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Pepić A, Stark M, Friede T, Kopp-Schneider A, Calderazzo S, Reichert M, Wolf M, Wirth U, Schopf S, Zapf A. A diagnostic phase III/IV seamless design to investigate the diagnostic accuracy and clinical effectiveness using the example of HEDOS and HEDOS II. Stat Methods Med Res 2024; 33:433-448. [PMID: 38327081 PMCID: PMC10981198 DOI: 10.1177/09622802241227951] [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: 02/09/2024]
Abstract
The development process of medical devices can be streamlined by combining different study phases. Here, for a diagnostic medical device, we present the combination of confirmation of diagnostic accuracy (phase III) and evaluation of clinical effectiveness regarding patient-relevant endpoints (phase IV) using a seamless design. This approach is used in the Thyroid HEmorrhage DetectOr Study (HEDOS & HEDOS II) investigating a post-operative hemorrhage detector named ISAR-M THYRO® in patients after thyroid surgery. Data from the phase III trial are reused as external controls in the control group of the phase IV trial. An unblinded interim analysis is planned between the two study stages which includes a recalculation of the sample size for the phase IV part after completion of the first stage of the seamless design. The study concept presented here is the first seamless design proposed in the field of diagnostic studies. Hence, the aim of this work is to emphasize the statistical methodology as well as feasibility of the proposed design in relation to the planning and implementation of the seamless design. Seamless designs can accelerate the overall trial duration and increase its efficiency in terms of sample size and recruitment. However, careful planning addressing numerous methodological and procedural challenges is necessary for successful implementation as well as agreement with regulatory bodies.
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Affiliation(s)
- Amra Pepić
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Maria Stark
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | | | - Silvia Calderazzo
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Michael Wolf
- CRI—The Clinical Research Institute, Munich, Germany
| | - Ulrich Wirth
- Clinic for General, Visceral and Transplant Surgery, Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Stefan Schopf
- RoMed Klinik Bad Aibling, Academic University Hospital of the Technical University of Munich, Bad Aibling, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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Wirth U, Schardey J, Bonleitner M, Weber D, von Ahnen T, Ladurner R, Andrassy J, Werner J, Schardey HM, Schopf S. A cervical compartment syndrome impairs cerebral circulation in post-thyroidectomy hemorrhage: data from an animal model. Gland Surg 2022; 11:651-662. [PMID: 35531110 PMCID: PMC9068534 DOI: 10.21037/gs-21-910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/25/2022] [Indexed: 06/26/2024]
Abstract
BACKGROUND Post thyroidectomy hemorrhage is a potentially life-threatening complication. As the mechanism leading to hypoxemic brain damage and death is still unknown, our aim was to examine the underlaying pathophysiology in an animal model. METHODS A series of experiments was performed in our established model for post thyroidectomy hemorrhage in 6 pigs. First, post thyroidectomy hemorrhage was simulated with an artificial increase of cervical compartment pressure. Second, spontaneous bleeding into the cervical compartment was initiated. Primary outcome measure is the correlation between cerebral oxygenation and cervical compartment pressure. RESULTS With an increase in cervical compartment pressure apnea could be detected in all experiments. A significant 24.2% (9.5-34.4%) decrease of cerebral oxygenation at time of apnea (47.0%; 38.0-65.0%) compared to baseline values (63.5%; 56.0-74.0%; P=0.043) occurred due increase of cervical compartment pressure concurrent with an impaired cerebral perfusion. Apnea occurred about 200 sec after a 10% decrease of cerebral oxygenation, but 35 sec before a 10% decrease of peripheral oxygenation. Spontaneous bleeding into the cervical compartment causes an increase of cervical compartment pressure reaching levels of the mean arterial blood pressure 56.0 (35.0-72.0) mmHg. CONCLUSIONS Peripheral hypoxemia occurs with relevant delay in time after decrease of cerebral perfusion and cerebral hypoxemia, therefore cerebral hypoxemia seems to be causal for a central apnea. With this evidence of impaired cerebral perfusion and cerebral hypoxemia due to an increased cervical compartment pressure we can disprove the historic theory of tracheal collapse due to a compressive hematoma in post thyroidectomy hemorrhage. A cervical compartment syndrome seems to be causal, not only for brain hypoxemia but also an additional laryngo-pharyngeal mucosal edema.
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Affiliation(s)
- Ulrich Wirth
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- Institute for Surgical Research Oberbayern, Hausham, Germany
| | - Josefine Schardey
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- Institute for Surgical Research Oberbayern, Hausham, Germany
| | - Magdalena Bonleitner
- Department for General, Visceral, Endocrine and Vascular Surgery, Krankenhaus Agatharied GmbH, Hausham, Germany
| | - Desiree Weber
- Department for General, Visceral, Endocrine and Vascular Surgery, Krankenhaus Agatharied GmbH, Hausham, Germany
- Center for Anesthesiology, Regional Hospital Lörrach, Lörrach, Germany
| | - Thomas von Ahnen
- Institute for Surgical Research Oberbayern, Hausham, Germany
- Department for General, Visceral, Endocrine and Vascular Surgery, Krankenhaus Agatharied GmbH, Hausham, Germany
| | - Roland Ladurner
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Hans Martin Schardey
- Institute for Surgical Research Oberbayern, Hausham, Germany
- Department for General, Visceral, Endocrine and Vascular Surgery, Krankenhaus Agatharied GmbH, Hausham, Germany
| | - Stefan Schopf
- Institute for Surgical Research Oberbayern, Hausham, Germany
- Surgical Department, RoMed Klink Bad Aibling, Bad Aibling, Germany
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Emil Tampu I, Maintz M, Koller D, Johansson K, Gimm O, Capitanio A, Eklund A, Haj-Hosseini N. Optical coherence tomography for thyroid pathology: 3D analysis of tissue microstructure. BIOMEDICAL OPTICS EXPRESS 2020; 11:4130-4149. [PMID: 32923033 PMCID: PMC7449746 DOI: 10.1364/boe.394296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 06/11/2023]
Abstract
To investigate the potential of optical coherence tomography (OCT) to distinguish between normal and pathologic thyroid tissue, 3D OCT images were acquired on ex vivo thyroid samples from adult subjects (n=22) diagnosed with a variety of pathologies. The follicular structure was analyzed in terms of count, size, density and sphericity. Results showed that OCT images highly agreed with the corresponding histopatology and the calculated parameters were representative of the follicular structure variation. The analysis of OCT volumes provides quantitative information that could make automatic classification possible. Thus, OCT can be beneficial for intraoperative surgical guidance or in the pathology assessment routine.
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Affiliation(s)
- Iulian Emil Tampu
- Department of Biomedical Engineering, Linköping University, Linköping 581 85, Sweden
| | - Michaela Maintz
- Department of Biomedical Engineering, Linköping University, Linköping 581 85, Sweden
| | - Daniela Koller
- Department of Biomedical Engineering, Linköping University, Linköping 581 85, Sweden
| | - Kenth Johansson
- Department of Surgery, Västervik Hospital and Örebro University Hospital, Västervik and Örebro, Sweden
| | - Oliver Gimm
- Department of Surgery, and Department of Biomedical and Clinical Sciences, Linköping University Hospital and Linköping University, Linköping 581 85, Sweden
| | - Arrigo Capitanio
- Department of Clinical Pathology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping 581 85, Sweden
| | - Anders Eklund
- Department of Biomedical Engineering, Linköping University, Linköping 581 85, Sweden
- Division of Statistics & Machine Learning, Department of Computer and Information Science, Linköping University, Linköping 581 83, Sweden
- Center for Medical Image Science and Visualization, Linköping University, Linköping 581 85, Sweden
| | - Neda Haj-Hosseini
- Department of Biomedical Engineering, Linköping University, Linköping 581 85, Sweden
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