BENJAMIN, CANDILLE CLARA, SIGAUD FLORIAN, RIU BEATRICE, PAPAZIAN LAURENT, VALERA SABINE, MOKART DJAMEL, CHOW CHINE LAURENT, BISBAL MAGALI, POULIQUEN CAMILLE, DE GUIBERT JEANMANUEL, TOURRET MAXIME, MALLET DAMIEN, LEONE MARC, ZIELESKIEWICZ LAURENT, COSSIC JEANNE, ASSEFI MONA, BARON ELODIE, QUEMENEUR CYRIL, MONSEL ANTOINE, BIAIS MATTHIEU, OUATTARA ALEXANDRE, BONNARDEL ELINE, MONZIOLS SIMON, MAHUL MARTIN, LEFRANT JEANYVES, ROGER CLAIRE, BARBAR SABER, LAMBIOTTE FABIEN, SAINT-LEGER PIEHR, PAUGAM CATHERINE, POTTECHER JULIEN, LUDES PIERREOLIVIER, DARRIVERE LUCIE, GARNIER MARC, KIPNIS ERIC, LEBUFFE GILLES, GAROT MATTHIAS, FALCONE JEREMY, CHOUSTERMAN BENJAMIN, COLLET MAGALI, GAYAT ETIENNE, DELLAMONICA JEAN, MFAM WILLYSERGE, OCHIN EVELINA, NEBLI MOHAMED, TILOUCHE NEJLA, MADEUX BENJAMIN, BOUGON DAVID, AARAB YASSIR, GARNIER FANNY, AZOULAY ELIE, MOLINARI NICOLAS, JABER SAMIR. Effect of non-invasive ventilation after extubation in critically ill patients with obesity in France: a multicentre, unblinded, pragmatic randomised clinical trial. THE LANCET. RESPIRATORY MEDICINE 2023:S2213-2600(22)00529-X. [PMID: 36693403 DOI: 10.1016/s2213-2600(22)00529-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Non-invasive ventilation (NIV) and oxygen therapy (high-flow nasal oxygen [HFNO] or standard oxygen) following extubation have never been compared in critically ill patients with obesity. We aimed to compare NIV (alternating with HFNO or standard oxygen) and oxygen therapy (HFNO or standard oxygen) following extubation of critically ill patients with obesity. METHODS In this multicentre, parallel group, pragmatic randomised controlled trial, conducted in 39 intensive care units in France, critically ill patients with obesity undergoing extubation were randomly assigned (1:1) to either the NIV group or the oxygen therapy group. Two randomisations were performed: first, randomisation to either NIV or oxygen therapy, and second, randomisation to either HFNO or standard oxygen (also 1:1), which was nested within the first randomisation. Blinding of the randomisation was not possible, but the statistician was masked to group assignment. The primary outcome was treatment failure within 3 days after extubation, a composite of reintubation for mechanical ventilation, switch to the other study treatment, or premature discontinuation of study treatment. The primary outcome was analysed by intention to treat. Effect of medical and surgical status was assessed. The reintubation within 3 days was analysed by intention to treat and after a post-hoc crossover analysis. This study is registered with ClinicalTrials.gov, number NCT04014920. FINDINGS From Oct 2, 2019, to July 17, 2021, of the 1650 screened patients, 981 were enrolled. Treatment failure occurred in 66 (13·5%) of 490 patients in the NIV group and in 130 (26·5%) of 491 patients in the oxygen-therapy group (relative risk 0·43; 95% CI 0·31-0·60, p<0·0001). Medical or surgical status did not modify the effect of NIV group on the treatment-failure rate. Reintubation within 3 days after extubation was similar in the non-invasive ventilation group and in the oxygen therapy group in the intention-to-treat analysis (48 (10%) of 490 patients and 59 (12%) of 491 patients, p=0·26) and lower in the NIV group than in the oxygen-therapy group in the post-hoc cross-over (51 (9%) of 560 patients and 56 (13%) of 421 patients, p=0·037) analysis. No severe adverse events were reported. INTERPRETATION Among critically ill adults with obesity undergoing extubation, the use of NIV was effective to reduce treatment-failure within 3 days. Our results are relevant to clinical practice, supporting the use of NIV after extubation of critically ill patients with obesity. However, most of the difference in the primary outcome was due to patients in the oxygen therapy group switching to NIV, and more evidence is needed to conclude that an NIV strategy leads to improved patient-centred outcomes. FUNDING French Ministry of Health.
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Affiliation(s)
- Audrey De Jong
- Department of Anaesthesia and Intensive Care unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier, CEDEX 5, France
| | - Anne Bignon
- CHU Lille, Réanimation Chirurgicale, F-59000, France
| | - François Stephan
- Surgical Intensive Care unit, Le Plessis Robinson Marie Lannelongue Hospital; Saclay University, school of Medicine, INSERM U999, France
| | - Thomas Godet
- CHU Clermont-Ferrand, Department of Peri-Operative Medicine, 63000 Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and critical care, Pitié-Salpêtrière Hospital, Paris, France
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, Hôtel Dieu, University Hospital of Nantes, Nantes, France
| | - Aude Sylvestre
- Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation, 13015 Marseille, France; Aix-Marseille Université, Faculté de médecine, Centre d'Études et de Recherches sur les Services de Santé et qualité de vie EA 3279, 13005 Marseille, France
| | | | - Raiko Blondonnet
- CHU Clermont-Ferrand, Department of Peri-Operative Medicine, 63000 Clermont-Ferrand, France
| | - Martine Ferrandière
- Département Anesthésie Réanimation, Université de Tours, CHU de Tours, Tours, France
| | - Philippe Seguin
- Département Anesthésie Réanimation, Université de Rennes, CHU de Rennes, Rennes, France
| | - Sigismond Lasocki
- Département Anesthésie Réanimation, Université d'Angers, CHU d'Angers, Angers, France
| | - Amélie Rollé
- Department of intensive care, Guadeloupe University Hospital, French Caribbean, France
| | - Pierre-Marie Fayolle
- Department of intensive care, Fort de France Hospital, Martinique, French Caribbean, France
| | - Laurent Muller
- Department of Intensive Care, Nîmes University Hospital, Nîmes, France
| | - Emmanuel Pardo
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care, Saint-Antoine Hospital, 75012 Paris, France
| | - Nicolas Terzi
- Department of Medical Intensive Care, CHU de Rennes, Rennes, France
| | - Séverin Ramin
- Anaesthesiology and Intensive Care, Anaesthesia and Critical Care Department A, Lapeyronie Teaching Hospital, Montpellier Cedex 5, France
| | - Boris Jung
- Département de Médecine Intensive-Réanimation, CHU de Montpellier, Université de Montpellier, Montpellier, France
| | - Paer-Selim Abback
- Département d'Anesthésie-Réanimation, Hôpital Beaujon, APHP, Paris, France
| | - Philippe Guerci
- Département d'Anesthésie-Réanimation, Hôpital de Nancy, Nancy, France
| | - Benjamine Sarton
- Critical Care Unit. University Teaching Hospital of Purpan, Place du Dr Baylac, F-31059, Toulouse Cedex 9, France
| | - Hadrien Rozé
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, F-33000 Bordeaux, France; Biology of Cardiovascular Diseases, Bordeaux University, INSERM, UMR 1034, F-33600 Pessac, France
| | - Claire Dupuis
- Service de médecine intensive et réanimation, CHU Gabriel-Montpied, Clermont-Ferrand, France
| | - Joel Cousson
- Pole Anesthésie Réanimation Hopital R Debré CHU de Reims, France
| | - Marion Faucher
- Département d'Anesthésie-Réanimation, Institut Paoli-Calmettes, Hôpital de Marseille, Marseille, France
| | - Virginie Lemiale
- Médecine Intensive et Réanimation, Groupe GRRROH, Hôpital Saint-Louis, Université de Paris, Paris, France
| | - Bernard Cholley
- Hôpital Européen Georges Pompidou, Université de Paris, Paris, France
| | - Gerald Chanques
- Department of Anaesthesia and Intensive Care unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier, CEDEX 5, France
| | - Fouad Belafia
- Department of Anaesthesia and Intensive Care unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier, CEDEX 5, France
| | - Helena Huguet
- IMAG, CNRS, Univ Montpellier, CHU Montpellier, Montpellier, France; Universite de Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Emmanuel Futier
- CHU Clermont-Ferrand, Department of Peri-Operative Medicine, 63000 Clermont-Ferrand, France
| | - Elie Azoulay
- Médecine Intensive et Réanimation, Groupe GRRROH, Hôpital Saint-Louis, Université de Paris, Paris, France
| | - Nicolas Molinari
- IMAG, CNRS, Univ Montpellier, CHU Montpellier, Montpellier, France; Universite de Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Samir Jaber
- Department of Anaesthesia and Intensive Care unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier, CEDEX 5, France.
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Patel B, Yver H, Woods-Hill CZ, Harhay MO, Yehya N. Elements of Statistical Power in Pediatric Critical Care Trials. Ann Am Thorac Soc 2023; 20:152-155. [PMID: 36044710 PMCID: PMC9819260 DOI: 10.1513/annalsats.202202-154rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Bhavesh Patel
- Children’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania
| | - Hugues Yver
- Children’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania
| | - Charlotte Z. Woods-Hill
- Children’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania
- University of PennsylvaniaPhiladelphia, Pennsylvania
| | | | - Nadir Yehya
- Children’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania
- University of PennsylvaniaPhiladelphia, Pennsylvania
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17
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Harhay MO, Blette BS, Granholm A, Moler FW, Zampieri FG, Goligher EC, Gardner MM, Topjian AA, Yehya N. A Bayesian Interpretation of a Pediatric Cardiac Arrest Trial (THAPCA-OH). NEJM EVIDENCE 2023; 2:EVIDoa2200196. [PMID: 38320098 DOI: 10.1056/evidoa2200196] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Pediatric out-of-hospital cardiac arrest results in high morbidity and mortality. Currently, there are no recommended therapies beyond supportive care. The THAPCA-OH (Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital) trial compared hypothermia (33.0°C) with normothermia (36.8°C) in 295 children. Good neurobehavioral outcome and survival at 1 year were higher in the hypothermia group (20 vs. 12% and 38 vs. 29%, respectively). These differences did not meet the planned statistical threshold of P75% for all informative prior integrations with the THAPCA-OH results, except those with the most pessimistic priors. CONCLUSIONS: There is a high probability that hypothermia provides a modest benefit in neurobehavioral outcome and survival at 1 year. (ClinicalTrials.gov number, NCT00878644.)
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Affiliation(s)
- Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Bryan S Blette
- Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Anders Granholm
- Department of Intensive Care 4131, Copenhagen University Hospital-Rigshospitalet, Copenhagen
| | - Frank W Moler
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Fernando G Zampieri
- Academic Research Organization, Hospital Albert Einstein, São Paulo
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, AB, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto
- Department of Medicine, Division of Respirology, University Health Network, Toronto
- Toronto General Hospital Research Institute, Toronto
| | - Monique M Gardner
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia
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18
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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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19
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Leligdowicz A, Harhay MO, Calfee CS. Immune Modulation in Sepsis, ARDS, and Covid-19 - The Road Traveled and the Road Ahead. NEJM EVIDENCE 2022; 1:EVIDra2200118. [PMID: 38319856 DOI: 10.1056/evidra2200118] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Immune Modulation in Sepsis, ARDS, and Covid-19Leligdowicz et al. consider the history and future of immunomodulating therapies in sepsis and ARDS, including ARDS due to Covid-19, and remark on the larger challenge of clinical research on therapies for syndromes with profound clinical and biologic heterogeneity.
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Affiliation(s)
- Aleksandra Leligdowicz
- Department of Medicine, Division of Critical Care Medicine, Western University, London, ON, Canada
- Robarts Research Institute, Western University, London, ON, Canada
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Carolyn S Calfee
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco
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20
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Moskowitz A, Shotwell MS, Gibbs KW, Harkins M, Rosenberg Y, Troendle J, Merck LH, Files DC, de Wit M, Hudock K, Thompson BT, Gong MN, Ginde AA, Douin DJ, Brown SM, Rubin E, Joly MM, Wang L, Lindsell CJ, Bernard GR, Semler MW, Collins SP, Self WH. Oxygen-Free Days as an Outcome Measure in Clinical Trials of Therapies for COVID-19 and Other Causes of New-Onset Hypoxemia. Chest 2022; 162:804-814. [PMID: 35504307 PMCID: PMC9055785 DOI: 10.1016/j.chest.2022.04.145] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/09/2022] [Accepted: 04/22/2022] [Indexed: 11/21/2022] Open
Abstract
Mortality historically has been the primary outcome of choice for acute and critical care clinical trials. However, undue reliance on mortality can limit the scope of trials that can be performed. Large sample sizes are usually needed for trials powered for a mortality outcome, and focusing solely on mortality fails to recognize the importance that reducing morbidity can have on patients' lives. The COVID-19 pandemic has highlighted the need for rapid, efficient trials to rigorously evaluate new therapies for hospitalized patients with acute lung injury. Oxygen-free days (OFDs) is a novel outcome for clinical trials that is a composite of mortality and duration of new supplemental oxygen use. It is designed to characterize recovery from acute lung injury in populations with a high prevalence of new hypoxemia and supplemental oxygen use. In these populations, OFDs captures two patient-centered consequences of acute lung injury: mortality and hypoxemic lung dysfunction. Power to detect differences in OFDs typically is greater than that for other clinical trial outcomes, such as mortality and ventilator-free days. OFDs is the primary outcome for the Fourth Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV-4) Host Tissue platform, which evaluates novel therapies targeting the host response to COVID-19 among adults hospitalized with COVID-19 and new hypoxemia. This article outlines the rationale for use of OFDs as an outcome for clinical trials, proposes a standardized method for defining and analyzing OFDs, and provides a framework for sample size calculations using the OFD outcome.
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Affiliation(s)
- Ari Moskowitz
- Department of Medicine, Montefiore Medical Center, The Bronx, NY
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Kevin W Gibbs
- Department of Medicine, Wake Forest University, Winston-Salem, NC
| | - Michelle Harkins
- Department of Medicine, University of New Mexico, Albuquerque, NM
| | | | | | - Lisa H Merck
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA
| | - D Clark Files
- Department of Medicine, Wake Forest University, Winston-Salem, NC
| | - Marjolein de Wit
- Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Kristin Hudock
- Department of Medicine, University of Cincinnati, Cincinnati, OH
| | | | - Michelle N Gong
- Department of Medicine, Montefiore Medical Center, The Bronx, NY
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
| | - Samuel M Brown
- Department of Medicine, Intermountain Medical Center, Murray, UT; Office of Research, Intermountain Medical Center, Murray, UT
| | | | - Meghan Morrison Joly
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Gordon R Bernard
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew W Semler
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Sean P Collins
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN
| | - Wesley H Self
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN.
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21
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Wick KD, Aggarwal NR, Curley MAQ, Fowler AA, Jaber S, Kostrubiec M, Lassau N, Laterre PF, Lebreton G, Levitt JE, Mebazaa A, Rubin E, Sinha P, Ware LB, Matthay MA. Opportunities for improved clinical trial designs in acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2022; 10:916-924. [PMID: 36057279 DOI: 10.1016/s2213-2600(22)00294-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/02/2022] [Accepted: 07/19/2022] [Indexed: 02/08/2023]
Abstract
The acute respiratory distress syndrome (ARDS) is a common critical illness syndrome with high morbidity and mortality. There are no proven pharmacological therapies for ARDS. The current definition of ARDS is based on shared clinical characteristics but does not capture the heterogeneity in clinical risk factors, imaging characteristics, physiology, timing of onset and trajectory, and biology of the syndrome. There is increasing interest within the ARDS clinical trialist community to design clinical trials that reduce heterogeneity in the trial population. This effort must be balanced with ongoing work to craft an inclusive, global definition of ARDS, with important implications for trial design. Ultimately, the two aims-to design trials that are applicable to the diverse global ARDS population while also advancing opportunities to identify targetable traits-should coexist. In this Personal View, we recommend two primary strategies to improve future ARDS trials: the development of new methods to target treatable traits in clinical trial populations, and improvements in the representativeness of ARDS trials, with the inclusion of global populations. We emphasise that these two strategies are complementary. We also discuss how a proposed expansion of the definition of ARDS could affect the future of clinical trials.
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Affiliation(s)
- Katherine D Wick
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Neil R Aggarwal
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado, Aurora, CO, USA; National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Martha A Q Curley
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Alpha A Fowler
- Division of Pulmonary Disease and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Samir Jaber
- University Hospital, CHU de Montpellier Hôpital Saint Eloi, Intensive Care Unit and Transplantation, Department of Anesthesiology DAR B, Montpellier, France
| | - Maciej Kostrubiec
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Nathalie Lassau
- Department of Imaging, Gustave Roussy, Université Paris Saclay, Villejuif, France; Biomaps, UMR1281 INSERM, CEA, CNRS, Université Paris Saclay, Villejuif, France
| | - Pierre François Laterre
- Intensive Care Medicine, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Guillaume Lebreton
- Institute of Cardiometabolism and Nutrition, Inserm, UMRS 1166-ICAN, Sorbonne University, Paris, France; Cardiac Surgery Service, Institute of Cardiology, AP-HP, Sorbonne University, Paris, France
| | - Joseph E Levitt
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, Paris, France
| | | | - Pratik Sinha
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA; Departments of Medicine and Anesthesia, University of California, San Francisco, CA, USA.
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22
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Anticoagulation in hospitalized patients with COVID-19. Blood 2022; 140:809-814. [PMID: 35653590 PMCID: PMC9361053 DOI: 10.1182/blood.2021014527] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/18/2022] [Indexed: 11/20/2022] Open
Abstract
Coronavirus disease-19 (COVID-19) includes a thromboinflammatory syndrome that may manifest with microvascular and macrovascular thrombosis. Patients with COVID-19 have a higher incidence of venous thromboembolism than other hospitalized patients. Three randomized control trials suggesting benefit of therapeutic heparin in hospitalized noncritically ill patients with COVID-19 have led to conditional guideline recommendations for this treatment. By contrast, prophylactic-dose heparin is recommended for critically ill patients. Unprecedented collaboration and rapidly funded research have improved care of hospitalized patients with COVID-19.
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23
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Patient-Important Outcomes Other Than Mortality in Contemporary ICU Trials: A Scoping Review. Crit Care Med 2022; 50:e759-e771. [PMID: 35894598 DOI: 10.1097/ccm.0000000000005637] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Randomized clinical trials (RCTs) conducted in adult ICU patients increasingly include patient-important outcomes other than mortality. This comes with challenges regarding outcome choices/definitions, handling of deceased patients and missing data in analyses, and choices of effect measures and statistical methods due to complex distributions. This scoping review aimed to characterize how these challenges are handled in relevant contemporary RCTs. DATA SOURCES We systematically searched 10 selected journals for RCTs conducted primarily in adult ICU patients published between 1 January 2018 and 5 May 2022 reporting at least one patient-important outcome other than mortality, including "days alive without"…-type outcomes, functional/cognitive/neurologic outcomes, health-related quality of life (HRQoL) outcomes, and ordinal/other outcomes. STUDY SELECTION Abstracts and full-texts were assessed independently and in duplicate by two reviewers. DATA EXTRACTION Data were extracted independently and in duplicate by two reviewers using predefined and pilot-tested extraction forms and subsequently categorized to facilitate analysis. DATA SYNTHESIS We included 687 outcomes from 167 RCTs, with 32% of RCTs using a patient-important outcome other than mortality as a (co-)primary outcome, most frequently "days alive without"…-type outcomes. Many different functional/cognitive/neurologic (103) and HRQoL (29) outcomes were reported. Handling of deceased patients varied, with analyses frequently restricted to survivors only for functional/cognitive/neurologic (62%) and HRQoL (89%) outcomes. Follow-up was generally longer and missing data proportions higher for functional/cognitive/neurologic and HRQoL outcomes. Most outcomes were analyzed using nonparametric tests (31%), linear regression/t tests (27%), chi-square-like tests (12%), and proportional odds logistic regression (9%), often without presentation of actual treatment effects estimates (38%). CONCLUSIONS In this sample of RCTs, substantial variation in practice and suboptimal methodological choices were observed. This calls for increased focus on standardizing outcome choices and definitions, adequate handling of missing data and deceased patients in analyses, and use of statistical methods quantifying effect sizes.
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24
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Systematic Review of the “Pragmatism” of Pragmatic Critical Care Trials. Crit Care Explor 2022; 4:e0738. [PMID: 35923590 PMCID: PMC9312432 DOI: 10.1097/cce.0000000000000738] [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: 11/25/2022] Open
Abstract
To assess the pragmatism of published critical care randomized controlled trials self-described as pragmatic using a validated tool.
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25
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Casey JD, Beskow LM, Brown J, Brown SM, Gayat É, Ng Gong M, Harhay MO, Jaber S, Jentzer JC, Laterre PF, Marshall JC, Matthay MA, Rice TW, Rosenberg Y, Turnbull AE, Ware LB, Self WH, Mebazaa A, Collins SP. Use of pragmatic and explanatory trial designs in acute care research: lessons from COVID-19. THE LANCET. RESPIRATORY MEDICINE 2022; 10:700-714. [PMID: 35709825 PMCID: PMC9191864 DOI: 10.1016/s2213-2600(22)00044-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/21/2021] [Accepted: 01/20/2022] [Indexed: 12/15/2022]
Abstract
Unique challenges arise when conducting trials to evaluate therapies already in common clinical use, including difficulty enrolling patients owing to widespread open-label use of trial therapies and the need for large sample sizes to detect small but clinically meaningful treatment effects. Despite numerous successes in trials evaluating novel interventions such as vaccines, traditional explanatory trials have struggled to provide definitive answers to time-sensitive questions for acutely ill patients with COVID-19. Pragmatic trials, which can increase efficiency by allowing some or all trial procedures to be embedded into clinical care, are increasingly proposed as a means to evaluate therapies that are in common clinical use. In this Personal View, we use two concurrently conducted COVID-19 trials of hydroxychloroquine (the US ORCHID trial and the UK RECOVERY trial) to contrast the effects of explanatory and pragmatic trial designs on trial conduct, trial results, and the care of patients managed outside of clinical trials. In view of the potential advantages and disadvantages of explanatory and pragmatic trial designs, we make recommendations for their optimal use in the evaluation of therapies in the acute care setting.
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Affiliation(s)
- Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Laura M Beskow
- Vanderbilt Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeremy Brown
- Office of Emergency Care Research, National Institute of Neurological Disorders and Stroke, Division of Clinical Research, National Institutes of Health, Bethesda, MD, USA
| | - Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and University of Utah, Salt Lake City, UT, USA
| | - Étienne Gayat
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; INSERM UMR-S 942, MASCOT, Université Paris Cité, Paris, France
| | - Michelle Ng Gong
- Division of Critical Care Medicine and Division of Pulmonary Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Michael O Harhay
- Palliative and Advanced Illness Research (PAIR) Center Clinical Trials Methods and Outcomes Lab, and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Samir Jaber
- Saint Eloi Intensive Care Unit, Montpellier University Hospital, and PhyMedExp, INSERM, CNRS, Université de Montpellier, Montpellier, France
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pierre-François Laterre
- Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, Brussels, Belgium
| | - John C Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; INSERM UMR-S 942, MASCOT, Université Paris Cité, Paris, France
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education,and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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26
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Granholm A, Schjørring OL, Jensen AKG, Kaas‐Hansen BS, Munch MW, Klitgaard TL, Crescioli E, Kjær MN, Strøm T, Perner A, Rasmussen BS, Møller MH. Health-related quality of life and days alive without life support or out of hospital: Protocol. Acta Anaesthesiol Scand 2022; 66:295-301. [PMID: 34811741 DOI: 10.1111/aas.14001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mortality is often the primary outcome in randomised clinical trials (RCTs) conducted in critically ill patients. Due to increased awareness on survivors after critical illness and outcomes other than mortality, health-related quality of life (HRQoL) and days alive without life support (DAWOLS) or days alive and out of hospital (DAAOOH) are increasingly being used. DAWOLS and DAAOOH convey more information than mortality, are easier to collect than HRQoL, and are usually assessed at earlier time points, which may be preferable in some situations. However, the associations between DAWOLS-DAAOOH and HRQoL are uncertain. METHODS We will assess associations between DAWOLS-DAAOOH at day 28 and 90 (independent variables/predictors) and HRQoL assessed using the EuroQol EQ-5D-5L questionnaire (EQ-VAS and EQ-5D-5L index values) at 6 or 12 months (dependent variables) in two RCTs: the COVID STEROID 2 RCT conducted in adult patients with COVID-19 and severe hypoxaemia and the Handling Oxygenation Targets in the Intensive Care Unit (HOT-ICU) RCT conducted in adult intensive care patients with acute hypoxaemic respiratory failure. We will describe associations using best-fitting fractional polynomial transformations separately in each dataset, with the resulting models presented and assessed in both datasets graphically and using measures of fit and prediction adequacy (i.e., internal performance and external validation). We will use multiple imputation if missingness exceeds 5%. DISCUSSION The outlined study will provide important knowledge on the associations between DAWOLS-DAAOOH and HRQoL in adult critically ill patients, which may help researchers and clinical trialists prioritise and select outcomes in future RCTs conducted in this population.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Olav Lilleholt Schjørring
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health University of Copenhagen Copenhagen Denmark
| | - Benjamin Skov Kaas‐Hansen
- Section of Biostatistics, Department of Public Health University of Copenhagen Copenhagen Denmark
- Clinical Pharmacology Unit Zealand University Hospital Roskilde Denmark
| | - Marie Warrer Munch
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Thomas Lass Klitgaard
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Elena Crescioli
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Maj‐Brit Nørregaard Kjær
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Thomas Strøm
- Department of Anaesthesia and Critical Care Medicine Odense University Hospital Odense Denmark
- Department of Anaesthesia and Critical Care Medicine Hospital Sønderjylland, University Hospital of Southern Denmark Odense Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Bodil Steen Rasmussen
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
- Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Morten Hylander Møller
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
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27
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Maláska J, Stašek J, Duška F, Balík M, Máca J, Hruda J, Vymazal T, Klementová O, Zatloukal J, Gabrhelík T, Novotný P, Demlová R, Kubátová J, Vinklerová J, Svobodník A, Kratochvíl M, Klučka J, Gál R, Singer M. Effect of dexamethasone in patients with ARDS and COVID-19 (REMED trial)-study protocol for a prospective, multi-centre, open-label, parallel-group, randomized controlled trial. Trials 2022; 23:35. [PMID: 35033182 PMCID: PMC8760569 DOI: 10.1186/s13063-021-05963-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/21/2021] [Indexed: 12/15/2022] Open
Abstract
Background Since December 2019, SARS-CoV-2 virus has infected millions of people worldwide. In patients with COVID-19 pneumonia in need of oxygen therapy or mechanical ventilation, dexamethasone 6 mg per day is currently recommended. However, the dose of 6 mg of dexamethasone is currently being reappraised and may miss important therapeutic potential or may prevent potential deleterious effects of higher doses of corticosteroids. Methods REMED is a prospective, open-label, randomised controlled trial testing the superiority of dexamethasone 20 mg (dexamethasone 20 mg on days 1–5, followed by dexamethasone 10 mg on days 6–10) vs 6 mg administered once daily intravenously for 10 days in adult patients with moderate or severe ARDS due to confirmed COVID-19. Three hundred participants will be enrolled and followed up for 360 days after randomization. Patients will be randomised in a 1:1 ratio into one of the two treatment arms. The following stratification factors will be applied: age, Charlson Comorbidity Index, CRP levels and trial centre. The primary endpoint is the number of ventilator-free days (VFDs) at 28 days after randomisation. The secondary endpoints are mortality from any cause at 60 days after randomisation; dynamics of the inflammatory marker, change in WHO Clinical Progression Scale at day 14; and adverse events related to corticosteroids and independence at 90 days after randomisation assessed by the Barthel Index. The long-term outcomes of this study are to assess long-term consequences on mortality and quality of life at 180 and 360 days. The study will be conducted in the intensive care units (ICUs) of ten university hospitals in the Czech Republic. Discussion We aim to compare two different doses of dexamethasone in patients with moderate to severe ARDS undergoing mechanical ventilation regarding efficacy and safety. Trial registration EudraCT No. 2020-005887-70. ClinicalTrials.gov NCT04663555. Registered on December 11, 2020
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Affiliation(s)
- Jan Maláska
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno and Masaryk University, Jihlavská 20, 625 00, Brno, Czech Republic
| | - Jan Stašek
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno and Masaryk University, Jihlavská 20, 625 00, Brno, Czech Republic.
| | - František Duška
- Department of Anaesthesia and Intensive Care, 3rd Faculty of Medicine, University Hospital Královské Vinohrady and Charles University, Šrobárova, 1150 100 34, Prague, Czech Republic
| | - Martin Balík
- Department of Anaesthesia and Intensive Care, 1st Faculty of Medicine, General University Hospital in Prague and Charles University, U Nemocnice 499/2, 128 08, Prague, Czech Republic
| | - Jan Máca
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Ostrava and University Ostrava, 17. listopadu 1790, 708 52, Ostrava-Poruba, Czech Republic
| | - Jan Hruda
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, St. Anne's University Hospital and Masaryk University, Pekařská 664/53, 656 91, Brno, Czech Republic
| | - Tomáš Vymazal
- Department of Anaesthesiology and Intensive Care Medicine, 2nd Faculty of Medicine, University Hospital Motol and Charles University, V Úvalu 84/1, 150 06, Prague, Czech Republic
| | - Olga Klementová
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Olomouc and Palacky University, I. P. Pavlova 185/6, 779 00, Olomouc, Czech Republic
| | - Jan Zatloukal
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Pilsen, University Hospital Plzeň and Charles University, alej Svobody 80, 304 60, Plzeň-Lochotín, Czech Republic
| | - Tomáš Gabrhelík
- Department of Anaesthesiology and Intensive Care Medicine, Tomáš Baťa Regional Hospital, Havlíčkovo nábřeží 600, 762 75, Zlín, Czech Republic
| | - Pavel Novotný
- Department of Anaesthesiology and Intensive Care, 1st Faculty of Medicine, Military University Hospital Praha and Charles University, U Vojenské nemocnice 1200, 169 02, Prague, Czech Republic
| | - Regina Demlová
- Department of Pharmacology/CZECRIN, Faculty of Medicine, Masaryk University, Kamenice 5, 62500, Brno, Czech Republic
| | - Jana Kubátová
- Department of Pharmacology/CZECRIN, Faculty of Medicine, Masaryk University, Kamenice 5, 62500, Brno, Czech Republic
| | - Jana Vinklerová
- Department of Pharmacology/CZECRIN, Faculty of Medicine, Masaryk University, Kamenice 5, 62500, Brno, Czech Republic
| | - Adam Svobodník
- Department of Pharmacology/CZECRIN, Faculty of Medicine, Masaryk University, Kamenice 5, 62500, Brno, Czech Republic
| | - Milan Kratochvíl
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno and Masaryk University, Jihlavská 20, 625 00, Brno, Czech Republic
| | - Jozef Klučka
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno and Masaryk University, Jihlavská 20, 625 00, Brno, Czech Republic
| | - Roman Gál
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno and Masaryk University, Jihlavská 20, 625 00, Brno, Czech Republic
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Gower Street, London, WC1E 6BT, UK
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Efficacy and Safety of Intravenous Iron Therapy for Treating Anaemia in Critically ill Adults: A Rapid Systematic Review With Meta-Analysis. Transfus Med Rev 2021; 36:97-106. [PMID: 35031197 DOI: 10.1016/j.tmrv.2021.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 12/16/2022]
Abstract
Our objective was to systematically evaluate the efficacy and safety of intravenous (IV) iron therapy for treating anaemia in critically ill adults (>16 years) admitted to intensive care or high dependency units. We excluded quasi-RCTs and other not truly randomised trials. We searched 7 electronic databases (including CENTRAL, MEDLINE, and Embase) using a pre-defined search strategy from inception to June 14, 2021. One reviewer screened, extracted, and analysed data, with verification by a second reviewer of all decisions. We used Cochrane risk of bias (ROB) 1 and GRADE to assess the certainty of the evidence. We reported 3 comparisons across 1198 patients, in 8 RCTs: (1) IV iron vs control (7 RCTs, 748 participants); our primary outcome (hemoglobin (Hb) concentration at 10 to 30 days) was reported in 7 of the 8 included trials. There was evidence of an effect (very-low certainty) in favour of IV iron over control in the main comparison only (6 RCTs, n = 528, mean difference (MD) 0.52g/dL [95%CI 0.23, 0.81], P = .0005). For the remaining outcomes there was no evidence of an effect in either direction (low certainty of evidence for Hb concentration at <10 days; very-low certainty of evidence for hospital duration, ICU duration, hospital readmission, infection, mortality; HRQoL outcomes were not GRADED). (2) IV iron + subcutaneous erythropoietin (EPO) vs control (2 RCTs, 104 participants); reported outcomes showed no evidence of effect in either direction, based on very-low certainty evidence (Hb concentration at 10-30 days, and <10 days, infection, mortality). (3) Hepcidin-guided treatment with IV iron or iron+ EPO vs standard care (1 RCT, 399 participants) reported evidence of an effect in favour of the intervention for 90-day mortality (low certainty of evidence), but no other group differences for the reported outcomes (low certainty evidence for Hb concentration at 10-30 days, hospital duration; HRQoL was not GRADED). The evidence across all comparisons was downgraded for high and unclear ROB for lack of blinding, incomplete outcome data, baseline imbalance, and imprecision around the estimate (wide CIs and small sample size). In conclusion, the current evidence continues to support further investigation into the role for iron therapy in increasing Hb in critically ill patients. Recent, small, trials have begun to focus on patient-centred outcomes but a large, well conducted, and adequately powered trial is needed to inform clinical practice.
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Randomised clinical trials in critical care: past, present and future. Intensive Care Med 2021; 48:164-178. [PMID: 34853905 PMCID: PMC8636283 DOI: 10.1007/s00134-021-06587-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/17/2021] [Indexed: 12/15/2022]
Abstract
Randomised clinical trials (RCTs) are the gold standard for providing unbiased evidence of intervention effects. Here, we provide an overview of the history of RCTs and discuss the major challenges and limitations of current critical care RCTs, including overly optimistic effect sizes; unnuanced conclusions based on dichotomization of results; limited focus on patient-centred outcomes other than mortality; lack of flexibility and ability to adapt, increasing the risk of inconclusive results and limiting knowledge gains before trial completion; and inefficiency due to lack of re-use of trial infrastructure. We discuss recent developments in critical care RCTs and novel methods that may provide solutions to some of these challenges, including a research programme approach (consecutive, complementary studies of multiple types rather than individual, independent studies), and novel design and analysis methods. These include standardization of trial protocols; alternative outcome choices and use of core outcome sets; increased acceptance of uncertainty, probabilistic interpretations and use of Bayesian statistics; novel approaches to assessing heterogeneity of treatment effects; adaptation and platform trials; and increased integration between clinical trials and clinical practice. We outline the advantages and discuss the potential methodological and practical disadvantages with these approaches. With this review, we aim to inform clinicians and researchers about conventional and novel RCTs, including the rationale for choosing one or the other methodological approach based on a thorough discussion of pros and cons. Importantly, the most central feature remains the randomisation, which provides unparalleled restriction of confounding compared to non-randomised designs by reducing confounding to chance.
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Pensier J, De Jong A, Chanques G, Futier E, Azoulay E, Molinari N, Jaber S. A multivariate model for successful publication of intensive care medicine randomized controlled trials in the highest impact factor journals: the SCOTI score. Ann Intensive Care 2021; 11:165. [PMID: 34837580 PMCID: PMC8626742 DOI: 10.1186/s13613-021-00954-x] [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: 08/29/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background Critical care randomized controlled trials (RCTs) are often published in high-impact journals, whether general journals [the New England Journal of Medicine (NEJM), The Lancet, the Journal of the American Medical Association (JAMA)] or critical care journals [Intensive Care Medicine (ICM), the American Journal of Respiratory and Critical Care Medicine (AJRCCM), Critical Care Medicine (CCM)]. As rejection occurs in up to 97% of cases, it might be appropriate to assess pre-submission probability of being published. The objective of this study was to develop and internally validate a simplified score predicting whether an ongoing trial stands a chance of being published in high-impact general journals. Methods A cohort of critical care RCTs published between 1999 and 2018 in the three highest impact medical journals (NEJM, The Lancet, JAMA) or the three highest impact critical care journals (ICM, AJRCCM, CCM) was split into two samples (derivation cohort, validation cohort) to develop and internally validate the simplified score. Primary outcome was journal of publication assessed as high-impact general journal (NEJM, The Lancet, JAMA) or critical care journal (ICM, AJRCCM, CCM). Results A total of 968 critical care RCTs were included in the predictive cohort and split into a derivation cohort (n = 510) and a validation cohort (n = 458). In the derivation cohort, the sample size (P value < 0.001), the number of centers involved (P value = 0.01), mortality as primary outcome (P value = 0.002) or a composite item including mortality as primary outcome (P value = 0.004), and topic [ventilation (P value < 0.001) or miscellaneous (P value < 0.001)] were independent factors predictive of publication in high-impact general journals, compared to high-impact critical care journals. The SCOTI score (Sample size, Centers, Outcome, Topic, and International score) was developed with an area under the ROC curve of 0.84 (95% Confidence Interval, 0.80–0.88) in validation by split sample. Conclusions The SCOTI score, developed and validated by split sample, accurately predicts the chances of a critical care RCT being published in high-impact general journals, compared to high-impact critical care journals. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00954-x.
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Affiliation(s)
- Joris Pensier
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214 CEDEX 5, Montpellier, France
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214 CEDEX 5, Montpellier, France
| | - Gerald Chanques
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214 CEDEX 5, Montpellier, France
| | - Emmanuel Futier
- Department of Peri-Operative Medicine, CHU Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Elie Azoulay
- Médecine Intensive et Réanimation, Groupe FAMIREA, Hôpital Saint-Louis, Université de Paris, Paris, France
| | - Nicolas Molinari
- IDESP, INSERM, Univ Montpellier, CHU Montpellier, Montpellier, France.,Universite de Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Samir Jaber
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214 CEDEX 5, Montpellier, France. .,Département d'Anesthésie Réanimation B (DAR B), 80 Avenue Augustin Fliche, 34295, Montpellier, France.
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Krutsinger DC, Yadav KN, Harhay MO, Bartels K, Courtright KR. A systematic review and meta-analysis of enrollment into ARDS and sepsis trials published between 2009 and 2019 in major journals. Crit Care 2021; 25:392. [PMID: 34781998 PMCID: PMC8591428 DOI: 10.1186/s13054-021-03804-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Enrollment problems are common among randomized controlled trials conducted in the ICU. However, little is known about actual trial enrollment rates and influential factors. We set out to determine the overall enrollment rate in recent randomized controlled trials (RCTs) of patients with acute respiratory distress syndrome (ARDS), acute lung injury (ALI), or sepsis, and which factors influenced enrollment rate. METHODS We conducted a systematic review by searching Pubmed using predefined terms for ARDS/ALI and sepsis to identify individually RCTs published among the seven highest impact general medicine and seven highest impact critical care journals between 2009 and 2019. Cluster randomized trials were excluded. Data were extracted by two independent reviewers using an electronic database management system. We conducted a random-effects meta-analysis of the eligible trials for the primary outcome of enrollment rate by time and site. RESULTS Out of 457 articles identified, 94 trials met inclusion criteria. Trials most commonly evaluated pharmaceutical interventions (53%), were non-industry funded (78%), and required prospective informed consent (81%). The overall mean enrollment rate was 0.83 (95% confidence interval: 0.57-1.21) participants per month per site. Enrollment in ARDS/ALI and sepsis trials were 0.48 (95% CI 0.32-0.70) and 0.98 (95% CI 0.62-1.56) respectively. The enrollment rate was significantly higher for single-center trials (4.86; 95% CI 2.49-9.51) than multicenter trials (0.52; 95% CI 0.41-0.66). Of the 36 trials that enrolled < 95% of the target sample size, 8 (22%) reported slow enrollment as the reason. CONCLUSIONS In this systematic review and meta-analysis, recent ARDS/ALI and sepsis clinical trials had an overall enrollment rate of less than 1 participant per site per month. Novel approaches to improve critical care trial enrollment efficiency are needed to facilitate the translation of best evidence into practice.
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Affiliation(s)
- Dustin C. Krutsinger
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Nebraska Medical Center, 985910 NE Medical Center, Omaha, NE 68198 USA
| | - Kuldeep N. Yadav
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, 300 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104 USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Michael O. Harhay
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, 300 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104 USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Karsten Bartels
- Department of Anesthesiology, University of Nebraska Medical Center, 985910 NE Medical Center, Omaha, NE 68198 USA
| | - Katherine R. Courtright
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, 300 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104 USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
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Fluid management in diabetic ketoacidosis: new tricks for old dogs? Intensive Care Med 2021; 47:1312-1314. [PMID: 34608527 DOI: 10.1007/s00134-021-06527-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
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Safety and tolerability of non-neutralizing adrenomedullin antibody adrecizumab (HAM8101) in septic shock patients: the AdrenOSS-2 phase 2a biomarker-guided trial. Intensive Care Med 2021; 47:1284-1294. [PMID: 34605947 PMCID: PMC8487806 DOI: 10.1007/s00134-021-06537-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/09/2021] [Indexed: 11/11/2022]
Abstract
Purpose Investigate safety and tolerability of adrecizumab, a humanized monoclonal adrenomedullin antibody, in septic shock patients with high adrenomedullin. Methods Phase-2a, double-blind, randomized, placebo-controlled biomarker-guided trial with a single infusion of adrecizumab (2 or 4 mg/kg b.w.) compared to placebo. Patients with adrenomedullin above 70 pg/mL, < 12 h of vasopressor start for septic shock were eligible. Randomization was 1:1:2. Primary safety (90-day mortality, treatment emergent adverse events (TEAE)) and tolerability (drug interruption, hemodynamics) endpoints were recorded. Efficacy endpoints included the Sepsis Support Index (SSI, reflecting ventilator- and shock-free days alive), change in Sequential-related Organ Failure Assessment (SOFA) and 28-day mortality. Results 301 patients were enrolled (median time of 8.5 h after vasopressor start). Adrecizumab was well tolerated (one interruption, no hemodynamic alteration) with no differences in frequency and severity in TEAEs between treatment arms (TEAE of grade 3 or higher: 70.5% in the adrecizumab group and 71.1% in the placebo group) nor in 90-day mortality. Difference in change in SSI between adrecizumab and placebo was 0.72 (CI −1.93–0.49, p = 0.24). Among various secondary endpoints, delta SOFA score (defined as maximum versus minimum SOFA) was more pronounced in the adrecizumab combined group compared to placebo [difference at 0.76 (95% CI 0.18–1.35); p = 0.007]. 28-day mortality in the adrecizumab group was 23.9% and 27.7% in placebo with a hazard ratio of 0.84 (95% confidence interval 0.53–1.31, log-rank p = 0.44). Conclusions Overall, we successfully completed a randomized trial evaluating selecting patients for enrolment who had a disease-related biomarker. There were no overt signals of harm with using two doses of the adrenomedullin antibody adrecizumab; however, further randomized controlled trials are required to confirm efficacy and safety of this agent in septic shock patients. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06537-5.
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Granholm A, Kaas‐Hansen BS, Kjær MN, Anthon CT, Sivapalan P, Schjørring OL, Andersen LW, Mathiesen O, Strøm T, Jensen AKG, Perner A, Møller MH. Patient-important outcomes other than mortality in recent ICU trials: Protocol for a scoping review. Acta Anaesthesiol Scand 2021; 65:1002-1007. [PMID: 34089522 DOI: 10.1111/aas.13937] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/29/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Randomised clinical trials (RCTs) conducted in intensive care units (ICUs) frequently focus on all-cause mortality, but other patient-important outcomes are increasingly used and recommended. Their use, however, is not straightforward: choices and definitions, operationalisation of death, handling of missing data, choice of effect measures, and statistical analyses for these outcomes vary greatly. METHODS We will conduct a scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. We will search 10 selected general and speciality journals for RCTs conducted in adult ICU patients from 2018 and onwards reporting at least 1 patient-important outcome other than mortality (including days alive without life support/days alive and out of hospital-type outcomes, health-related quality of life, functional/cognitive/neurological outcomes, and other general patient-important outcomes). We will summarise data on outcome measures and definitions, assessment time points, proportions and handling of death, proportions and handling of missing data, and effect measures and statistical methods used for analysis. DISCUSSION The outlined scoping review will provide an overview of choices, definitions and handling of patient-important outcomes other than mortality in contemporary RCTs conducted in adult ICU patients. This may guide discussions with patients and relatives, the design of future RCTs, and research on optimal outcome choices and handling.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Benjamin Skov Kaas‐Hansen
- NNF Center for Protein Research University of Copenhagen Copenhagen Denmark
- Clinical Pharmacology Unit Zealand University Hospital Roskilde Denmark
| | | | - Carl Thomas Anthon
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Praleene Sivapalan
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet 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
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology Zealand University Hospital Køge Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Thomas Strøm
- Department of Anaesthesia and Critical Care Medicine Odense University Hospital Odense Denmark
- Department of Anaesthesia and Critical Care Medicine Hospital Sønderjylland, University Hospital of Southern Denmark Odense Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health University of Copenhagen Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care Copenhagen University Hospital—Rigshospitalet Copenhagen Denmark
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Optimising clinical trials in acute myocardial infarction complicated by cardiogenic shock: a statement from the 2020 Critical Care Clinical Trialists Workshop. THE LANCET RESPIRATORY MEDICINE 2021; 9:1192-1202. [PMID: 34245691 DOI: 10.1016/s2213-2600(21)00172-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/23/2021] [Accepted: 03/25/2021] [Indexed: 12/12/2022]
Abstract
Acute myocardial infarction complicated by cardiogenic shock (AMICS) is a critical syndrome with a high risk of morbidity and mortality. Current management consists of coronary revascularisation, vasoactive drugs, and circulatory and ventilatory support, which are tailored to patients mainly on the basis of clinicians' experience rather than evidence-based recommendations. For many therapeutic interventions in AMICS, randomised clinical trials have not shown a meaningful survival benefit, and a disproportionately high rate of neutral and negative results has been reported. In this context, an accurate definition of the AMICS syndrome for appropriate patient selection and optimisation of study design are warranted to achieve meaningful results and pave the way for new, evidence-based therapeutic options. In this Position Paper, we provide a statement of priorities and recommendations agreed by a multidisciplinary group of experts at the Critical Care Clinical Trialists Workshop in February, 2020, for the optimisation and harmonisation of clinical trials in AMICS. Implementation of proposed criteria to define the AMICS population-moving beyond a cardio-centric definition to that of a systemic disease-and steps to improve the design of clinical trials could lead to improved outcomes for patients with this life-threatening syndrome.
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Kowalkowski M, Eaton T, McWilliams A, Tapp H, Rios A, Murphy S, Burns R, Gutnik B, O'Hare K, McCurdy L, Dulin M, Blanchette C, Chou SH, Halpern S, Angus DC, Taylor SP. Protocol for a two-arm pragmatic stepped-wedge hybrid effectiveness-implementation trial evaluating Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship (ENCOMPASS). BMC Health Serv Res 2021; 21:544. [PMID: 34078374 PMCID: PMC8170654 DOI: 10.1186/s12913-021-06521-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sepsis survivors experience high morbidity and mortality, and healthcare systems lack effective strategies to address patient needs after hospital discharge. The Sepsis Transition and Recovery (STAR) program is a navigator-led, telehealth-based multicomponent strategy to provide proactive care coordination and monitoring of high-risk patients using evidence-driven, post-sepsis care tasks. The purpose of this study is to evaluate the effectiveness of STAR to improve outcomes for sepsis patients and to examine contextual factors that influence STAR implementation. METHODS This study uses a hybrid type I effectiveness-implementation design to concurrently test clinical effectiveness and gather implementation data. The effectiveness evaluation is a two-arm, pragmatic, stepped-wedge cluster randomized controlled trial at eight hospitals in North Carolina comparing clinical outcomes between sepsis survivors who receive Usual Care versus care delivered through STAR. Each hospital begins in a Usual Care control phase and transitions to STAR in a randomly assigned sequence (one every 4 months). During months that a hospital is allocated to Usual Care, all eligible patients will receive usual care. Once a hospital transitions to STAR, all eligible patients will receive STAR during their hospitalization and extending through 90 days from discharge. STAR includes centrally located nurse navigators using telephonic counseling and electronic health record-based support to facilitate best-practice post-sepsis care strategies including post-discharge review of medications, evaluation for new impairments or symptoms, monitoring existing comorbidities, and palliative care referral when appropriate. Adults admitted with suspected sepsis, defined by clinical criteria for infection and organ failure, are included. Planned enrollment is 4032 patients during a 36-month period. The primary effectiveness outcome is the composite of all-cause hospital readmission or mortality within 90 days of discharge. A mixed-methods implementation evaluation will be conducted before, during, and after STAR implementation. DISCUSSION This pragmatic evaluation will test the effectiveness of STAR to reduce combined hospital readmissions and mortality, while identifying key implementation factors. Results will provide practical information to advance understanding of how to integrate post-sepsis management across care settings and facilitate implementation, dissemination, and sustained utilization of best-practice post-sepsis management strategies in other heterogeneous healthcare delivery systems. TRIAL REGISTRATION NCT04495946 . Submitted July 7, 2020; Posted August 3, 2020.
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Affiliation(s)
- Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA.
| | - Tara Eaton
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Andrew McWilliams
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA.,Department of Internal Medicine, Atrium Health, Charlotte, USA
| | - Hazel Tapp
- Department of Family Medicine, Atrium Health, Charlotte, USA
| | - Aleta Rios
- Ambulatory Care Management, Atrium Health, Charlotte, USA
| | | | - Ryan Burns
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Bella Gutnik
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | | | - Lewis McCurdy
- Division of Infectious Disease, Department of Internal Medicine, Atrium Health, Charlotte, USA
| | - Michael Dulin
- Academy for Population Health Innovation, University of North Carolina Charlotte & Mecklenburg County Public Health Department, Charlotte, USA.,Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA
| | - Christopher Blanchette
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA.,Health Economics and Outcomes Research Strategy, Novo Nordisk, Plainsboro Township, USA
| | - Shih-Hsiung Chou
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Scott Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
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38
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Yehya N, Harhay MO. Severity of hypoxemia may explain indeterminate results in pediatric trials of inhaled nitric oxide. Intensive Care Med 2021; 47:913-915. [PMID: 33993339 DOI: 10.1007/s00134-021-06434-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, 6040A Wood Building, CHOP, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA. .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Michael O Harhay
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.,PAIR (Palliative and Advanced Illness Research) Center Clinical Trials Methods and Outcomes Lab, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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39
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Granholm A, Munch MW, Myatra SN, Vijayaraghavan BKT, Cronhjort M, Wahlin RR, Jakob SM, Cioccari L, Kjær MN, Vesterlund GK, Meyhoff TS, Helleberg M, Møller MH, Benfield T, Venkatesh B, Hammond N, Micallef S, Bassi A, John O, Jha V, Kristiansen KT, Ulrik CS, Jørgensen VL, Smitt M, Bestle MH, Andreasen AS, Poulsen LM, Rasmussen BS, Brøchner AC, Strøm T, Møller A, Khan MS, Padmanaban A, Divatia JV, Saseedharan S, Borawake K, Kapadia F, Dixit S, Chawla R, Shukla U, Amin P, Chew MS, Gluud C, Lange T, Perner A. Higher vs Lower Doses of Dexamethasone in Patients with COVID-19 and Severe Hypoxia (COVID STEROID 2) trial: Protocol for a secondary Bayesian analysis. Acta Anaesthesiol Scand 2021; 65:702-710. [PMID: 33583027 PMCID: PMC8014670 DOI: 10.1111/aas.13793] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) can lead to severe hypoxic respiratory failure and death. Corticosteroids decrease mortality in severely or critically ill patients with COVID-19. However, the optimal dose remains unresolved. The ongoing randomised COVID STEROID 2 trial investigates the effects of higher vs lower doses of dexamethasone (12 vs 6 mg intravenously daily for up to 10 days) in 1,000 adult patients with COVID-19 and severe hypoxia. METHODS This protocol outlines the rationale and statistical methods for a secondary, pre-planned Bayesian analysis of the primary outcome (days alive without life support at day 28) and all secondary outcomes registered up to day 90. We will use hurdle-negative binomial models to estimate the mean number of days alive without life support in each group and present results as mean differences and incidence rate ratios with 95% credibility intervals (CrIs). Additional count outcomes will be analysed similarly and binary outcomes will be analysed using logistic regression models with results presented as probabilities, relative risks and risk differences with 95% CrIs. We will present probabilities of any benefit/harm, clinically important benefit/harm and probabilities of effects smaller than pre-defined clinically minimally important differences for all outcomes analysed. Analyses will be adjusted for stratification variables and conducted using weakly informative priors supplemented by sensitivity analyses using sceptic priors. DISCUSSION This secondary, pre-planned Bayesian analysis will supplement the primary, conventional analysis and may help clinicians, researchers and policymakers interpret the results of the COVID STEROID 2 trial while avoiding arbitrarily dichotomised interpretations of the results. TRIAL REGISTRATION ClinicalTrials.gov: NCT04509973; EudraCT: 2020-003363-25.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
| | - Marie Warrer Munch
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
| | - Sheila Nainan Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial HospitalHomi Bhabha National InstituteMumbaiIndia
| | - Bharath Kumar Tirupakuzhi Vijayaraghavan
- Department of Critical CareApollo HospitalsChennaiIndia
- Chennai Critical Care ConsultantsChennaiIndia
- The George Institute for Global HealthUniversity of New South WalesNew DelhiIndia
| | - Maria Cronhjort
- Department of Clinical Science and EducationSödersjukhuset, Karolinska InstitutetStockholmSweden
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science and EducationSödersjukhuset, Karolinska InstitutetStockholmSweden
| | - Stephan M. Jakob
- Department of Intensive Care MedicineInselspital, Bern University Hospital, University of BernSwitzerland
| | - Luca Cioccari
- Department of Intensive Care MedicineInselspital, Bern University Hospital, University of BernSwitzerland
| | - Maj‐Brit Nørregaard Kjær
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
| | - Gitte Kingo Vesterlund
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
| | - Tine Sylvest Meyhoff
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
| | - Marie Helleberg
- Department of Infectious Diseases, RigshospitaletUniversity of CopenhagenDenmark
| | - Morten Hylander Møller
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
| | - Thomas Benfield
- Center of Research and Disruption of Infectious Diseases, Department of Infectious DiseasesCopenhagen University Hospital – Amager and HvidovreDenmark
| | | | - Naomi Hammond
- The George Institute for Global HealthUniversity of New South WalesAustralia
| | - Sharon Micallef
- The George Institute for Global HealthUniversity of New South WalesAustralia
| | - Abhinav Bassi
- The George Institute for Global HealthUniversity of New South WalesNew DelhiIndia
| | - Oommen John
- The George Institute for Global HealthUniversity of New South WalesNew DelhiIndia
- Prasanna School of Public HealthManipal Academy of Higher EducationIndia
| | - Vivekanand Jha
- The George Institute for Global HealthUniversity of New South WalesNew DelhiIndia
- Prasanna School of Public HealthManipal Academy of Higher EducationIndia
- School of Public HealthImperial College LondonUnited Kingdom
| | | | | | - Vibeke Lind Jørgensen
- Department of Thoracic Anaesthesiology, RigshospitaletUniversity of CopenhagenDenmark
| | - Margit Smitt
- Department of Neuroanaesthesiology, RigshospitaletUniversity of CopenhagenDenmark
| | - Morten H. Bestle
- Department of Anaesthesiology Intensive CareCopenhagen University HospitalNordsjællandDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Anne Sofie Andreasen
- Department of Anaesthesia and Intensive CareHerlev Hospital, University of CopenhagenDenmark
| | | | - Bodil Steen Rasmussen
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
- Department of Anaesthesia and Intensive CareAalborg University HospitalDenmark
| | | | - Thomas Strøm
- Department of Anaesthesia and Critical Care MedicineOdense University HospitalOdense CDenmark
- Department of Anaesthesia and Critical Care MedicineHospital Sønderjylland, University Hospital of Southern DenmarkDenmark
| | - Anders Møller
- Department of Anaesthesia and Intensive CareNæstved‐Slagelse‐Ringsted HospitalSlagelseDenmark
| | - Mohd Saif Khan
- Department of Critical Care MedicineRajendra Institute of Medical SciencesRanchiIndia
| | | | - Jigeeshu Vasishtha Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial HospitalHomi Bhabha National InstituteMumbaiIndia
| | | | | | - Farhad Kapadia
- Section of Critical Care, Department of MedicineHinduja HospitalMahimIndia
| | - Subhal Dixit
- Department of Critical Care MedicineSanjeevan HospitalPuneIndia
| | - Rajesh Chawla
- Department of Respiratory and Critical Care MedicineIndraprastha Apollo HospitalNew DelhiIndia
| | - Urvi Shukla
- Intensive Care Unit and Emergency ServicesSymbiosis University Hospital and Research CentrePuneIndia
| | - Pravin Amin
- Department of Critical Care MedicineBombay Hospital Institute of Medical SciencesMumbaiIndia
| | - Michelle S. Chew
- Department of Anesthesiology and Intensive Care, Biomedical and Clinical SciencesLinköping UniversityLinköpingSweden
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, RigshospitaletCopenhagen University HospitalCopenhagenDenmark
| | - Theis Lange
- Department of Public Health, Section of BiostatisticsUniversity of CopenhagenCopenhagenDenmark
| | - Anders Perner
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenDenmark
- Collaboration for Research in Intensive Care (CRIC)CopenhagenDenmark
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Bose S, Hoenig B, Karamourtopoulos M, Banner-Goodspeed V, Brown S. Beyond survival: identifying what matters to survivors of critical illness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:129. [PMID: 33823888 PMCID: PMC8025480 DOI: 10.1186/s13054-021-03565-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/01/2021] [Indexed: 12/30/2022]
Affiliation(s)
- Somnath Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, One Deaconess Road, Rosenberg 470, Boston, MA, 02215, USA. .,Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA.
| | - Benjamin Hoenig
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, One Deaconess Road, Rosenberg 470, Boston, MA, 02215, USA.,Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA.,Albany Medical College, Albany, NY, 12208, USA
| | - Maria Karamourtopoulos
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, One Deaconess Road, Rosenberg 470, Boston, MA, 02215, USA.,Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Valerie Banner-Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, One Deaconess Road, Rosenberg 470, Boston, MA, 02215, USA.,Department of Anesthesia, Critical Care and Pain Medicine, Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Samuel Brown
- Center for Humanizing Critical Care and Pulmonary Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA.,Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, 84132, USA
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41
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Zampieri FG, Casey JD, Shankar-Hari M, Harrell FE, Harhay MO. Using Bayesian Methods to Augment the Interpretation of Critical Care Trials. An Overview of Theory and Example Reanalysis of the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial. Am J Respir Crit Care Med 2021; 203:543-552. [PMID: 33270526 PMCID: PMC7924582 DOI: 10.1164/rccm.202006-2381cp] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/03/2020] [Indexed: 12/27/2022] Open
Abstract
Most randomized trials are designed and analyzed using frequentist statistical approaches such as null hypothesis testing and P values. Conceptually, P values are cumbersome to understand, as they provide evidence of data incompatibility with a null hypothesis (e.g., no clinical benefit) and not direct evidence of the alternative hypothesis (e.g., clinical benefit). This counterintuitive framework may contribute to the misinterpretation that the absence of evidence is equal to evidence of absence and may cause the discounting of potentially informative data. Bayesian methods provide an alternative, probabilistic interpretation of data. The reanalysis of completed trials using Bayesian methods is becoming increasingly common, particularly for trials with effect estimates that appear clinically significant despite P values above the traditional threshold of 0.05. Statistical inference using Bayesian methods produces a distribution of effect sizes that would be compatible with observed trial data, interpreted in the context of prior assumptions about an intervention (called "priors"). These priors are chosen by investigators to reflect existing beliefs and past empirical evidence regarding the effect of an intervention. By calculating the likelihood of clinical benefit, a Bayesian reanalysis can augment the interpretation of a trial. However, if priors are not defined a priori, there is a legitimate concern that priors could be constructed in a manner that produces biased results. Therefore, some standardization of priors for Bayesian reanalysis of clinical trials may be desirable for the critical care community. In this Critical Care Perspective, we discuss both frequentist and Bayesian approaches to clinical trial analysis, introduce a framework that researchers can use to select priors for a Bayesian reanalysis, and demonstrate how to apply our proposal by conducting a novel Bayesian trial reanalysis.
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Affiliation(s)
- Fernando G. Zampieri
- Research Institute, HCor‐Hospital do Coração, São Paulo, Brazil
- Center for Epidemiological Research, Southern Denmark University, Odense, Denmark
| | | | - Manu Shankar-Hari
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Guy’s and St. Thomas’ NHS Foundation Trust, ICU Support Offices, St. Thomas’ Hospital, London, United Kingdom
| | - Frank E. Harrell
- School of Immunology & Microbial Sciences, King’s College London, London, United Kingdom; and
| | - Michael O. Harhay
- PAIR (Palliative and Advanced Illness Research) Center Clinical Trials Methods and Outcomes Lab
- Department of Biostatistics, Epidemiology, and Informatics, and
- Division of Pulmonary and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Matthay MA, Thompson BT. Dexamethasone in hospitalised patients with COVID-19: addressing uncertainties. THE LANCET. RESPIRATORY MEDICINE 2020; 8:1170-1172. [PMID: 33129421 PMCID: PMC7598750 DOI: 10.1016/s2213-2600(20)30503-8] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Michael A Matthay
- Cardiovascular Research Institute, Departments of Medicine and Anesthesia, University of California, San Francisco, CA 94143, USA.
| | - B Taylor Thompson
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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43
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Casey JD, Semler MW. Renin, Angiotensin II, and the Journey to Evidence-based Individual Treatment Effects. Am J Respir Crit Care Med 2020; 202:1209-1211. [PMID: 32749864 PMCID: PMC7605191 DOI: 10.1164/rccm.202007-2731ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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44
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Ware LB, Matthay MA, Mebazaa A. Designing an ARDS trial for 2020 and beyond: focus on enrichment strategies. Intensive Care Med 2020; 46:2153-2156. [PMID: 33136196 PMCID: PMC7605340 DOI: 10.1007/s00134-020-06232-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/26/2020] [Indexed: 02/07/2023]
Abstract
With the exception of a few successes in trials of supportive care, the majority of interventional clinical trials for acute respiratory distress syndrome (ARDS) have not led to new therapies. To improve the likelihood of benefit from clinical trial interventions in ARDS, clinical trial design must be improved. To optimize trial design, many factors need to be considered including the type of therapy to be tested, the type of trial (phase 2 or 3), how patients will be selected, primary and secondary end-points, and strategy for conduct of the trial, including potential newer trial designs such as platform or adaptive trials. Of these, optimization of patient selection is central to the likelihood of success and is particularly relevant in ARDS, which is a heterogeneous clinical syndrome, not a homogeneous disease. Recent advances including improved understanding of pathophysiologic mechanisms and better tools for outcome prediction in ARDS should facilitate both predictive and prognostic enrichment. This commentary focuses on new information and novel methods for prognostic and predictive enrichment that may be useful to optimize patient selection and increase the likelihood of positive clinical trials in ARDS.
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Affiliation(s)
- Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Michael A Matthay
- Departments of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Alexandre Mebazaa
- Department of Anaesthesia and Critical Care, Lariboisière Hospital, APHP; Inserm UMR-S942 Mascot, FHU PROMICE and Université de Paris, Paris, France
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45
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Casaer MP, De Jong A, Perner A. Clinical validation of precision medicine protocols: the last mile is the longest. Intensive Care Med 2020; 47:80-82. [PMID: 33123786 DOI: 10.1007/s00134-020-06301-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/13/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Michael P Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Audrey De Jong
- University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France
- Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier Cedex 5, France
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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46
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47
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Brown PM, Rogne T, Solligård E. The promise and pitfalls of composite endpoints in sepsis and COVID-19 clinical trials. Pharm Stat 2020; 20:413-417. [PMID: 32893957 DOI: 10.1002/pst.2070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/18/2020] [Accepted: 08/25/2020] [Indexed: 01/19/2023]
Abstract
Composite endpoints reveal the tendency for statistical convention to arise locally within subfields. Composites are familiar in cardiovascular trials, yet almost unknown in sepsis. However, the VITAMINS trial in patients with septic shock adopted a composite of mortality and vasopressor-free days, and an ordinal scale describing patient status rapidly became standard in COVID studies. Aware that recent use could incite interest in such endpoints, we are motivated to flag their potential value and pitfalls for sepsis research and COVID studies.
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Affiliation(s)
- P M Brown
- Gemini Center for Sepsis Research, Clinic of Anesthesia and Intensive Care, St. Olav's hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tormod Rogne
- Gemini Center for Sepsis Research, Clinic of Anesthesia and Intensive Care, St. Olav's hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Erik Solligård
- Gemini Center for Sepsis Research, Clinic of Anesthesia and Intensive Care, St. Olav's hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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48
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Casey JD, Johnson NJ, Semler MW, Collins SP, Aggarwal NR, Brower RG, Chang SY, Eppensteiner J, Filbin M, Gibbs KW, Ginde AA, Gong MN, Harrell F, Hayden DL, Hough CL, Khan A, Leither LM, Moss M, Oldmixon CF, Park PK, Reineck LA, Ringwood NJ, Robinson BRH, Schoenfeld DA, Shapiro NI, Steingrub JS, Torr DK, Weissman A, Lindsell CJ, Rice TW, Thompson BT, Brown SM, Self WH. Rationale and Design of ORCHID: A Randomized Placebo-controlled Clinical Trial of Hydroxychloroquine for Adults Hospitalized with COVID-19. Ann Am Thorac Soc 2020; 17:1144-1153. [PMID: 32492354 PMCID: PMC7462324 DOI: 10.1513/annalsats.202005-478sd] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/03/2020] [Indexed: 01/02/2023] Open
Abstract
The ORCHID (Outcomes Related to COVID-19 treated with Hydroxychloroquine among In-patients with symptomatic Disease) trial is a multicenter, blinded, randomized trial of hydroxychloroquine versus placebo for the treatment of adults hospitalized with coronavirus disease (COVID-19). This document provides the rationale and background for the trial and highlights key design features. We discuss five novel challenges to the design and conduct of a large, multicenter, randomized trial during a pandemic, including 1) widespread, off-label use of the study drug before the availability of safety and efficacy data; 2) the need to adapt traditional procedures for documentation of informed consent during an infectious pandemic; 3) developing a flexible and robust Bayesian analysis incorporating significant uncertainty about the disease, outcomes, and treatment; 4) obtaining indistinguishable drug and placebo without delaying enrollment; and 5) rapidly obtaining administrative and regulatory approvals. Our goals in describing how the ORCHID trial progressed from study conception to enrollment of the first patient in 15 days are to inform the development of other high-quality, multicenter trials targeting COVID-19. We describe lessons learned to improve the efficiency of future clinical trials, particularly in the setting of pandemics. The ORCHID trial will provide high-quality, clinically relevant data on the safety and efficacy of hydroxychloroquine for the treatment of COVID-19 among hospitalized adults.Clinical trial registered with www.clinicaltrials.gov (NCT04332991).
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Affiliation(s)
- Jonathan D Casey
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine
| | - Nicholas J Johnson
- Department of Emergency Medicine
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, and
| | - Matthew W Semler
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine
| | | | - Neil R Aggarwal
- Division of Lung Diseases, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Roy G Brower
- Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Steven Y Chang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | | | | | - Kevin W Gibbs
- Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - Michelle N Gong
- Division of Epidemiology and Population Health, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, New York
| | - Frank Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Catherine L Hough
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, and
| | - Akram Khan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland, Oregon
| | - Lindsay M Leither
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and University of Utah, Salt Lake City, Utah
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Pauline K Park
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lora A Reineck
- Division of Lung Diseases, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | | | | | | | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Jay S Steingrub
- Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | - Donna K Torr
- Department of Pharmacy Services, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Todd W Rice
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and University of Utah, Salt Lake City, Utah
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49
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Deniau B, Blet A, Santos K, Vaittinada Ayar P, Genest M, Kästorf M, Sadoune M, de Sousa Jorge A, Samuel JL, Vodovar N, Bergmann A, Mebazaa A, Azibani F. Inhibition of circulating dipeptidyl-peptidase 3 restores cardiac function in a sepsis-induced model in rats: A proof of concept study. PLoS One 2020; 15:e0238039. [PMID: 32853284 PMCID: PMC7451654 DOI: 10.1371/journal.pone.0238039] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/07/2020] [Indexed: 12/16/2022] Open
Abstract
Sepsis is a global economic and health burden. Dipeptidyl peptidase 3 (DPP3) is elevated in the plasma of septic patients. The highest levels of circulating DPP3 (cDPP3) are found in non-survivor septic shock patients. The aim of this study was to evaluate the benefits of inhibiting cDPP3 by a specific antibody, Procizumab (PCZ), on cardiac function in an experimental model of sepsis, the caecal ligature and puncture (CLP) model. Rats were monitored by invasive blood pressure and echocardiography. Results are presented as mean ± SD, with p <0.05 considered significant. PCZ rapidly restored left ventricular shortening fraction (from 39 ± 4% to 51 ± 2% before and 30 min after PCZ administration (p = 0.004)). Cardiac output and stroke volume were higher in the CLP + PCZ group when compared to the CLP + PBS group (152 ± 33 mL/min vs 97 ± 25 mL/min (p = 0.0079), and 0.5 ± 0.1 mL vs 0.3 ± 1.0 mL (p = 0.009), respectively) with a markedly reduced plasma DPP3 activity (138 ± 70 U/L in CLP + PCZ group versus 735 ± 255 U/L (p = 0.048) in the CLP + PBS group). Of note, PCZ rapidly reduced oxidative stress in the heart of the CLP + PCZ group when compared to those of the CLP + PBS group (13.3 ± 8.2 vs 6.2 ± 2.5 UI, p = 0.005, 120 min after administration, respectively). Our study demonstrates that inhibition of cDPP3 by PCZ restored altered cardiac function during sepsis in rats.
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Affiliation(s)
- Benjamin Deniau
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis- Lariboisière, AP-HP, Paris, France
- UMR-S 942, INSERM, MASCOT, Paris, France
| | - Alice Blet
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis- Lariboisière, AP-HP, Paris, France
- UMR-S 942, INSERM, MASCOT, Paris, France
| | | | - Prabakar Vaittinada Ayar
- UMR-S 942, INSERM, MASCOT, Paris, France
- Université de Paris, Paris, France
- Emergency Department, University Hospital of Beaujon, APHP, Clichy, France
| | | | | | | | | | | | | | | | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis- Lariboisière, AP-HP, Paris, France
- UMR-S 942, INSERM, MASCOT, Paris, France
- Université de Paris, Paris, France
- * E-mail:
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Affiliation(s)
- Katherine R Courtright
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia.,Department of Medicine, University of Pennsylvania, Philadelphia
| | - Scott D Halpern
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia.,Department of Medicine, University of Pennsylvania, Philadelphia
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