1
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Jia P, Wang L, Yang X, Pei W, Xu C, Feng J, Han Y. The quality of reporting in case reports of permanent neonatal diabetes mellitus: a cross-sectional study. BMC Med Res Methodol 2024; 24:117. [PMID: 38769533 PMCID: PMC11103994 DOI: 10.1186/s12874-024-02226-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 04/22/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Although randomized trials and systematic reviews provide the best evidence to guide medical practice, many permanent neonatal diabetes mellitus (PNDM) studies have been published as case reports. However, the quality of these studies has not been assessed. The purpose of this study was to assess the extent to which the current case reports for PNDM comply with the Case Report (CARE) guidelines and to explore variables associated with the reporting. METHOD Six English and four Chinese databases were searched from their inception to December 2022 for PNDM case reports. The 23 items CARE checklist was used to measure reporting quality. Primary outcome was the adherence rate of each CARE item and second outcome was total reporting score for each included PNDM case report. Linear and logistic regression analyses were used to examine the connection between five pre-specified predictor variables and the reporting quality. The predictor variables were impact factor of the published journal (<3.4 vs. ≥3.4, categorized according to the median), funding (yes vs. no), language (English vs. other language), published journal type (general vs. special) and year of publication (>2013 vs. ≤ 2013). RESULT In total, 105 PNDM case reports were included in this study. None of the 105 PNDM case reports fulfilled all 23 items of the CARE checklist. The response rate of 11 items were under 50%, including prognostic characteristics presentation (0%), patient perspective interpretation (0%), diagnostic challenges statement (2.9%), clinical course summary (21.0%), diagnostic reasoning statement (22.9%), title identification (24.8%), case presentation (33.3%), disease history description (34.3%), strengths and limitations explanation (41.0%), informed consent statement (45.7%), and lesson elucidation (47.6%). This study identified that the PNDM case reports published in higher impact factor journals were statistically associated with a higher reporting quality. CONCLUSION The reporting of case reports for PNDM is generally poor. As a result, this information may be misleading to providers, and the clinical applications may be detrimental to patient care. To improve reporting quality, journals should encourage strict adherence to the CARE guidelines.
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Affiliation(s)
- Pengli Jia
- School of Management, Shanxi Medical University, Taiyuan, China
| | - Ling Wang
- The Second Clinical Medical College of Anhui Medical University, Hefei, China
| | - Xi Yang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, China
| | - WenTing Pei
- The Second Clinical Medical College of Anhui Medical University, Hefei, China
| | - Chang Xu
- Proof of Concept Center, Eastern Hepatobiliary Surgery Hospital, Third Affiliated Hospital, Second Military Medical University, Naval Medical University, Shanghai, China
| | - Jinglin Feng
- School of Management, Shanxi Medical University, Taiyuan, China
| | - Ying Han
- School of Management, Shanxi Medical University, Taiyuan, China.
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2
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Thach NN. Applying Monte Carlo Simulations to a Small Data Analysis of a Case of Economic Growth in COVID-19 Times. SAGE OPEN 2023; 13:21582440231181540. [PMID: 37362768 PMCID: PMC10285188 DOI: 10.1177/21582440231181540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Studies on the going-on COVID-19 pandemic face small sample issues. In this context, Bayesian estimation is considered a viable alternative to frequentist estimation. Demonstrating the Bayesian approach's advantage in dealing with this problem, our research conducted a case study concerning ASEAN economic growth during the COVID-19 pandemic. By using Monte Carlo standard errors and interval hypothesis testing to check parameter bias within a Bayesian MCMC simulation study, the author obtained significant conclusions as follows: first, in insufficient sample sizes, in contrast to frequentist estimation, the Bayesian framework can offer meaningful results, that is, expansionary monetary and contractionary fiscal policies are positively associated with economic growth; second, in the face of a small sample, by incorporating more information into prior distributions for the model parameters, Bayesian Monte Carlo simulations perform so far better than naïve Bayesian and frequentist estimation; third, in case of a correctly specified prior, the inferences are robust to different prior specifications. The author strongly recommends applying specific informative priors to Bayesian analyses, particularly in small sample investigations.
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3
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Afolabi MO, Kelly LE. Non-static framework for understanding adaptive designs: an ethical justification in paediatric trials. JOURNAL OF MEDICAL ETHICS 2022; 48:825-831. [PMID: 34362828 PMCID: PMC9626916 DOI: 10.1136/medethics-2021-107263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/25/2021] [Indexed: 06/13/2023]
Abstract
Many drugs used in paediatric medicine are off-label. There is a rising call for the use of adaptive clinical trial designs (ADs) in responding to the need for safe and effective drugs given their potential to offer efficiency and cost-effective benefits compared with traditional clinical trials. ADs have a strong appeal in paediatric clinical trials given the small number of available participants, limited understanding of age-related variability and the desire to limit exposure to futile or unsafe interventions. Although the ethical value of adaptive trials has increasingly come under scrutiny, there is a paucity of literature on the ethical dilemmas that may be associated with paediatric adaptive designs (PADs). This paper highlights some of these ethical concerns around safety, scientific/social value and caregiver/guardian comprehension of the trial design. Against this background, the paper develops a non-static conceptual lens for understanding PADs. It shows that ADs are epistemically open and reduce some of the knowledge-associated uncertainties inherent in clinical trials as well as fast-track the time to draw conclusions about the value of evaluated drugs/treatments. On this note, the authors argue that PADs are ethically justifiable given they (1) have multiple layers of safety, exposing enrolled children to lesser potential risks, (2) create social/scientific value generally and for paediatric populations in particular, (3) specifically foster the flourishing of paediatric populations and (4) can significantly improve paediatric trial efficiency when properly designed and implemented. However, because PADs are relatively new and their regulatory, ethical and logistical characteristics are yet to be clarified in some jurisdictions, the cooperation of various public and private stakeholders is required to ensure that the interests of children, their caregivers and parents/guardians are best served while exposing paediatric research subjects to the most minimal of risks when they are enrolled in paediatric trials that use ADs.
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Affiliation(s)
- Michael Os Afolabi
- Department of Pediatrics and Child Health, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lauren E Kelly
- Department of Pediatrics and Child Health, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada
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4
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Izem R, McCarter R. Randomized and non-randomized designs for causal inference with longitudinal data in rare disorders. Orphanet J Rare Dis 2021; 16:491. [PMID: 34814939 PMCID: PMC8609847 DOI: 10.1186/s13023-021-02124-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 11/06/2021] [Indexed: 11/10/2022] Open
Abstract
In the United States, approximately 7000 rare diseases affect 30 million patients, and only 10% of these diseases have existing therapies. Sound study design and causal inference methods are essential to demonstrate the therapeutic efficacy, safety, and effectiveness of new therapies. In the rare diseases setting, several factors challenge the use of typical parallel control designs: the small patient population size, genotypic and phenotypic diversity, and the complexity and incomplete understanding of the disorder’s progression. Repeated measures, when spaced appropriately relative to disease progression and exploited in design and analysis, can increase study power and reduce variability in treatment effect estimation. This paper reviews these longitudinal designs and draws the parallel between some new and existing randomized studies in rare diseases and their less well-known controlled observational study designs. We show that self-controlled randomized crossover and N-of-1 designs have similar considerations as the observational case series and case-crossover designs. Also, randomized sequential designs have similar considerations to longitudinal cohort studies using sequential matching or weighting to control confounding. We discuss design and analysis considerations for valid causal inference and illustrate them with examples of analyses in multiple rare disorders, including urea cycle disorder and cystic fibrosis.
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Affiliation(s)
- Rima Izem
- Division of Biostatistics and Study Methodology, Children's Research Institute at Children's National Medical Center, The George Washington University, Washington, DC, USA.
| | - Robert McCarter
- Division of Biostatistics and Study Methodology, Children's Research Institute at Children's National Medical Center, The George Washington University, Washington, DC, USA
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5
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Yates J, Gutiérrez-Sacristán A, Jouhet V, LeBlanc K, Esteves C, DeSain TN, Benik N, Stedman J, Palmer N, Mellon G, Kohane I, Avillach P. Finding commonalities in rare diseases through the undiagnosed diseases network. J Am Med Inform Assoc 2021; 28:1694-1702. [PMID: 34009343 PMCID: PMC8324228 DOI: 10.1093/jamia/ocab050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/05/2021] [Indexed: 11/14/2022] Open
Abstract
Objective When studying any specific rare disease, heterogeneity and scarcity of affected individuals has historically hindered investigators from discerning on what to focus to understand and diagnose a disease. New nongenomic methodologies must be developed that identify similarities in seemingly dissimilar conditions. Materials and Methods This observational study analyzes 1042 patients from the Undiagnosed Diseases Network (2015-2019), a multicenter, nationwide research study using phenotypic data annotated by specialized staff using Human Phenotype Ontology terms. We used Louvain community detection to cluster patients linked by Jaccard pairwise similarity and 2 support vector classifier to assign new cases. We further validated the clusters’ most representative comorbidities using a national claims database (67 million patients). Results Patients were divided into 2 groups: those with symptom onset before 18 years of age (n = 810) and at 18 years of age or older (n = 232) (average symptom onset age: 10 [interquartile range, 0-14] years). For 810 pediatric patients, we identified 4 statistically significant clusters. Two clusters were characterized by growth disorders, and developmental delay enriched for hypotonia presented a higher likelihood of diagnosis. Support vector classifier showed 0.89 balanced accuracy (0.83 for Human Phenotype Ontology terms only) on test data. Discussions To set the framework for future discovery, we chose as our endpoint the successful grouping of patients by phenotypic similarity and provide a classification tool to assign new patients to those clusters. Conclusion This study shows that despite the scarcity and heterogeneity of patients, we can still find commonalities that can potentially be harnessed to uncover new insights and targets for therapy.
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Affiliation(s)
- Josephine Yates
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Vianney Jouhet
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberly LeBlanc
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Cecilia Esteves
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Thomas N DeSain
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Nick Benik
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason Stedman
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Nathan Palmer
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Guillaume Mellon
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Isaac Kohane
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Avillach
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
- Corresponding Author: Paul Avillach, MD, PhD, 10 Shattuck Street, 02115 Boston, MA, USA;
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6
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Safety and Efficacy of Intermittent Colonic Exoperistalsis Device to Treat Chronic Constipation: A Prospective Multicentric Clinical Trial. Clin Transl Gastroenterol 2021; 11:e00267. [PMID: 33512794 PMCID: PMC7671882 DOI: 10.14309/ctg.0000000000000267] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Chronic constipation is associated with various comorbidities and reduced quality of life. Current solutions, either pharmacological or invasive, show limited efficacy. Manual colon-specific massage is a well-established intervention to treat chronic constipation, but it should be applied daily. MOWOOT automatically provides intermittent colonic exo-peristalsis (ICE) treatment like that in manual massage.
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7
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Barriuso J, Lamarca A. Clinical and Translational Research Challenges in Neuroendocrine Tumours. Curr Med Chem 2020; 27:4823-4839. [PMID: 32031064 DOI: 10.2174/0929867327666200207120725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 12/04/2019] [Accepted: 01/16/2020] [Indexed: 12/31/2022]
Abstract
Neuroendocrine tumours (NETs) represent a range of neoplasms that may arise from any (neuro)endocrine cell situated in any part of the human body. As any other rare diseases, NETs face several difficulties in relation to research. This review will describe some of the main challenges and proposed solutions faced by researchers with expertise in rare malignancies. Some of the most common challenges in clinical and translational research are enumerated in this review, covering aspects from clinical, translational and basic research. NETs being a heterogeneous group of diseases and a limited sample size of clinical and translational research projects are the main challenges. Challenges with NETs lay over the disparities between healthcare models to tackle rare diseases. NETs add an extra layer of complexity due to a numerous group of different entities. Prospective real-world data trials are an opportunity for rare cancers with the revolution of electronic health technologies. This review explores potential solutions to these challenges that could be useful not only to the NET community but also to other rare tumours researchers.
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Affiliation(s)
- Jorge Barriuso
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Angela Lamarca
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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8
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Sieluk J, Slejko JF, Silverman H, Perfetto E, Mullins CD. Medical costs of Alpha-1 antitrypsin deficiency-associated COPD in the United States. Orphanet J Rare Dis 2020; 15:260. [PMID: 32967697 PMCID: PMC7510284 DOI: 10.1186/s13023-020-01523-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 08/24/2020] [Indexed: 11/25/2022] Open
Abstract
Background There are limited data on economic aspects of the genetic variant of chronic obstructive pulmonary disease (COPD) in the context of the more prevalent form of COPD. The objective of this study was to isolate the healthcare resource utilization and economic burden attributable to the presence of a genetic factor among COPD patients with and without Alpha-1 Antitrypsin Deficiency (AATD), twelve months before and after their initial COPD diagnosis. Methods Retrospective analysis of OptumLabs® Data Warehouse claims (OLDW; 2000–2017). The OLDW is a comprehensive, longitudinal real-world data asset with de-identified lives across claims and clinical information. AATD-associated COPD cases were matched with up to 10 unique non-AATD-associated COPD controls. Healthcare resource use and costs were assigned into the following categories: office (OV), outpatient (OP), and emergency room visits (ER), inpatients stays (IP), prescription drugs (RX), and other services (OTH). A generalized linear model was used to estimate total pre- and post-index (initial COPD diagnosis) costs from a third-party payer’s perspective (2018 USD) controlling for confounders. Healthcare resource utilization was estimated using a negative binomial regression. Results The study population consisted of 8881 patients (953 cases matched with 7928 controls). The AATD-associated COPD cohort had higher expenditures and use of office visits (OV) and other (OTH) services, as well as OV, outpatient (OP), emergency room (ER), and prescription drugs (RX) before and after the index date, respectively. Adjusted total all-healthcare cost ratios for AATD-associated COPD patients as compared to controls were 2.04 [95% CI: 1.60–2.59] and 1.98 [95% CI: 1.55–2.52] while the incremental cost difference totaled $6861 [95% CI: $3025 - $10,698] and $5772 [95% CI: $1940 - $9604] per patient before and after the index date, respectively. Conclusions Twelve months before and after their initial COPD diagnosis, patients with AATD incur higher healthcare utilization costs that are double the cost of similar COPD patients without AATD. This study also suggests that increased costs of AATD-associated COPD are not solely attributable to augmentation therapy use. Future studies should further explore the relationship between augmentation therapy, healthcare resource use, and other AATD-associated COPD expenditures.
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Affiliation(s)
- Jan Sieluk
- Pharmaceutical Health Services Research Department, University of Maryland, School of Pharmacy, 220 Arch Street, Baltimore, MD, 21201, USA.,OptumLabs Visiting Fellow, OptumLabs, Cambridge, MA, USA
| | - Julia F Slejko
- Pharmaceutical Health Services Research Department, University of Maryland, School of Pharmacy, 220 Arch Street, Baltimore, MD, 21201, USA
| | - Henry Silverman
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eleanor Perfetto
- Pharmaceutical Health Services Research Department, University of Maryland, School of Pharmacy, 220 Arch Street, Baltimore, MD, 21201, USA.,National Health Council, Washington, DC, USA
| | - C Daniel Mullins
- Pharmaceutical Health Services Research Department, University of Maryland, School of Pharmacy, 220 Arch Street, Baltimore, MD, 21201, USA.
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9
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El Taguri A, Nasef A. The world is waiting, use sequential analysis and get us the evidence-based treatment we need for COVID-19. Libyan J Med 2020; 15:1770518. [PMID: 32459574 PMCID: PMC7646536 DOI: 10.1080/19932820.2020.1770518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
In spite of the relatively high morbidity and mortality, there is no approved medication yet for COVID-19. There are more than 200 ongoing trials on different drugs or vaccines, but new medications may take until 2021 to develop. Defining the optimal number of patients to be included in a study is a considerable challenge in these interventional researches. Ethical considerations prompt researchers to minimize the number of patients included in a trial. This gains particular importance when the disease is rare or lethal which is particularly so in the case of COVID-19. It is of paramount importance to explore some of the available tools that could help accelerate the adoption of any or some of the many proposed modalities for the treatment of diseases. These tools should be effective, yet efficient, for rapid testing of such treatments. Sequential analysis has not been frequently used in many clinical trials where it should have been used. None of the authors in published literature, as far as we know, used sequential analysis techniques to test potential drugs for COVID-19. In addition to its usefulness when the results of new forms of treatment are quickly needed, other important benefit of sequential analysis includes the ability to reach a similar conclusion about the utility of a new drug without unduly exposing more patients to the side effect of the old drug, in particularly, for the treatment of a rare disease.
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Affiliation(s)
- Adel El Taguri
- National Center for Accreditation of Health Establishments- , Tripoli-Libya, Libya.,Community Medicine Department, Faculty of Medicine-University of Tripoli , Tripoli-Libya, Libya
| | - Aisha Nasef
- Authority of Natural Science Research and Technology , Tripoli-Libya, Libya.,Scientific Council of Laboratory Medicine, Medical Specialty council , Tripoli-Libya, Libya
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10
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Hepburn CM, Gilpin A, Autmizguine J, Denburg A, Dupuis LL, Finkelstein Y, Gruenwoldt E, Ito S, Jong G, Lacaze-Masmonteil T, Levy D, Macleod S, Miller SP, Offringa M, Pinsk M, Power B, Rieder M, Litalien C. L’amélioration des médicaments à usage pédiatrique : une prescription pour les enfants et les adolescents canadiens. Paediatr Child Health 2019. [DOI: 10.1093/pch/pxz094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Andrea Gilpin
- Le Centre de formulations pédiatriques de la famille Rosalind et Morris Goodman du Centre hospitalier universitaire Sainte-Justine, Montréal (Québec)
| | - Julie Autmizguine
- Le Centre de formulations pédiatriques de la famille Rosalind et Morris Goodman du Centre hospitalier universitaire Sainte-Justine, Montréal (Québec)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Catherine Litalien
- Le Centre de formulations pédiatriques de la famille Rosalind et Morris Goodman du Centre hospitalier universitaire Sainte-Justine, Montréal (Québec)
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11
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Hepburn CM, Gilpin A, Autmizguine J, Denburg A, Dupuis LL, Finkelstein Y, Gruenwoldt E, Ito S, Jong G', Lacaze-Masmonteil T, Levy D, Macleod S, P Miller S, Offringa M, Pinsk M, Power B, Rieder M, Litalien C. Improving paediatric medications: A prescription for Canadian children and youth. Paediatr Child Health 2019; 24:333-339. [PMID: 31379437 DOI: 10.1093/pch/pxz079] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 04/18/2019] [Indexed: 12/24/2022] Open
Affiliation(s)
| | - Andrea Gilpin
- The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Julie Autmizguine
- The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Avram Denburg
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - L Lee Dupuis
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Yaron Finkelstein
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Emily Gruenwoldt
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Shinya Ito
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Geert 't Jong
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Thierry Lacaze-Masmonteil
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Deborah Levy
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Stuart Macleod
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Steven P Miller
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Martin Offringa
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Maury Pinsk
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Barry Power
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Michael Rieder
- Canadian Paediatric Society, Ottawa, Ontario.,The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
| | - Catherine Litalien
- The Rosalind and Morris Goodman Family Pediatric Formulations Centre of the Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec
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12
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Ruggenenti P, Daina E, Gennarini A, Carrara C, Gamba S, Noris M, Rubis N, Peraro F, Gaspari F, Pasini A, Rigotti A, Lerchner RM, Santoro D, Pisani A, Pasi A, Remuzzi G. C5 Convertase Blockade in Membranoproliferative Glomerulonephritis: A Single-Arm Clinical Trial. Am J Kidney Dis 2019; 74:224-238. [PMID: 30929851 DOI: 10.1053/j.ajkd.2018.12.046] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 12/26/2018] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Primary membranoproliferative glomerulonephritis (MPGN) is a rare glomerulopathy characterized by complement dysregulation. MPGN progresses rapidly to kidney failure when it is associated with nephrotic syndrome. We assessed the effects of C5 convertase blockade in patients with MPGN and terminal complement activation. STUDY DESIGN Prospective off-on-off-on open-label clinical trial. SETTING & PARTICIPANTS Consenting patients with immune complex-mediated MPGN (n=6) or C3 glomerulonephritis (n=4) with sC5b-9 (serum complement membrane attack complex) plasma levels>1,000ng/mL and 24-hour proteinuria with protein excretion>3.5g identified from the Italian Registry of MPGN and followed up at the Istituto di Ricerche Farmacologiche Mario Negri IRCCS (Bergamo, Italy) between March 4, 2014, and January 7, 2015. INTERVENTION Anti-C5 monoclonal antibody eculizumab administered during 2 sequential 48-week treatment periods separated by one 12-week washout period. OUTCOMES Primary outcome was change in 24-hour proteinuria (median of 3 consecutive measurements) at 24 and 48 weeks. RESULTS Median proteinuria decreased from protein excretion of 6.03 (interquartile range [IQR], 4.8-12.4) g/d at baseline to 3.74 (IQR, 3.2-4.4) g/d at 24 weeks (P=0.01) and to 5.06 (IQR, 3.1-5.8) g/d (P=0.006) at 48 weeks of treatment, recovered toward baseline during the washout period, and did not significantly decrease thereafter. Hypoalbuminemia, dyslipidemia, and glomerular sieving function improved during the first treatment period. 3 patients achieved partial remission of nephrotic syndrome and all had undetectable C3 nephritic factors before treatment. Mean measured glomerular filtration rate was 69.7±35.2 versus 87.4±55.1 and 75.8±42.7 versus 76.6±44.1mL/min/1.73m2 at the start versus the end of the first and second treatment periods, respectively, among all 10 study participants. Unlike C3, sC5b-9 plasma levels normalized during both treatment periods and recovered toward baseline during the washout in all patients. LIMITATIONS Single-arm design, small sample size. CONCLUSIONS Eculizumab blunted terminal complement activation in all patients with immune complex-mediated MPGN or C3 glomerulonephritis and nephrotic syndrome, but persistently reduced proteinuria in just a subgroup. TRIAL REGISTRATION Registered in the EU Clinical Trials Register with study no. 2013-003826-10.
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Affiliation(s)
- Piero Ruggenenti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Erica Daina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Alessia Gennarini
- Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Camillo Carrara
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; Unit of Nephrology and Dialysis, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Sara Gamba
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Nadia Rubis
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco Peraro
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Flavio Gaspari
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Andrea Pasini
- Nephrology and Dialysis Unit, Department of Pediatrics, Azienda Ospedaliero Universitaria, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | - Angelo Rigotti
- Unit of Nephrology and Dialysis, Ospedale Infermi di Rimini, AUSL della Romagna, Bolzano, Italy
| | | | - Domenico Santoro
- Unit of Nephrology and Dialysis, Policlinico "G. Martino", Messina, Italy
| | - Antonio Pisani
- Cattedra di Nefrologia, Università Federico II, Napoli, Italy
| | | | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.
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Kelly LE, Dyson MP, Butcher NJ, Balshaw R, London AJ, Neilson CJ, Junker A, Mahmud SM, Driedger SM, Wang X. Considerations for adaptive design in pediatric clinical trials: study protocol for a systematic review, mixed-methods study, and integrated knowledge translation plan. Trials 2018; 19:572. [PMID: 30340624 PMCID: PMC6194696 DOI: 10.1186/s13063-018-2934-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 09/24/2018] [Indexed: 11/25/2022] Open
Abstract
Background Although children have historically been excluded from clinical trials (CTs), many require medicines tested and approved in CTs, forcing health care providers to treat their pediatric patients based on extrapolated data. Unfortunately, traditional randomized CTs can be slow and resource-intensive, and they often require multi-center collaboration. However, an adaptive design (AD) framework for CTs could be used to increase the efficiency of pediatric CTs by incorporating prospectively planned modifications to CT methods without undermining the integrity or validity of the study. There are many possible adaptations, but each will have ethical, logistical, and statistical implications. It remains unclear which adaptations (or combinations thereof) will lead to real-world improvements in pediatric CT efficiency. This study will identify, evaluate, and synthesize the various regulatory, ethical, logistical, and statistical considerations and emerging issues of AD in CTs that could be used to evaluate the use of drugs in children. Methods/design Following the development of a peer-reviewed search strategy, a systematic review on AD in CTs will be conducted. Data on regulatory, ethical, logistic, and statistical considerations as well as population and trial design characteristics will be synthesized. A mixed-methods study including surveys and focus groups with regulators, research ethics board members, biostatisticians, clinicians, and scientists, as well as representatives from patient groups and the public will evaluate the opportunities and challenges in applying AD in trials enrolling children and propose recommendations on best practices. Discussion This study will deliver practical recommendations on the use of AD in pediatric CTs. Collaboration and consultation with national and global partners will ensure that our results meet the needs of researchers, regulators, and patients, both locally and globally, and that they remain current and relevant by engaging a wide variety of stakeholders. Overall, this research will enrich the knowledge base regarding if, how, and when AD can be used to answer research questions with fewer resources while still meeting the highest ethical standards and regulatory requirements for CTs. In turn, this will result in increased high-quality clinical research needed by health care providers so they have access to appropriate, population-specific evidence regarding the safe and effective use of medicines in children.
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Affiliation(s)
- Lauren E Kelly
- Department of Pediatrics and Child Health, The University of Manitoba, 405 Chown, 753 McDermot Ave., Winnipeg, MB, R3E0T6, Canada. .,Clinical Trials Platform, George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada. .,Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
| | - Michele P Dyson
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Nancy J Butcher
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Robert Balshaw
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Data Science Platform, George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
| | - Alex John London
- Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Christine J Neilson
- Neil John Maclean Health Sciences Library, University of Manitoba, Winnipeg, MB, Canada
| | - Anne Junker
- Department of Allergy and Immunology, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Salaheddin M Mahmud
- Clinical Trials Platform, George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada.,Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Vaccine and Drug Evaluation Centre, University of Manitoba, Winnipeg, MB, Canada
| | - S Michelle Driedger
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Xikui Wang
- Department of Statistics, University of Manitoba, Winnipeg, MB, Canada
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14
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Tingley K, Coyle D, Graham ID, Sikora L, Chakraborty P, Wilson K, Mitchell JJ, Stockler-Ipsiroglu S, Potter BK. Using a meta-narrative literature review and focus groups with key stakeholders to identify perceived challenges and solutions for generating robust evidence on the effectiveness of treatments for rare diseases. Orphanet J Rare Dis 2018; 13:104. [PMID: 29954425 PMCID: PMC6022712 DOI: 10.1186/s13023-018-0851-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/20/2018] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION For many rare diseases, strong analytic study designs for evaluating the efficacy and effectiveness of interventions are challenging to implement because of small, geographically dispersed patient populations and underlying clinical heterogeneity. The objective of this study was to integrate perspectives from published literature and key rare disease stakeholders to better understand the perceived challenges and proposed methodological approaches to research on clinical interventions for rare diseases. METHODS We used a meta-narrative literature review and focus group interviews with key rare disease stakeholders to better understand the perceived challenges in generating and synthesizing treatment effectiveness evidence, and to describe various research methods for mitigating these identified challenges. Data from both components of this study were synthesized narratively according to research paradigms that emerged from our data. RESULTS Results from our meta-narrative literature review and focus group interviews revealed three fundamental challenges in generating robust treatment effectiveness evidence for rare diseases: i) limitations in recruiting a sufficient sample size to achieve planned statistical power; ii) inability to account for clinical heterogeneity and assess treatment effects across a clinical spectrum; and iii) reliance on short-term, surrogate outcomes whose clinical relevance is often unclear. We mapped these challenges and associated solutions to three interrelated research paradigms: i) explanatory evidence generation; ii) comparative effectiveness/pragmatic evidence generation; and iii) patient-oriented evidence generation. Within each research paradigm, numerous criticisms and potential solutions have been described with respect to overcoming these challenges from a research study design perspective. CONCLUSIONS Over time, discussions about clinical research for interventions for rare diseases have moved beyond methodological approaches to overcome challenges related to explanatory evidence generation, with increased recognition of the importance of pragmatic and patient-oriented evidence. Future directions for our work include developing a framework to expand current evidence synthesis practices to take into consideration many of the concepts discussed in this paper.
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Affiliation(s)
- Kylie Tingley
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
| | - Ian D. Graham
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, ON Canada
| | - Pranesh Chakraborty
- Metabolics and Newborn Screening, Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, ON Canada
- Department of Pediatrics, University of Ottawa, Ottawa, ON Canada
- Newborn Screening Ontario, Ottawa, ON Canada
| | - Kumanan Wilson
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - John J. Mitchell
- Department of Pediatrics and Department of Medical Genetics, McGill University Health Centre, Montreal, QC, Canada
| | - Sylvia Stockler-Ipsiroglu
- Division of Biochemical Diseases, BC Children’s Hospital, Vancouver, BC Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC Canada
| | - Beth K. Potter
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
| | - in collaboration with the Canadian Inherited Metabolic Diseases Research Network
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
- Health Sciences Library, University of Ottawa, Ottawa, ON Canada
- Metabolics and Newborn Screening, Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, ON Canada
- Department of Pediatrics, University of Ottawa, Ottawa, ON Canada
- Newborn Screening Ontario, Ottawa, ON Canada
- Department of Pediatrics and Department of Medical Genetics, McGill University Health Centre, Montreal, QC, Canada
- Division of Biochemical Diseases, BC Children’s Hospital, Vancouver, BC Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC Canada
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15
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Randomized controlled trials in pediatric patients had higher completion rates than adult trials: a cross-sectional study. J Clin Epidemiol 2018; 100:53-60. [PMID: 29705092 DOI: 10.1016/j.jclinepi.2018.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 04/09/2018] [Accepted: 04/20/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Conduct of clinical trials is perceived to be more challenging in children than in adults. This study aimed to evaluate the impact of the age of participants on completion rates of randomized controlled trials (RCTs). STUDY DESIGN AND SETTING A cross-sectional study on RCTs registered in the ClinicalTrials.gov database. All RCTs registered up to December 31, 2016, were extracted and were classified according to their recruitment status: active, completed, or discontinued and according to the age of participants: children (<17 years), adults (≥18 years), and mixed-age population. A logistic regression model was applied to assess the impact of participant's age category on trial completion while controlling for other relevant trial features. RESULTS A total of 65,095 registered RCTs were identified. Among pediatric trials, 49.9% were completed and 8.5% were discontinued. Among adult and mixed age RCTs, respectively, 49.7% and 47.9% were completed whereas, 10.2% and 9.4% were discontinued. Overall, pediatric and mixed age RCTs were more likely to be registered as completed than adult RCTs (odds ratio: 1.16, 95% CI: 1.02-1.30; odds ratio: 1.15, 95% CI: 1.04-1.27, respectively). Also, funding source, type of intervention under evaluation, primary trial purpose, use of a blinding procedure, use of a placebo, and participants' assignment model were identified as independent predictors of RCT completion. CONCLUSION Contrary to current perceptions and despite several specific challenges, recruitment of children and adolescents is not a limiting factor to completing a RCT. Other study features such as funding source, impact completeness and should be carefully considered before initiating research.
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16
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van Eijk RPA, Nikolakopoulos S, Ferguson TA, Liu D, Eijkemans MJC, van den Berg LH. Increasing the efficiency of clinical trials in neurodegenerative disorders using group sequential trial designs. J Clin Epidemiol 2018; 98:80-88. [PMID: 29486281 DOI: 10.1016/j.jclinepi.2018.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/21/2017] [Accepted: 02/16/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Clinical trials in neurodegenerative disorders are facing high futility rates and rising development costs. We aim to review and exemplify the value of group sequential trial designs (i.e., designs with one or more prospectively planned interim analyses) within the field of amyotrophic lateral sclerosis. STUDY DESIGN AND SETTING We reviewed the literature to identify sequentially conducted trials. Subsequently, we reanalyzed the dexpramipexole trial (EMPOWER), a classically designed and conducted trial involving 942 participants, by sequentially monitoring the functional questionnaire and survival endpoint. Finally, we simulated the performance of the sequential methodology under different treatment effects. RESULTS Only six (12%) randomized, placebo-controlled trials incorporated stopping rules for both futility and superiority. Despite its high enrollment rate, sequential reanalysis of the EMPOWER study reduced the total trial duration with 140 days (23.4%, 95% confidence interval [CI] 13.2-34.4%), the number of follow-ups with 2,688 visits (23.6%, 95% CI 11.3-38.6%), and the total drug exposure time with 73,377 days (20.6%, 95% CI 9.8-35.9%). The functional questionnaire considerably increased the heterogeneity in the test statistics, which may negatively affect sequential monitoring. CONCLUSION Group sequential trials can result in important reductions in the trial duration, which could make clinical trials more ethical by reducing the patients' exposure to noneffective treatments or by limiting their time on placebo.
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Affiliation(s)
- Ruben P A van Eijk
- Department of Neurology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Stavros Nikolakopoulos
- Department of Biostatistics and Research Support, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | - Marinus J C Eijkemans
- Department of Biostatistics and Research Support, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Whicher D, Philbin S, Aronson N. An overview of the impact of rare disease characteristics on research methodology. Orphanet J Rare Dis 2018; 13:14. [PMID: 29351763 PMCID: PMC5775563 DOI: 10.1186/s13023-017-0755-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 12/29/2017] [Indexed: 11/19/2022] Open
Abstract
Background About 30 million individuals in the United States are living with a rare disease, which by definition have a prevalence of 200,000 or fewer cases in the United States ([National Organization for Rare Disorders], [About NORD], [2016]). Disease heterogeneity and geographic dispersion add to the difficulty of completing robust studies in small populations. Improving the ability to conduct research on rare diseases would have a significant impact on population health. The purpose of this paper is to raise awareness of methodological approaches that can address the challenges to conducting robust research on rare diseases. Approach We conducted a landscape review of available methodological and analytic approaches to address the challenges of rare disease research. Our objectives were to: 1. identify algorithms for matching study design to rare disease attributes and the methodological approaches applicable to these algorithms; 2. draw inferences on how research communities and infrastructure can contribute to the efficiency of research on rare diseases; and 3. to describe methodological approaches in the rare disease portfolio of the Patient-Centered Outcomes Research Institute (PCORI), a funder promoting both rare disease research and research infrastructure. Results We identified three algorithms for matching study design to rare disease or intervention characteristics (Gagne, et.al, BMJ 349:g6802, 2014); (Gupta, et.al, J Clin Epidemiol 64:1085-1094, 2011); (Cornu, et. al, Orphet J Rare Dis 8:48,2012) and summarized the applicable methodological and analytic approaches. From this literature we were also able to draw inferences on how an effective research infrastructure can set an agenda, prioritize studies, accelerate accrual, catalyze patient engagement and terminate poorly performing studies. Of the 24 rare disease projects in the PCORI portfolio, 11 are randomized controlled trials (RCTs) using standard designs. Thirteen are observational studies using case-control, prospective cohort, or natural history designs. PCORI has supported the development of 9 Patient-Powered Research Networks (PPRNs) focused on rare diseases. Conclusion Matching research design to attributes of rare diseases and interventions can facilitate the completion of RCTs that are adequately powered. An effective research infrastructure can improve efficiency and avoid waste in rare disease research. Our review of the PCORI research portfolio demonstrates that it is feasible to conduct RCTs in rare disease. However, most of these studies are using standard RCT designs. This suggests that use of a broader array of methodological approaches to RCTs --such as adaptive trials, cross-over trials, and early escape designs can improve the productivity of robust research in rare diseases.
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Affiliation(s)
- Danielle Whicher
- National Academy of Medicine, 500 5th Street NW, Washington, DC, 20001, USA.
| | - Sarah Philbin
- Patient-Centered Outcomes Research Institute (PCORI), 1919 M Street NW, Washington, DC, 20036, USA
| | - Naomi Aronson
- Blue Cross Blue Shield Association, 300 E Randolph Street, Chicago, IL, 60601, USA
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Zondervan-Zwijnenburg M, Peeters M, Depaoli S, Van de Schoot R. Where Do Priors Come From? Applying Guidelines to Construct Informative Priors in Small Sample Research. RESEARCH IN HUMAN DEVELOPMENT 2017. [DOI: 10.1080/15427609.2017.1370966] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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19
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Wu Q, Chang J, Chen H, Chen Y, Yang H, Fei Y, Zhang P, Zeng X, Zhang F, Zhang W. Efficacy between high and medium doses of glucocorticoid therapy in remission induction of IgG4-related diseases: a preliminary randomized controlled trial. Int J Rheum Dis 2017; 20:639-646. [PMID: 28556584 DOI: 10.1111/1756-185x.13088] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Qingjun Wu
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Jie Chang
- Department of Rheumatology; The Fourth Affiliated Hospital; Zhejiang University School of Medicine; Yiwu Zhejiang China
| | - Hua Chen
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Yu Chen
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Hongxian Yang
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Yunyun Fei
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Panpan Zhang
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Xiaofeng Zeng
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Fengchun Zhang
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
| | - Wen Zhang
- Department of Rheumatology; Chinese Academy of Medical Science; Peking Union Medical College Hospital; Beijing China
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Abrahamyan L, Feldman BM, Tomlinson G, Faughnan ME, Johnson SR, Diamond IR, Gupta S. Alternative designs for clinical trials in rare diseases. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2016; 172:313-331. [PMID: 27862920 DOI: 10.1002/ajmg.c.31533] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Evidence-based medicine requires strong scientific evidence upon which to base treatment. In rare diseases, study populations are often small, and thus this evidence is difficult to accrue. Investigators, though, should be creative and develop a flexible toolkit of methods to deal with the problems inherent in the study of rare disease. This narrative review presents alternative clinical trial designs for studying treatments of rare diseases, including cross-over and n-of-1 trials, randomized placebo-phase design, enriched enrollment, randomized withdrawal design, and classes of adaptive designs. Examples of applications of these designs are presented along with their advantages and disadvantages. Additional analytical considerations such as Bayesian analysis, internal pilots, and use of biomarkers as surrogate outcomes are further discussed. A framework for selecting appropriate clinical trial design is proposed to guide investigators in the process of selecting alternative designs for rare diseases. © 2016 Wiley Periodicals, Inc.
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Bolignano D, Pisano A. Good-quality research in rare diseases: trials and tribulations. Pediatr Nephrol 2016; 31:2017-23. [PMID: 26817476 DOI: 10.1007/s00467-016-3323-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 01/11/2016] [Accepted: 01/13/2016] [Indexed: 12/21/2022]
Abstract
Despite the fact that rare diseases affecting the kidney are not as uncommon as generally believed, proper clinical guidelines for guiding therapeutic management are scarce or absent owing to the overall lack of reliable scientific evidence. Although the randomized controlled trial (RCT) is the best study design for dealing with questions of intervention, RCTs under low-prevalence conditions are extremely challenging because of the limited number of patients, the variable phenotypic expression, and the long course of these disorders. In this brief review, we aimed to summarize the main alternative methods to traditional RCTs designed with the intent of minimizing the number of subjects needed for recruitment or maximizing the statistical efficiency of study analyses. Most of these approaches have not yet been extensively employed, may denote crucial limitations to wide applicability, or still lack proper validation in the field of rare diseases. Nevertheless, the growing number of proposed strategies is indicative of the perceived necessity by the scientific community to fill the quality gap between clinical guidelines for common and rare pathological conditions.
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Affiliation(s)
- Davide Bolignano
- CNR - Institute of Clinical Physiology, c/o EUROLINE, Via Vallone Petrara 55-57, 89124, Reggio, Calabria, Italy.
| | - Anna Pisano
- CNR - Institute of Clinical Physiology, c/o EUROLINE, Via Vallone Petrara 55-57, 89124, Reggio, Calabria, Italy
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Rieder M, Hawcutt D. Design and conduct of early phase drug studies in children: challenges and opportunities. Br J Clin Pharmacol 2016; 82:1308-1314. [PMID: 27353241 PMCID: PMC5061783 DOI: 10.1111/bcp.13058] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/03/2016] [Accepted: 06/12/2016] [Indexed: 12/14/2022] Open
Abstract
It has historically been very difficult to conduct early phase drug studies in children for a number of reasons related to ethics, acceptability, rarity, standardization, end points, safety, dosing and feasibility. Over the past decade there have been a number of developments including novel clinical trial design, in silico pharmacology and microdosing that have significantly enhanced the ability of investigators to conduct early phase drug studies in children. While the evolution of drug therapy is creating a series of new challenges, there has never been a better time for conducting drug studies in children.
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Affiliation(s)
- Michael Rieder
- Department of Paediatrics, Robarts Research Institute, University of Western Ontario, Canada.
- Department of Paediatrics, Western University, London, Ontario, Canada.
| | - Daniel Hawcutt
- NIHR Alder Hey Clinical Research Facility, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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Kesselheim AS, McGraw S, Thompson L, O'Keefe K, Gagne JJ. Development and use of new therapeutics for rare diseases: views from patients, caregivers, and advocates. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2016; 8:75-84. [PMID: 25362528 DOI: 10.1007/s40271-014-0096-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with rare diseases experience the health care system differently than patients with more common conditions. They can therefore provide important perspectives on the process of developing therapeutics for their conditions. METHODS We conducted three in-person focus groups involving rare disease patients (n = 9), caregivers (n = 8), and advocates (n = 9). Focus group participants were asked to describe their experiences with a rare disease, what they would want to know about a new drug for the disease, what outcomes they believe should be assessed in drug testing, perceptions of off-label use of a drug for treating a rare disease, views on participation in clinical trials, and opinions of the US Food and Drug Administration's (FDA's) function. The coding structure was populated from the transcripts of the sessions, using Atlas.ti qualitative analysis software, and then analyzed for common themes. RESULTS Participants described the challenges of learning to live with a poorly understood condition for which treatment is limited. Rare disease patients were willing to accept certain risks in their care in the hopes of finding some benefit, but also expressed frustrations with the costs of their care and the lack of scientific data about their treatments. They were concerned that the development and testing of therapies should, as quickly as possible, yield effective treatments to advance their quality of life. CONCLUSION With limited therapeutic options, rare disease patients often considered off-label treatments or novel drugs that posed substantial risk. Nonetheless, rare disease patients generally appreciated the rigor of the research underlying the drugs and supported the FDA's gatekeeping role.
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Affiliation(s)
- Aaron S Kesselheim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA,
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24
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Nikolakopoulos S, Roes KC, van der Tweel I. Sequential designs with small samples: Evaluation and recommendations for normal responses. Stat Methods Med Res 2016; 27:1115-1127. [PMID: 27342574 DOI: 10.1177/0962280216653778] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Sequential monitoring is a well-known methodology for the design and analysis of clinical trials. Driven by the lower expected sample size, recent guidelines and published research suggest the use of sequential methods for the conduct of clinical trials in rare diseases. However, the vast majority of the developed and most commonly used sequential methods relies on asymptotic assumptions concerning the distribution of the test statistics. It is not uncommon for trials in (very) rare diseases to be conducted with only a few decades of patients and the use of sequential methods that rely on large-sample approximations could inflate the type I error probability. Additionally, the setting of a rare disease could make the traditional paradigm of designing a clinical trial (deciding on the sample size given type I and II errors and anticipated effect size) irrelevant. One could think of the situation where the number of patients available has a maximum and this should be utilized in the most efficient way. In this work, we evaluate the operational characteristics of sequential designs in the setting of very small to moderate sample sizes with normally distributed outcomes and demonstrate the necessity of simple corrections of the critical boundaries. We also suggest a method for deciding on an optimal sequential design given a maximum sample size and some (data driven or based on expert opinion) prior belief on the treatment effect.
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Affiliation(s)
- Stavros Nikolakopoulos
- Department of Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kit Cb Roes
- Department of Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ingeborg van der Tweel
- Department of Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Katz DM, Bird A, Coenraads M, Gray SJ, Menon DU, Philpot BD, Tarquinio DC. Rett Syndrome: Crossing the Threshold to Clinical Translation. Trends Neurosci 2016; 39:100-113. [PMID: 26830113 PMCID: PMC4924590 DOI: 10.1016/j.tins.2015.12.008] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/14/2015] [Accepted: 12/15/2015] [Indexed: 12/11/2022]
Abstract
Lying at the intersection between neurobiology and epigenetics, Rett syndrome (RTT) has garnered intense interest in recent years, not only from a broad range of academic scientists, but also from the pharmaceutical and biotechnology industries. In addition to the critical need for treatments for this devastating disorder, optimism for developing RTT treatments derives from a unique convergence of factors, including a known monogenic cause, reversibility of symptoms in preclinical models, a strong clinical research infrastructure highlighted by an NIH-funded natural history study and well-established clinics with significant patient populations. Here, we review recent advances in understanding the biology of RTT, particularly promising preclinical findings, lessons from past clinical trials, and critical elements of trial design for rare disorders.
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Affiliation(s)
- David M Katz
- Departments of Neurosciences and Psychiatry, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA.
| | - Adrian Bird
- Wellcome Trust Centre for Cell Biology, University of Edinburgh, Edinburgh, UK
| | - Monica Coenraads
- Rett Syndrome Research Trust, 67 Under Cliff Road, Trumbull, CT 06611, USA
| | - Steven J Gray
- Gene Therapy Center and Department of Ophthalmology, University of North Carolina, Chapel Hill, NC USA
| | - Debashish U Menon
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Benjamin D Philpot
- Department of Cell Biology and Physiology, Neuroscience Center, and Carolina Institute for Developmental Disabilities, UNC School of Medicine, Chapel Hill, NC 27599, USA
| | - Daniel C Tarquinio
- Children's Healthcare of Atlanta, Emory University, 1605 Chantilly Drive NE, Atlanta, GA 30324, USA
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Billingham L, Malottki K, Steven N. Research methods to change clinical practice for patients with rare cancers. Lancet Oncol 2016; 17:e70-e80. [PMID: 26868356 DOI: 10.1016/s1470-2045(15)00396-4] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 09/30/2015] [Accepted: 10/05/2015] [Indexed: 12/11/2022]
Abstract
Rare cancers are a growing group as a result of reclassification of common cancers by molecular markers. There is therefore an increasing need to identify methods to assess interventions that are sufficiently robust to potentially affect clinical practice in this setting. Methods advocated for clinical trials in rare diseases are not necessarily applicable in rare cancers. This Series paper describes research methods that are relevant for rare cancers in relation to the range of incidence levels. Strategies that maximise recruitment, minimise sample size, or maximise the usefulness of the evidence could enable the application of conventional clinical trial design to rare cancer populations. Alternative designs that address specific challenges for rare cancers with the aim of potentially changing clinical practice include Bayesian designs, uncontrolled n-of-1 trials, and umbrella and basket trials. Pragmatic solutions must be sought to enable some level of evidence-based health care for patients with rare cancers.
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Affiliation(s)
- Lucinda Billingham
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK.
| | - Kinga Malottki
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Neil Steven
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Spino C, Jahnke JS, Selewski DT, Massengill S, Troost J, Gipson DS. Changing the Paradigm for the Treatment and Development of New Therapies for FSGS. Front Pediatr 2016; 4:25. [PMID: 27047908 PMCID: PMC4803734 DOI: 10.3389/fped.2016.00025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/08/2016] [Indexed: 12/13/2022] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a renal pathology finding that represents a constellation of rare kidney diseases, which manifest as proteinuria, edema nephrotic syndrome, hypertension, and increased risk for kidney failure. Therapeutic options for FSGS are reviewed displaying the expected efficacy from 25 to 69% depending on specific therapy, patient characteristics, cost, and common side effects. This variability in treatment response is likely caused, in part, by the heterogeneity in the etiology and active molecular mechanisms of FSGS. Clinical trials in FSGS have been scant in number and slow to recruit, which may stem, in part, from reliance on classic clinical trial design paradigms. Traditional clinical trial designs based on the "learn and confirm" paradigm may not be appropriate for rare diseases, such as FSGS. Future drug development and testing will require novel approaches to trial designs that have the capacity to enrich study populations and adapt the trial in a planned way to gain efficiencies in trial completion timelines. A clinical trial simulation is provided that compares a classical and more modern design to determine the maximum tolerated dose in FSGS.
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Affiliation(s)
- Cathie Spino
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA; NephCure Accelerating Cures Institute, King of Prussia, PA, USA
| | - Jordan S Jahnke
- Department of General Internal Medicine, University of Pennsylvania , Philadelphia, PA , USA
| | - David T Selewski
- NephCure Accelerating Cures Institute, King of Prussia, PA, USA; Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Susan Massengill
- NephCure Accelerating Cures Institute, King of Prussia, PA, USA; Department of Pediatrics, Division of Nephrology, Carolinas Medical Center, Charlotte, NC, USA
| | - Jonathan Troost
- NephCure Accelerating Cures Institute, King of Prussia, PA, USA; Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Debbie S Gipson
- NephCure Accelerating Cures Institute, King of Prussia, PA, USA; Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, MI, USA
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Improving evidence on anticoagulant therapies for venous thromboembolism in children: key challenges and opportunities. Blood 2015; 126:2541-7. [DOI: 10.1182/blood-2015-06-651539] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/11/2015] [Indexed: 12/25/2022] Open
Abstract
Abstract
Venous thromboembolism (VTE) is increasingly diagnosed in pediatric patients, and anticoagulant use in this population has become common, despite the absence of US Food and Drug Administration (FDA) approval for this indication. Guidelines for the use of anticoagulants in pediatrics are largely extrapolated from large randomized controlled trials (RCTs) in adults, smaller dose-finding and observational studies in children, and expert opinion. The recently FDA-approved direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, apixaban, and edoxaban, provide potential advantages over oral vitamin K antagonists and subcutaneous low-molecular-weight heparins (LMWHs). However, key questions arise regarding their potential off-label clinical application in pediatric thromboembolic disease. In this Perspective, we provide background on the use of LMWHs such as enoxaparin as the mainstay of treatment of pediatric provoked VTE; identify key questions and challenges with regard to DOAC trials and future DOAC therapy in pediatric VTE; and discuss applicable lessons learned from the recent pilot/feasibility phase of a large multicenter RCT of anticoagulant duration in pediatric VTE. The challenges and lessons learned present opportunities to improve evidence for anticoagulant therapies in pediatric VTE through future clinical trials.
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da Silva PSL, de Aguiar VE, Fonseca MCM. Iatrogenic pneumothorax in mechanically ventilated children: Incidence, risk factors and other outcomes. Heart Lung 2015; 44:238-42. [DOI: 10.1016/j.hrtlng.2015.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 01/09/2015] [Accepted: 01/10/2015] [Indexed: 10/24/2022]
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Gagne JJ, Thompson L, O'Keefe K, Kesselheim AS. Innovative research methods for studying treatments for rare diseases: methodological review. BMJ 2014; 349:g6802. [PMID: 25422272 PMCID: PMC4242670 DOI: 10.1136/bmj.g6802] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To examine methods for generating evidence on health outcomes in patients with rare diseases. DESIGN Methodological review of existing literature. SETTING PubMed, Embase, and Academic Search Premier searched for articles describing innovative approaches to randomized trial design and analysis methods and methods for conducting observational research in patients with rare diseases. MAIN OUTCOME MEASURES We assessed information related to the proposed methods, the specific rare disease being studied, and outcomes from the application of the methods. We summarize methods with respect to their advantages in studying health outcomes in rare diseases and provide examples of their application. RESULTS We identified 46 articles that proposed or described methods for studying patient health outcomes in rare diseases. Articles covered a wide range of rare diseases and most (72%) were published in 2008 or later. We identified 16 research strategies for studying rare disease. Innovative clinical trial methods minimize sample size requirements (n=4) and maximize the proportion of patients who receive active treatment (n=2), strategies crucial to studying small populations of patients with limited treatment choices. No studies describing unique methods for conducting observational studies in patients with rare diseases were identified. CONCLUSIONS Though numerous studies apply unique clinical trial designs and considerations to assess patient health outcomes in rare diseases, less attention has been paid to innovative methods for studying rare diseases using observational data.
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Affiliation(s)
- Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lauren Thompson
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kelly O'Keefe
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Aaron S Kesselheim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Bernard A, Vaneau M, Fournel I, Galmiche H, Nony P, Dubernard JM. Methodological choices for the clinical development of medical devices. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2014; 7:325-34. [PMID: 25285025 PMCID: PMC4181748 DOI: 10.2147/mder.s63869] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Clinical evidence available for the assessment of medical devices (MDs) is frequently insufficient. New MDs should be subjected to high quality clinical studies to demonstrate their benefit to patients. The randomized controlled trial (RCT) is the study design reaching the highest level of evidence in order to demonstrate the efficacy of a new MD. However, the clinical context of some MDs makes it difficult to carry out a conventional RCT. The objectives of this review are to present problems related to conducting conventional RCTs and to identify other experimental designs, their limitations, and their applications. A systematic literature search was conducted for the period January 2000 to July 2012 by searching medical bibliographic databases. Problems related to conducting conventional RCTs of MDs were identified: timing the assessment, eligible population and recruitment, acceptability, blinding, choice of comparator group, and learning curve. Other types of experimental designs have been described. Zelen's design trials and randomized consent design trials facilitate the recruitment of patients, but can cause ethical problems to arise. Expertise-based RCTs involve randomization to a team that specializes in a given intervention. Sometimes, the feasibility of an expertise-based randomized trial may be greater than that of a conventional trial. Cross-over trials reduce the number of patients, but are not applicable when a learning curve is required. Sequential trials have the advantage of allowing a trial to be stopped early depending on the results of first inclusions, but they require an independent committee. Bayesian methods combine existing information with information from the ongoing trial. These methods are particularly useful in situations where the number of subjects is small. The disadvantage is the risk of including erroneous prior information. Other types of experimental designs exist when conventional trials cannot always be applied to the clinical development of MDs.
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Affiliation(s)
- Alain Bernard
- Department of Thoracic Surgery CHU Bocage, Dijon, France
| | - Michel Vaneau
- Department for Assessment of Medical Devices, HAS (French National Authority of Health), Saint-Denis La Plaine, France
| | - Isabelle Fournel
- Centre of Epidemiology of the Populations, Burgundy University, Dijon, France
| | - Hubert Galmiche
- Department for Assessment of Medical Devices, HAS (French National Authority of Health), Saint-Denis La Plaine, France
| | - Patrice Nony
- Department of Clinical Pharmacology, Lyon University CNRS, Lyon, France
- Laboratory of Biometry and Biology, CNRS, Lyon, France
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What are the long-term effects of treatment on survivors of childhood leukaemia? A review of the literature. JOURNAL OF RADIOTHERAPY IN PRACTICE 2014. [DOI: 10.1017/s146039691300040x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurposeKey advances in cancer treatment have led to an increasing number of long-term cancer survivors. Knowledge of the long-term effects of cancer treatment on leukaemia survivors is to some degree limited. This article investigates the effects of the treatment of childhood leukaemia on the quality of life (QOL), the physical and the psychological wellbeing and general development of survivors. This article reviews current literature to examine existing gaps in knowledge and identify a potential focus of future research and clinical practice.Materials and methodsOnline systematic searching, along with historical searching took place in order to retrieve relevant primary research papers for the review. Strict inclusion and exclusion criteria were applied to the literature, to create a manageable amount of research papers.ResultsThe extent of intellectual impairment among radiotherapy patients was significantly greater than those treated with chemotherapy only. Body composition, including endocrine function, is readily affected by cancer treatment. Early identification and interventions can greatly improve the QOL of survivors.ConclusionFurther research into the effect of treatment modality on the extent of chronic effects, along with investigations into the needs of the whole family unit, is required. Future practice must take into account long-term implications while ensuring effective holistic care.
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Bolignano D, Nagler EV, Van Biesen W, Zoccali C. Providing guidance in the dark: rare renal diseases and the challenge to improve the quality of evidence. Nephrol Dial Transplant 2014; 29:1628-1632. [DOI: 10.1093/ndt/gft344] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Strategies for Postmarketing Surveillance of Drugs for Rare Diseases. Clin Pharmacol Ther 2013; 95:265-8. [DOI: 10.1038/clpt.2013.218] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 10/28/2013] [Indexed: 11/08/2022]
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Picavet E, Cassiman D, Hollak CE, Maertens JA, Simoens S. Clinical evidence for orphan medicinal products-a cause for concern? Orphanet J Rare Dis 2013; 8:164. [PMID: 24131572 PMCID: PMC3852769 DOI: 10.1186/1750-1172-8-164] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 09/13/2013] [Indexed: 11/10/2022] Open
Abstract
Background The difficulties associated with organising clinical studies for orphan medicinal products (OMPs) are plentiful. Recent debate on the long-term effectiveness of some OMPs, led us to question whether the initial standards for clinical evidence for OMPs, set by the European Medicines Agency (EMA) at the time of marketing authorization, are too low. Therefore, the aim of this study was to quantitatively evaluate the characteristics and quality of clinical evidence that is presented for OMPs to obtain marketing authorization in Europe, using the new and validated COMPASS tool. Methods We quantitatively assessed the characteristics and quality of clinical evidence of the pivotal studies of 64 OMPs as described in the European Public Assessment Report and/or the Scientific Discussion document prepared by the Committee for Human Medicinal Products of the EMA. Results The 64 OMPs were altogether authorized for 78 orphan indications, for which 117 studies were identified as 'pivotal’ or 'main’ studies. In approximately two thirds of the studies, the allocation was randomized (64.8%) and a control arm was used (68.5%). Half of the studies applied some type of blinding. Only a minority (26.9%) of the studies included a Quality-of-Life (QoL) related endpoint, of which a third claim an improvement in QoL. Upon analyzing the quality of reporting, we found that some aspects (i.e. the endpoints, the sampling criteria, and the interventions) are well described, whereas other items (i.e. a description of the patients and of potential biases) are not reported for all studies. Conclusions In conclusion, the pivotal studies that are the basis for marketing authorization of OMPs are a cause for concern, as they exhibit methodological flaws i.e. the lack of QoL-related endpoints as outcome, lack of blinding in the study design and the use of surrogate endpoints. Additionally, there are shortcomings in the reporting of those studies that complicate the interpretation. A more demanding regulatory process for OMPs is needed to guide evidence-based clinical decision-making.
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Affiliation(s)
- Eline Picavet
- KU Leuven, Department of Pharmaceutical and Pharmacological Sciences, Herestraat 49, PO box 521, Leuven 3000, Belgium.
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Pemberton J, Frankfurter C, Bailey K, Jones L, Walton JM. Gastrostomy matters--the impact of pediatric surgery on caregiver quality of life. J Pediatr Surg 2013; 48:963-70. [PMID: 23701768 DOI: 10.1016/j.jpedsurg.2013.02.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 02/03/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION While pediatric surgeons consider gastrostomy to be routine treatment for children with feeding difficulties, the impact on the family is not fully understood. This study focuses on Quality of Life (QoL) of parents of children who require a gastrostomy tube. METHODS A prospective repeated measures cohort study was conducted between November 2009 and March 2012. Demographic, surgical, and QoL data were collected at Baseline, 2 weeks, 3, 6, 9, and 12 months after surgery. At each time-point parents completed three QoL measures: Short Form 36v2 (SF-36), Caregiver Strain Index (CSI), and Parent Experience of Childhood Illness (PECI). RESULTS A total of 31 caregivers were recruited with a mean age of 32.6 years (SD=7.0). Overall, a 38% increased risk of depression was seen in the SF-36 when compared to population norms, and a moderate effect was seen in mental health at 12 months (ES=0.56). The CSI demonstrated a decrease in caregiver burden (8.72 to 7.05, p=0.007, 95% CI (0.57-3.18)), while the PECI revealed a decrease in frequency of feelings of guilt, worry, sorrow, anger, and long term uncertainty over 12 months. CONCLUSION Gastrostomy not only improves the child's physical health, but also improves the mental health of the child's caregivers, especially at (or after) one year.
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Affiliation(s)
- Julia Pemberton
- McMaster Pediatric Surgery Research Collaborative, Hamilton, Ontario, Canada
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Chan AW, Tetzlaff JM, Gøtzsche PC, Altman DG, Mann H, Berlin JA, Dickersin K, Hróbjartsson A, Schulz KF, Parulekar WR, Krleza-Jeric K, Laupacis A, Moher D. SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials. BMJ 2013; 346:e7586. [PMID: 23303884 PMCID: PMC3541470 DOI: 10.1136/bmj.e7586] [Citation(s) in RCA: 3254] [Impact Index Per Article: 295.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2012] [Indexed: 02/06/2023]
Abstract
High quality protocols facilitate proper conduct, reporting, and external review of clinical trials. However, the completeness of trial protocols is often inadequate. To help improve the content and quality of protocols, an international group of stakeholders developed the SPIRIT 2013 Statement (Standard Protocol Items: Recommendations for Interventional Trials). The SPIRIT Statement provides guidance in the form of a checklist of recommended items to include in a clinical trial protocol. This SPIRIT 2013 Explanation and Elaboration paper provides important information to promote full understanding of the checklist recommendations. For each checklist item, we provide a rationale and detailed description; a model example from an actual protocol; and relevant references supporting its importance. We strongly recommend that this explanatory paper be used in conjunction with the SPIRIT Statement. A website of resources is also available (www.spirit-statement.org). The SPIRIT 2013 Explanation and Elaboration paper, together with the Statement, should help with the drafting of trial protocols. Complete documentation of key trial elements can facilitate transparency and protocol review for the benefit of all stakeholders.
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Affiliation(s)
- An-Wen Chan
- Women's College Research Institute at Women's College Hospital, Department of Medicine, University of Toronto, Toronto, Canada M5G 1N8
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Ferris M, Norwood V, Radeva M, Gassman JJ, Al-Uzri A, Askenazi D, Matoo T, Pinsk M, Sharma A, Smoyer W, Stults J, Vyas S, Weiss R, Gipson D, Kaskel F, Friedman A, Moxey-Mims M, Trachtman H. Patient recruitment into a multicenter randomized clinical trial for kidney disease: report of the focal segmental glomerulosclerosis clinical trial (FSGS CT). Clin Transl Sci 2012; 6:13-20. [PMID: 23399084 DOI: 10.1111/cts.12003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
We describe the experience of the focal segmental glomerulosclerosis clinical trial (FSGS CT) in the identification and recruitment of participants into the study. This National Institutes of Health funded study, a multicenter, open-label, randomized comparison of cyclosporine versus oral dexamethasone pulses plus mycophenolate mofetil, experienced difficulty and delays meeting enrollment goals. These problems occurred despite the support of patient advocacy groups and aggressive recruitment strategies. Multiple barriers were identified including: (1) inaccurate estimates of the number of potential incident FSGS patients at participating centers; (2) delays in securing one of the test agents; (3) prolonged time between IRB approval and execution of a subcontract (mean 7.5 ± 0.8 months); (4) prolonged time between IRB approval and enrollment of the first patient at participating sites (mean 19.6 ± 1.4 months); and (5) reorganization of clinical coordinating core infrastructure to align resources with enrollment. A Web-based anonymous survey of site investigators revealed site-related barriers to patient recruitment. The value of a variety of recruitment tools was of marginal utility in facilitating patient enrollment. We conclude that improvements in the logistics of study approval and regulatory start-up and testing of promising novel agents are important factors in promoting enrollment into randomized clinical trials in nephrology.
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Affiliation(s)
- Maria Ferris
- University of North Carolina, Chapel Hill, NC, USA
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Kanaan Z, Rai SN, Eichenberger MR, Barnes C, Dworkin AM, Weller C, Cohen E, Roberts H, Keskey B, Petras RE, Crawford NPS, Galandiuk S. Differential microRNA expression tracks neoplastic progression in inflammatory bowel disease-associated colorectal cancer. Hum Mutat 2012; 33:551-60. [PMID: 22241525 DOI: 10.1002/humu.22021] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
One of the most serious complications faced by patients with inflammatory bowel disease (IBD) is the potential development of colorectal cancer (CRC). There is a compelling need to enhance the accuracy of cancer screening of IBD patients. MicroRNAs (miRNAs) are small nonprotein-coding RNAs that play important roles in CRC oncogenesis. In this study, we report differential miRNA expression in IBD patients with associated CRC from non-neoplastic tissue to dysplasia and eventually cancer. In addition, we identify and examine the role of dysregulated miRNAs in the TP53 pathway. In our CD patients, six miRNAs were upregulated from non-neoplastic tissue to dysplasia, but downregulated from dysplasia to cancer (miR-122, miR-181a, miR-146b-5p, let-7e, miR-17, miR-143) (P < 0.001). Six differentially expressed miRNAs affected the TP53 pathway (miR-122, miR-214, miR-372, miR-15b, let-7e, miR-17) (P < 0.001). Using two human colon cancer cell lines (HT-29 and HCT-116), E2F1, an upstream regulator of TP53, was downregulated in both cell lines transfected with let-7e (P < 0.05) as well as in HCT-116 cells transfected with miR-17 (P < 0.05). Additionally, cyclin G, a cell-cycle regulator miR-122 target was downregulated in both cell lines (P < 0.05). Unique differentially expressed miRNAs were observed in CD-associated CRC progression. Six of these miRNAs had a tumorigenic effect on the TP53 pathway; the effect of three of which was studied using cell lines.
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Affiliation(s)
- Ziad Kanaan
- Department of Surgery, Price Institute of Surgical Research and the Section of Colorectal Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Shamliyan T, Kane RL. Clinical research involving children: registration, completeness, and publication. Pediatrics 2012; 129:e1291-300. [PMID: 22529271 DOI: 10.1542/peds.2010-2847] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Effective health care for children must be based on thorough analyses of the best research evidence. The objective of this study was to examine registration, completeness, and publication of studies involving children. METHODS We searched the ClinicalTrials.gov registry to identify all closed studies involving children and examined them for completeness and availability of results. We examined publication in peer-reviewed journals for 160 randomly selected National Institutes of Health (NIH)-funded studies from 2000 through 2010 and for 758 randomly selected completed studies. RESULTS Of 3428 closed studies involving children identified in ClinicalTrials.gov, 2385 (70%) were completed, 28 (0.8%) suspended, 152 (4.4%) terminated, and 38 (1.1%) withdrawn. The proportion of non-completed studies (terminated and suspended) increased linearly by 186% between 2001 and 2009, from 1.9% to 8.4%. Of the 152 terminated studies, 48 did not report reasons for termination, 21 cited safety concerns, and 83 cited poor recruitment or other administrative reasons. Only 29% of completed studies were published. Publication that did occur was an average of 2 years after study completion. Completed interventional studies were published more often than observational studies. Completed industry-funded studies were published less often than studies funded by the NIH. Registered NIH-funded trials were published more often than unregistered. CONCLUSIONS Results are unavailable for more than half of the studies involving children, revealing a substantial publication bias. Registration and posting of results on ClinicalTrials.gov should be mandatory for all studies involving children.
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Affiliation(s)
- Tatyana Shamliyan
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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Gupta S, Faughnan ME, Tomlinson GA, Bayoumi AM. A framework for applying unfamiliar trial designs in studies of rare diseases. J Clin Epidemiol 2011; 64:1085-94. [DOI: 10.1016/j.jclinepi.2010.12.019] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Revised: 11/25/2010] [Accepted: 12/02/2010] [Indexed: 10/18/2022]
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Ilk O, Rajabli F, Dungul DC, Ozdag H, Ilk HG. A novel approach for small sample size family-based association studies: sequential tests. Eur J Hum Genet 2011; 19:915-20. [PMID: 21427757 PMCID: PMC3172932 DOI: 10.1038/ejhg.2011.51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 02/15/2011] [Accepted: 02/25/2011] [Indexed: 02/08/2023] Open
Abstract
In this paper, we propose a sequential probability ratio test (SPRT) to overcome the problem of limited samples in studies related to complex genetic diseases. The results of this novel approach are compared with the ones obtained from the traditional transmission disequilibrium test (TDT) on simulated data. Although TDT classifies single-nucleotide polymorphisms (SNPs) to only two groups (SNPs associated with the disease and the others), SPRT has the flexibility of assigning SNPs to a third group, that is, those for which we do not have enough evidence and should keep sampling. It is shown that SPRT results in smaller ratios of false positives and negatives, as well as better accuracy and sensitivity values for classifying SNPs when compared with TDT. By using SPRT, data with small sample size become usable for an accurate association analysis.
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Affiliation(s)
- Ozlem Ilk
- Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey.
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Abstract
In this chapter, the design of pharmacokinetic studies and phase III trials in children is discussed. Classical approaches and relatively novel approaches, which may be more useful in the context of drug research in children, are discussed. The burden of repeated blood sampling in pediatric pharmacokinetic studies may be overcome by the population pharmacokinetics approach using nonlinear mixed effect modeling as the statistical solution to sparse data. Indications and contraindications for phase III trials are discussed: only when there is true "equipoise" in the medical scientific community, it is ethical to conduct a randomized clinical trial. The many reasons why a pediatric trial may fail are illustrated with examples. Inadequate sample sizes lead to inconclusive results. Twelve classical strategies to minimize sample sizes are discussed followed by an introduction to group sequential design, boundaries design, and adaptive design. The evidence that these designs reduce sample sized between 35 and 70% is reviewed. The advantages and disadvantages of the different approaches are highlighted to give the reader a broad idea of the design types that can be considered. Finally, working with DMCs during the conduct of trials is introduced. The evidence regarding DMC activities, interim analysis results, and early termination of pediatric trials is presented. So far reporting is incomplete and heterogeneous, and users of trial reports may be misled by the results. A proposal for a checklist for the reporting of DMC issues, interim analyses, and early stopping is presented.
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Sequential design with boundaries approach in pediatric intervention research reduces sample size. J Clin Epidemiol 2010; 63:19-27. [DOI: 10.1016/j.jclinepi.2009.07.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 06/09/2009] [Accepted: 07/03/2009] [Indexed: 11/22/2022]
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Fernandes RM, van der Lee JH, Offringa M. A systematic review of the reporting of Data Monitoring Committees' roles, interim analysis and early termination in pediatric clinical trials. BMC Pediatr 2009; 9:77. [PMID: 20003383 PMCID: PMC2801486 DOI: 10.1186/1471-2431-9-77] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 12/13/2009] [Indexed: 12/15/2022] Open
Abstract
Background Decisions about interim analysis and early stopping of clinical trials, as based on recommendations of Data Monitoring Committees (DMCs), have far reaching consequences for the scientific validity and clinical impact of a trial. Our aim was to evaluate the frequency and quality of the reporting on DMC composition and roles, interim analysis and early termination in pediatric trials. Methods We conducted a systematic review of randomized controlled clinical trials published from 2005 to 2007 in a sample of four general and four pediatric journals. We used full-text databases to identify trials which reported on DMCs, interim analysis or early termination, and included children or adolescents. Information was extracted on general trial characteristics, risk of bias, and a set of parameters regarding DMC composition and roles, interim analysis and early termination. Results 110 of the 648 pediatric trials in this sample (17%) reported on DMC or interim analysis or early stopping, and were included; 68 from general and 42 from pediatric journals. The presence of DMCs was reported in 89 of the 110 included trials (81%); 62 papers, including 46 of the 89 that reported on DMCs (52%), also presented information about interim analysis. No paper adequately reported all DMC parameters, and nine (15%) reported all interim analysis details. Of 32 trials which terminated early, 22 (69%) did not report predefined stopping guidelines and 15 (47%) did not provide information on statistical monitoring methods. Conclusions Reporting on DMC composition and roles, on interim analysis results and on early termination of pediatric trials is incomplete and heterogeneous. We propose a minimal set of reporting parameters that will allow the reader to assess the validity of trial results.
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Affiliation(s)
- Ricardo M Fernandes
- Departamento da Criança e da Família, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte-EPE, Laboratório de Farmacologia Clínica e Terapêutica, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Portugal.
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Klassen TP, Hartling L, Hamm M, van der Lee JH, Ursum J, Offringa M. StaR Child Health: an initiative for RCTs in children. Lancet 2009; 374:1310-2. [PMID: 19837237 DOI: 10.1016/s0140-6736(09)61803-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Terry P Klassen
- Alberta Research Center for Health Evidence, Women's and Children's Health Research Institute, Stollery Children's Hospital and University of Alberta, Edmonton, AB, Canada
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Serrano-Aguilar P, Trujillo-Martín MM, Ramos-Goñi JM, Mahtani-Chugani V, Perestelo-Pérez L, Posada-de la Paz M. Patient involvement in health research: a contribution to a systematic review on the effectiveness of treatments for degenerative ataxias. Soc Sci Med 2009; 69:920-5. [PMID: 19647357 DOI: 10.1016/j.socscimed.2009.07.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Indexed: 11/21/2022]
Abstract
This study aims to incorporate patients' perspective in the design of a systematic review of scientific literature on the effectiveness of degenerative ataxias (DA) treatments. 53 patients with DA from different regions of Spain were consulted using the Delphi method, with three rounds via e-mail. In the first round, obtained information was on treatments used and relevant self-perceived health problems related to DA. The following two rounds were used to prioritize and achieve a consensus on the answers. The participation rate was 100% for all rounds. The most relevant self-perceived health problems were limitations in activities of daily living (ADL), visual and auditory problems and diminished self-esteem. The bibliographic search for the systematic review was enriched by these patient contributions. No study offered information on treatment effectiveness for the following problems prioritized by patients: ADL, social relationships, disease acceptance and quality of life. Thus some of the self-perceived DA-related health problems identified by the patients have never been investigated and should be considered to improve future research projects which should be adapted to meet patients' needs. Effective participation of patients can extend the value of systematic reviews to ensure they respond to both clinicians' information needs and patients' expectations.
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Affiliation(s)
- P Serrano-Aguilar
- Planning & Evaluation Unit, Canary Islands Health Authority, Santa Cruz de Tenerife, Canary Islands, CIBERESP, Spain.
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van der Lee JH, Tanck MWT, Wesseling J, Offringa M. Pitfalls in the design and analysis of paediatric clinical trials: a case of a 'failed' multi-centre study, and potential solutions. Acta Paediatr 2009; 98:385-91. [PMID: 18826493 PMCID: PMC2659390 DOI: 10.1111/j.1651-2227.2008.01048.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Aim: To increase awareness of possible pitfalls in the design and analysis of a multi-centre randomized clinical trial and to give an overview of alternative study designs and their consequences for power analyses in case of limited availability of trial participants. Methods: Investigation of the assumptions in the power calculation and re-analysis of the original data of a ‘failed’ trial on the effect of dexamethasone on the duration of mechanical ventilation in young children with respiratory syncytial virus infection. Use of ‘boundaries approach’ is explored using the data from this trial. A comprehensive overview of the various modern solutions for the design of a subsequent trial in this field is given. Results: Two frequent major deficiencies of trial design and data analysis are reviewed in depth, i.e. too optimistic assumptions for the sample size calculation and failure to adjust for centre effects. Conclusion: Critical review of trial assumptions and if necessary sample size recalculation based on an internal pilot by a data monitoring committee is recommended to maximize the probability of obtaining conclusive results.
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Affiliation(s)
- Johanna H van der Lee
- Department of Paediatric Clinical Epidemiology, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, The Netherlands.
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