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Dietz VA, Roberts N, Knox K, Moore S, Pitonak M, Barr C, Centeno J, Leininger S, New KC, Nowell P, Rodreick M, Geoffroy CG, Stampas A, Dulin JN. Fighting for recovery on multiple fronts: The past, present, and future of clinical trials for spinal cord injury. Front Cell Neurosci 2022; 16:977679. [PMID: 36212690 PMCID: PMC9533868 DOI: 10.3389/fncel.2022.977679] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022] Open
Abstract
Through many decades of preclinical research, great progress has been achieved in understanding the complex nature of spinal cord injury (SCI). Preclinical research efforts have guided and shaped clinical trials, which are growing in number by the year. Currently, 1,149 clinical trials focused on improving outcomes after SCI are registered in the U.S. National Library of Medicine at ClinicalTrials.gov. We conducted a systematic analysis of these SCI clinical trials, using publicly accessible data downloaded from ClinicalTrials.gov. After extracting all available data for these trials, we categorized each trial according to the types of interventions being tested and the types of outcomes assessed. We then evaluated clinical trial characteristics, both globally and by year, in order to understand the areas of growth and change over time. With regard to clinical trial attributes, we found that most trials have low enrollment, only test single interventions, and have limited numbers of primary outcomes. Some gaps in reporting are apparent; for instance, over 75% of clinical trials with "Completed" status do not have results posted, and the Phase of some trials is incorrectly classified as "Not applicable" despite testing a drug or biological compound. When analyzing trials based on types of interventions assessed, we identified the largest representation in trials testing rehab/training/exercise, neuromodulation, and behavioral modifications. Most highly represented primary outcomes include motor function of the upper and lower extremities, safety, and pain. The most highly represented secondary outcomes include quality of life and pain. Over the past 15 years, we identified increased representation of neuromodulation and rehabilitation trials, and decreased representation of drug trials. Overall, the number of new clinical trials initiated each year continues to grow, signifying a hopeful future for the clinical treatment of SCI. Together, our work provides a comprehensive glimpse into the past, present, and future of SCI clinical trials, and suggests areas for improvement in clinical trial reporting.
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Affiliation(s)
- Valerie A. Dietz
- Department of Biology, Texas A&M University, College Station, TX, United States
| | - Nolan Roberts
- Department of Biology, Texas A&M University, College Station, TX, United States
| | - Katelyn Knox
- Department of Biology, Texas A&M University, College Station, TX, United States
| | - Sherilynne Moore
- Department of Biology, Texas A&M University, College Station, TX, United States
| | - Michael Pitonak
- Department of Biology, Texas A&M University, College Station, TX, United States
| | - Chris Barr
- Unite 2 Fight Paralysis, Minneapolis, MN, United States
| | - Jesus Centeno
- Unite 2 Fight Paralysis, Minneapolis, MN, United States
| | | | - Kent C. New
- Unite 2 Fight Paralysis, Minneapolis, MN, United States
| | - Peter Nowell
- Unite 2 Fight Paralysis, Minneapolis, MN, United States
| | | | - Cedric G. Geoffroy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University, College Station, TX, United States
- Texas A&M Institute for Neuroscience, Texas A&M University, College Station, TX, United States
| | - Argyrios Stampas
- Department of Physical Medicine and Rehabilitation, UTHealth Houston McGovern Medical School, Houston, TX, United States
| | - Jennifer N. Dulin
- Department of Biology, Texas A&M University, College Station, TX, United States
- Texas A&M Institute for Neuroscience, Texas A&M University, College Station, TX, United States
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Klimek M, Gravesteijn BY, Costa AM, Lobo FA. How to Study the Brain While Anesthetizing It?! A Scoping Review on Running Neuroanesthesiologic Studies and Trials That Include Neurosurgical Patients. World Neurosurg 2022; 161:376-381. [PMID: 35505557 DOI: 10.1016/j.wneu.2021.08.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/13/2021] [Indexed: 11/26/2022]
Abstract
This scoping review addresses the challenges of neuroanesthesiologic research: the population, the methods/treatment/exposure, and the outcome/results. These challenges are put into the context of a future research agenda for peri-/intraoperative anesthetic management, neurocritical care, and applied neurosciences. Finally, the opportunities of adaptive trial design in neuroanesthesiologic research are discussed.
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Affiliation(s)
- Markus Klimek
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Benjamin Y Gravesteijn
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Andreia M Costa
- Department of Anesthesiology, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Francisco A Lobo
- Institute of Anesthesiology, Cleveland Clinic, Abu Dhabi, United Arabic Emirates
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Adaptive trial designs for spinal cord injury clinical trials directed to the central nervous system. Spinal Cord 2020; 58:1235-1248. [DOI: 10.1038/s41393-020-00547-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 02/08/2023]
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Aimetti AA, Kirshblum S, Curt A, Mobley J, Grossman RG, Guest JD. Natural history of neurological improvement following complete (AIS A) thoracic spinal cord injury across three registries to guide acute clinical trial design and interpretation. Spinal Cord 2019; 57:753-762. [PMID: 31182786 PMCID: PMC6760562 DOI: 10.1038/s41393-019-0299-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/28/2019] [Accepted: 05/09/2019] [Indexed: 01/07/2023]
Abstract
STUDY DESIGN Retrospective, longitudinal analysis of motor and sensory outcomes following thoracic (T2-T12) sensorimotor complete spinal cord injury (SCI) in selected patients enrolled into three SCI) registries. OBJECTIVES To establish a modern-day international benchmark for neurological recovery following traumatic complete thoracic sensorimotor SCI in a population similar to those enrolled in acute clinical trials. SETTING Affiliates of the North American Clinical Trial Network (NACTN), European Multicenter Study about Spinal Cord Injury (EMSCI), and the Spinal Cord Injury Model Systems (SCIMS). METHODS Only traumatic thoracic injured patients between 2006 and 2016 meeting commonly used clinical trial inclusion/exclusion criteria such as: age 16-70, T2-T12 neurological level of injury (NLI), ASIA Impairment Scale (AIS) A, non-penetrating injury, acute neurological exam within 7 days of injury, and follow-up neurological exam at least ~ 6 months post injury, were included in this analysis. International Standards for Neurological Classification of Spinal Cord injury outcomes including AIS conversion rate, NLI, and sensory and motor scores/levels were compiled. RESULTS A total of 170 patients were included from the three registries: 12 from NACTN, 64 from EMSCI, and 94 from SCIMS. AIS conversion rates at approximately 6 months post injury varied from 16.7% to 23.4% (21.1% weighted average). Improved conversion rates were observed in all registries for low thoracic (T10-T12) injuries when compared with high/mid thoracic (T2-T9) injuries. The NLI was generally stable and lower extremity motor score (LEMS) improvement was uncommon and usually limited to low thoracic injuries only. CONCLUSIONS This study presents the aggregation of selected multinational natural history recovery data in thoracic AIS A patients from three SCI registries and demonstrates comparable minimal improvement of ISNCSCI-scored motor and sensory function following these injuries, whereas conversions to higher AIS grades occur at a frequency of ~20%. These data inform the development of future clinical trial protocols in this important patient population for the interpretation of the safety and potential clinical benefit of new therapies, and the potential applicability in a multinational setting. SPONSORSHIP InVivo Therapeutics.
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Affiliation(s)
| | | | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Joseph Mobley
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - Robert G Grossman
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, TX, USA
| | - James D Guest
- Department of Neurosurgery, University of Miami, Miami, FL, USA.
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Blight AR, Hsieh J, Curt A, Fawcett JW, Guest JD, Kleitman N, Kurpad SN, Kwon BK, Lammertse DP, Weidner N, Steeves JD. The challenge of recruitment for neurotherapeutic clinical trials in spinal cord injury. Spinal Cord 2019; 57:348-359. [DOI: 10.1038/s41393-019-0276-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/13/2019] [Accepted: 03/15/2019] [Indexed: 11/09/2022]
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Guetterman TC, Fetters MD, Mawocha S, Legocki LJ, Barsan WG, Lewis RJ, Berry DA, Meurer WJ. The life cycles of six multi-center adaptive clinical trials focused on neurological emergencies developed for the Advancing Regulatory Science initiative of the National Institutes of Health and US Food and Drug Administration: Case studies from the Adaptive Designs Accelerating Promising Treatments Into Trials Project. SAGE Open Med 2017; 5:2050312117736228. [PMID: 29085638 PMCID: PMC5648086 DOI: 10.1177/2050312117736228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 09/18/2017] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Clinical trials are complicated, expensive, time-consuming, and frequently do not lead to discoveries that improve the health of patients with disease. Adaptive clinical trials have emerged as a methodology to provide more flexibility in design elements to better answer scientific questions regarding whether new treatments are efficacious. Limited observational data exist that describe the complex process of designing adaptive clinical trials. To address these issues, the Adaptive Designs Accelerating Promising Treatments Into Trials project developed six, tailored, flexible, adaptive, phase-III clinical trials for neurological emergencies, and investigators prospectively monitored and observed the processes. The objective of this work is to describe the adaptive design development process, the final design, and the current status of the adaptive trial designs that were developed. METHODS To observe and reflect upon the trial development process, we employed a rich, mixed methods evaluation that combined quantitative data from visual analog scale to assess attitudes about adaptive trials, along with in-depth qualitative data about the development process gathered from observations. RESULTS The Adaptive Designs Accelerating Promising Treatments Into Trials team developed six adaptive clinical trial designs. Across the six designs, 53 attitude surveys were completed at baseline and after the trial planning process completed. Compared to baseline, the participants believed significantly more strongly that the adaptive designs would be accepted by National Institutes of Health review panels and non-researcher clinicians. In addition, after the trial planning process, the participants more strongly believed that the adaptive design would meet the scientific and medical goals of the studies. CONCLUSION Introducing the adaptive design at early conceptualization proved critical to successful adoption and implementation of that trial. Involving key stakeholders from several scientific domains early in the process appears to be associated with improved attitudes towards adaptive designs over the life cycle of clinical trial development.
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Affiliation(s)
| | - Michael D Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Samkeliso Mawocha
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Laurie J Legocki
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - William G Barsan
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Donald A Berry
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
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Mawocha SC, Fetters MD, Legocki LJ, Guetterman TC, Frederiksen S, Barsan WG, Lewis RJ, Berry DA, Meurer WJ. A conceptual model for the development process of confirmatory adaptive clinical trials within an emergency research network. Clin Trials 2017; 14:246-254. [PMID: 28135827 DOI: 10.1177/1740774516688900] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Adaptive clinical trials use accumulating data from enrolled subjects to alter trial conduct in pre-specified ways based on quantitative decision rules. In this research, we sought to characterize the perspectives of key stakeholders during the development process of confirmatory-phase adaptive clinical trials within an emergency clinical trials network and to build a model to guide future development of adaptive clinical trials. METHODS We used an ethnographic, qualitative approach to evaluate key stakeholders' views about the adaptive clinical trial development process. Stakeholders participated in a series of multidisciplinary meetings during the development of five adaptive clinical trials and completed a Strengths-Weaknesses-Opportunities-Threats questionnaire. In the analysis, we elucidated overarching themes across the stakeholders' responses to develop a conceptual model. RESULTS Four major overarching themes emerged during the analysis of stakeholders' responses to questioning: the perceived statistical complexity of adaptive clinical trials and the roles of collaboration, communication, and time during the development process. Frequent and open communication and collaboration were viewed by stakeholders as critical during the development process, as were the careful management of time and logistical issues related to the complexity of planning adaptive clinical trials. CONCLUSION The Adaptive Design Development Model illustrates how statistical complexity, time, communication, and collaboration are moderating factors in the adaptive design development process. The intensity and iterative nature of this process underscores the need for funding mechanisms for the development of novel trial proposals in academic settings.
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Affiliation(s)
- Samkeliso C Mawocha
- 1 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael D Fetters
- 2 Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Laurie J Legocki
- 2 Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Shirley Frederiksen
- 1 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - William G Barsan
- 1 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Roger J Lewis
- 3 Department of Emergency Medicine, Los Angeles Biomedical Research Institute, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA, USA.,4 Berry Consultants, Austin, TX, USA
| | | | - William J Meurer
- 1 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.,5 Department of Neurology, University of Michigan, Ann Arbor, MI, USA
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Estrada V, Müller HW. Spinal cord injury - there is not just one way of treating it. F1000PRIME REPORTS 2014; 6:84. [PMID: 25343041 PMCID: PMC4166939 DOI: 10.12703/p6-84] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In the last century, research in the field of spinal cord trauma has brought insightful knowledge which has led to a detailed understanding of mechanisms that are involved in injury- and recovery-related processes. The quest for a cure for the yet generally incurable condition as well as the exponential rise in gained information has brought about the development of numerous treatment approaches while at the same time the abundance of data has become quite unmanageable. Owing to an enormous amount of preclinical therapeutic approaches, this report highlights important trends rather than specific treatment strategies. We focus on current advances in the treatment of spinal cord injury and want to further draw attention to arising problems in spinal cord injury (SCI) research and discuss possible solutions.
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Affiliation(s)
- Veronica Estrada
- Molecular Neurobiology Laboratory, Department of Neurology, Heinrich-Heine-University Medical Center Düsseldorf Moorenstr. 5, 40225 Düsseldorf Germany
| | - Hans Werner Müller
- Molecular Neurobiology Laboratory, Department of Neurology, Heinrich-Heine-University Medical Center Düsseldorf Moorenstr. 5, 40225 Düsseldorf Germany
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