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Verret M, Le JBP, Lalu MM, Jeffers MS, McIsaac DI, Nicholls SG, Turgeon AF, Ramchandani R, Li H, Hutton B, Zivkovic F, Graham M, Lê M, Geist A, Bérubé M, O'Hearn K, Gilron I, Poulin P, Daudt H, Martel G, McVicar J, Moloo H, Fergusson DA. Effectiveness of dexmedetomidine on patient-centred outcomes in surgical patients: a systematic review and Bayesian meta-analysis. Br J Anaesth 2024; 133:615-627. [PMID: 39019769 DOI: 10.1016/j.bja.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/23/2024] [Accepted: 06/13/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Dexmedetomidine is increasingly used for surgical patients requiring general anaesthesia. However, its effectiveness on patient-centred outcomes remains uncertain. Our main objective was to evaluate the patient-centred effectiveness of intraoperative dexmedetomidine for adult patients requiring surgery under general anaesthesia. METHODS We conducted a systematic search of MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL from inception to October 2023. Randomised controlled trials (RCTs) comparing intraoperative use of dexmedetomidine with placebo, opioid, or usual care in adult patients requiring surgery under general anaesthesia were included. Study selection, data extraction, and risk of bias assessment were performed by two reviewers independently. We synthesised data using a random-effects Bayesian regression framework to derive effect estimates and the probability of a clinically important effect. For continuous outcomes, we pooled instruments with similar constructs using standardised mean differences (SMDs) and converted SMDs and credible intervals (CrIs) to their original scale when appropriate. We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Our primary outcome was quality of recovery after surgery. To guide interpretation on the original scale, the Quality of Recovery-15 (QoR-15) instrument was used (range 0-150 points, minimally important difference [MID] of 6 points). RESULTS We identified 49,069 citations, from which 44 RCTs involving 5904 participants were eligible. Intraoperative dexmedetomidine administration was associated with improvement in postoperative QoR-15 (mean difference 9, 95% CrI 4-14, n=21 RCTs, moderate certainty of evidence). We found 99% probability of any benefit and 88% probability of achieving the MID. There was a reduction in chronic pain incidence (odds ratio [OR] 0.42, 95% CrI 0.19-0.79, n=7 RCTs, low certainty of evidence). There was also increased risk of clinically significant hypotension (OR 1.98, 95% CrI 0.84-3.92, posterior probability of harm 94%, n=8 RCTs) and clinically significant bradycardia (OR 1.74, 95% CrI 0.93-3.34, posterior probability of harm 95%, n=10 RCTs), with very low certainty of evidence for both. There was limited evidence to inform other secondary patient-centred outcomes. CONCLUSIONS Compared with placebo or standard of care, intraoperative dexmedetomidine likely results in meaningful improvement in the quality of recovery and chronic pain after surgery. However, it might increase clinically important bradycardia and hypotension. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42023439896).
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Affiliation(s)
- Michael Verret
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada; Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Québec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Quebec Pain Research Network, Sherbrooke, QC, Canada.
| | - John B P Le
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Manoj M Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Matthew S Jeffers
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Ottawa Methods Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Québec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Rashi Ramchandani
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Hongda Li
- MDCM, Faculty of Medicine and Health Science, McGill University, Montreal, QC, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Fiona Zivkovic
- Patient Partner, The Ottawa Hospital, Ottawa, ONT, Canada
| | - Megan Graham
- Patient Partner, The Ottawa Hospital, Ottawa, ONT, Canada
| | - Maxime Lê
- Patient Partner, The Ottawa Hospital, Ottawa, ONT, Canada
| | - Allison Geist
- Patient Partner, The Ottawa Hospital, Ottawa, ONT, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Québec City, QC, Canada; Quebec Pain Research Network, Sherbrooke, QC, Canada; Faculty of Nursing, Université Laval, Québec City, QC, Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Ian Gilron
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ONT, Canada
| | - Patricia Poulin
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa and The Ottawa Hospital Pain Clinic, Ottawa, ON, Canada
| | | | - Guillaume Martel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jason McVicar
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Royal Inland Hospital, Kamloops, BC, Canada
| | - Husein Moloo
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada; Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
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2
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Yoshimoto T, Shinoda S, Yamamoto K, Tahata K. Bayesian Predictive Probability Based on a Bivariate Index Vector for Single-Arm Phase II Study With Binary Efficacy and Safety Endpoints. Pharm Stat 2024. [PMID: 39138927 DOI: 10.1002/pst.2431] [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: 12/26/2023] [Revised: 06/26/2024] [Accepted: 07/22/2024] [Indexed: 08/15/2024]
Abstract
In oncology, Phase II studies are crucial for clinical development plans as such studies identify potent agents with sufficient activity to continue development in the subsequent Phase III trials. Traditionally, Phase II studies are single-arm studies, with the primary endpoint being short-term treatment efficacy. However, drug safety is also an important consideration. In the context of such multiple-outcome designs, predictive probability-based Bayesian monitoring strategies have been developed to assess whether a clinical trial will provide enough evidence to continue with a Phase III study at the scheduled end of the trial. Therefore, we propose a new simple index vector to summarize the results that cannot be captured by existing strategies. Specifically, we define the worst and most promising situations for the potential effect of a treatment, then use the proposed index vector to measure the deviation between the two situations. Finally, simulation studies are performed to evaluate the operating characteristics of the design. The obtained results demonstrate that the proposed method makes appropriate interim go/no-go decisions.
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Affiliation(s)
- Takuya Yoshimoto
- Biometrics Department, Chugai Pharmaceutical Co. Ltd, Chuo-ku, Tokyo, Japan
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Satoru Shinoda
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Kouji Yamamoto
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Kouji Tahata
- Department of Information Sciences, Faculty of Science and Technology, Tokyo University of Science, Chiba, Japan
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Broglio KR, Blau JE, Pilling EA, Wason JMS. Multidisciplinary considerations for implementing Bayesian borrowing in basket trials. Drug Discov Today 2024; 29:104127. [PMID: 39098385 DOI: 10.1016/j.drudis.2024.104127] [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: 04/18/2024] [Revised: 07/19/2024] [Accepted: 07/30/2024] [Indexed: 08/06/2024]
Abstract
Drug development has historically relied on phase I-III clinical trials including participants sharing the same disease. However, drug development has evolved as the discovery of mechanistic drivers of disease demonstrated that the same therapeutic target may provide benefits across different diseases. A basket trial condenses evaluation of one therapy among multiple related diseases into a single trial and presents an opportunity to borrow information across them rather than viewing each in isolation. Borrowing is a statistical tool but requires a foundation of clinical and therapeutic mechanistic justification. We review the Bayesian borrowing approach, including its assumptions, and provide a framework for how this approach can be evaluated for successful use in a basket trial for drug development.
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Affiliation(s)
- Kristine R Broglio
- Oncology Statistical Innovation, AstraZeneca Pharmaceuticals, Gaithersburg, MD, USA.
| | - Jenny E Blau
- Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Elizabeth A Pilling
- Biometrics, Late-stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - James M S Wason
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Venkatakrishnan K, Jayachandran P, Seo SK, van der Graaf PH, Wagner JA, Gupta N. Moving the Needle for Oncology Dose Optimization: A Call for Action. Clin Pharmacol Ther 2024; 115:1187-1197. [PMID: 38736240 DOI: 10.1002/cpt.3263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/05/2024] [Indexed: 05/14/2024]
Affiliation(s)
| | | | - Shirley K Seo
- Division of Cardiometabolic and Endocrine Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | | | | | - Neeraj Gupta
- Takeda Pharmaceuticals, Cambridge, Massachusetts, USA
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Venkatakrishnan K, Jayachandran P, Seo SK, van der Graaf PH, Wagner JA, Gupta N. Moving the needle for oncology dose optimization: A call for action. CPT Pharmacometrics Syst Pharmacol 2024; 13:909-918. [PMID: 38778466 PMCID: PMC11179700 DOI: 10.1002/psp4.13157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 05/25/2024] Open
Affiliation(s)
| | | | - Shirley K Seo
- Division of Cardiometabolic and Endocrine Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | | | | | - Neeraj Gupta
- Takeda Pharmaceuticals, Cambridge, Massachusetts, USA
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Venkatakrishnan K, Jayachandran P, Seo SK, van der Graaf PH, Wagner JA, Gupta N. Moving the needle for oncology dose optimization: A call for action. Clin Transl Sci 2024; 17:e13859. [PMID: 38923292 PMCID: PMC11196242 DOI: 10.1111/cts.13859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024] Open
Affiliation(s)
| | | | - Shirley K. Seo
- Division of Cardiometabolic and Endocrine Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and ResearchU.S. Food and Drug AdministrationSilver SpringMarylandUSA
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Solitano V, Prins H, Archer M, Guizzetti L, Jairath V. Toward Patient Centricity: Why Do Patients With Inflammatory Bowel Disease Participate in Pharmaceutical Clinical Trials? A Mixed-Methods Exploration of Study Participants. CROHN'S & COLITIS 360 2024; 6:otae019. [PMID: 38595967 PMCID: PMC11003535 DOI: 10.1093/crocol/otae019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Background A better understanding of motivations to participate as well as recommendations to reduce barriers to enrollment may assist in design of future clinical trials. Methods We developed a 32-item electronic questionnaire to explore motivations, experiences, and recommendations of inflammatory bowel disease patients, who had participated in pharmaceutical clinical trials in a tertiary center in Canada over the last decade. We employed a mixed-methods approach that integrates both quantitative and qualitative research methods. Results We distributed a total of 69 e-mails with surveys and received 46 responses (66.6% response rate). Study participants were mostly male (27/46, 58.7%), non-Hispanic White (43/46, 93.5%), with a mean age of 45.5 years (SD 10.9). Most decided to participate in a clinical trial to benefit future patients (29/46, 63.0%). Half of the participants (23/46, 50.0%) reported they were worried about the possibility of receiving placebo, although the majority (29/46, 63.0%) understood they could improve on placebo. The most challenging aspect reported was the number and length of questionnaires (15/46, 32.6%), as well as the number of colonoscopies (14/46, 30.4%). Strategies recommended to increase enrollment were reduction of the chance of receiving placebo (20/46, 43.5%), facilitating inclusion of patients who have failed multiple therapies (20/46, 43.5%), allowing virtual visits (18/46, 39.1%), including subtypes of disease traditionally excluded from trials (16/46, 34.8%) and improving outreach to underrepresented populations (13/46, 28.3%). The vast majority (37/46, 80.4%) reported their experience of participation to be better than expected. Conclusions These results should help inform the design of future clinical trials with a focus on patient-centricity.
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Affiliation(s)
- Virginia Solitano
- Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
| | - Heather Prins
- Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
| | - Meagan Archer
- Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
| | | | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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8
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García-Sosa AT. Benford's Law and distributions for better drug design. Expert Opin Drug Discov 2024; 19:131-137. [PMID: 37921672 DOI: 10.1080/17460441.2023.2277342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Modern drug discovery incorporates various tools and data, heralding the beginning of the data-driven drug design (DD) era. The distributions of chemical and physical data used for Artificial Intelligence (AI)/Machine Learning (ML) and to drive DD have thus become highly important to be understood and used effectively. AREAS COVERED The authors perform a comprehensive exploration of the statistical distributions driving the data-intensive era of drug discovery, including Benford's Law in AI/ML-based DD. EXPERT OPINION As the relevance of data-driven discovery escalates, we anticipate meticulous scrutiny of datasets utilizing principles like Benford's Law to enhance data integrity and guide efficient resource allocation and experimental planning. In this data-driven era of the pharmaceutical and medical industries, addressing critical aspects such as bias mitigation, algorithm effectiveness, data stewardship, effects, and fraud prevention are essential. Harnessing Benford's Law and other distributions and statistical tests in DD provides a potent strategy to detect data anomalies, fill data gaps, and enhance dataset quality. Benford's Law is a fast method for data integrity and quality of datasets, the backbone of AI/ML and other modeling approaches, proving very useful in the design process.
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Affiliation(s)
- Alfonso T García-Sosa
- Chair of Molecular Technology, Institute of Chemistry, University of Tartu, Tartu, Estonia
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Maher TM, Brown KK, Cunningham S, DeBoer EM, Deterding R, Fiorino EK, Griese M, Schwerk N, Warburton D, Young LR, Gahlemann M, Voss F, Stock C. Estimating the effect of nintedanib on forced vital capacity in children and adolescents with fibrosing interstitial lung disease using a Bayesian dynamic borrowing approach. Pediatr Pulmonol 2024. [PMID: 38289091 DOI: 10.1002/ppul.26882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/15/2023] [Accepted: 01/10/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND The rarity of childhood interstitial lung disease (chILD) makes it challenging to conduct powered trials. In the InPedILD trial, among 39 children and adolescents with fibrosing ILD, there was a numerical benefit of nintedanib versus placebo on change in forced vital capacity (FVC) over 24 weeks (difference in mean change in FVC % predicted of 1.21 [95% confidence interval: -3.40, 5.81]). Nintedanib has shown a consistent effect on FVC across populations of adults with different diagnoses of fibrosing ILD. METHODS In a Bayesian dynamic borrowing analysis, prespecified before data unblinding, we incorporated data on the effect of nintedanib in adults and the data from the InPedILD trial to estimate the effect of nintedanib on FVC in children and adolescents with fibrosing ILD. The data from adults were represented as a meta-analytic predictive (MAP) prior distribution with mean 1.69 (95% credible interval: 0.49, 3.08). The adult data were weighted according to expert judgment on their relevance to the efficacy of nintedanib in chILD, obtained in a formal elicitation exercise. RESULTS Combined data from the MAP prior and InPedILD trial analyzed within the Bayesian framework resulted in a median difference between nintedanib and placebo in change in FVC % predicted at Week 24 of 1.63 (95% credible interval: -0.69, 3.40). The posterior probability for superiority of nintedanib versus placebo was 95.5%, reaching the predefined success criterion of at least 90%. CONCLUSION These findings, together with the safety data from the InPedILD trial, support the use of nintedanib in children and adolescents with fibrosing ILDs.
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Affiliation(s)
- Toby M Maher
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Kevin K Brown
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
| | - Steven Cunningham
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Emily M DeBoer
- Section of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, USA
- The Children's Hospital Colorado, Aurora, Colorado, USA
| | - Robin Deterding
- Section of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, USA
- The Children's Hospital Colorado, Aurora, Colorado, USA
| | - Elizabeth K Fiorino
- Departments of Science Education and Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Matthias Griese
- Hauner Children's Hospital, German Center for Lung Research (DZL), Ludwig Maximilians University, Munich, Germany
| | - Nicolaus Schwerk
- Clinic for Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - David Warburton
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Lisa R Young
- Division of Pulmonary and Sleep Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Florian Voss
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Christian Stock
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
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Suzuka T, Tanaka N, Kadoya Y, Ida M, Iwata M, Ozu N, Kawaguchi M. Comparison of Quality of Recovery between Modified Thoracoabdominal Nerves Block through Perichondrial Approach versus Oblique Subcostal Transversus Abdominis Plane Block in Patients Undergoing Total Laparoscopic Hysterectomy: A Pilot Randomized Controlled Trial. J Clin Med 2024; 13:712. [PMID: 38337406 PMCID: PMC10856699 DOI: 10.3390/jcm13030712] [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: 12/18/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Modified thoracoabdominal nerves block through a perichondrial approach (M-TAPA) provides a wide analgesic range. Herein, we examined the quality of recovery (QoR) of M-TAPA for total laparoscopic hysterectomy (TLH) compared with oblique subcostal transversus abdominis plane block (OSTAPB) and measured plasma levobupivacaine concentrations (PClevo). Forty female patients undergoing TLH were randomized to each group. Nerve blocks were performed bilaterally with 25 mL of 0.25% levobupivacaine administered per side. The primary outcome was changes in QoR-15 scores on postoperative days (POD) 1 and 2 from the preoperative baseline. The main secondary outcomes were PClevo at 15, 30, 45, 60, and 120 min after performing nerve block. Group differences (M-TAPA-OSTAPB) in mean changes from baseline in QoR-15 scores on POD 1 and 2 were -11.3 (95% confidence interval (CI), -24.9 to 2.4, p = 0.104; standard deviation (SD), 22.8) and -7.0 (95% CI, -20.5 to 6.6, p = 0.307; SD, 18.7), respectively. Changes in PClevo were similar in both groups. The post hoc analysis using Bayesian statistics revealed that posterior probabilities of M-TAPA being clinically more effective than OSTAPB were up to 22.4 and 24.4% for POD 1 and 2, respectively. In conclusion, M-TAPA may not be superior to OSTAPB for TLH.
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Affiliation(s)
- Takanori Suzuka
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.S.); (M.I.); (M.K.)
| | - Nobuhiro Tanaka
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.S.); (M.I.); (M.K.)
| | - Yuma Kadoya
- Department of Anesthesiology, Ikeda City Hospital, 3-1-18 Jonan, Ikeda 635-8501, Osaka, Japan;
| | - Mitsuru Ida
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.S.); (M.I.); (M.K.)
| | - Masato Iwata
- Department of Anesthesiology, Yamatotakada Municipal Hospital, 1-1, Isonokita-cho, Yamatotakada 635-8501, Nara, Japan;
| | - Naoki Ozu
- Institute for Clinical and Translational Science, Nara Medical University Hospital, 840 Shijocho, Kashihara 634-8522, Nara, Japan;
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Nara, Japan; (T.S.); (M.I.); (M.K.)
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Hosack T, Thomas T, Ravindran R, Uhlig HH, Travis SPL, Buckley CD. Inflammation across tissues: can shared cell biology help design smarter trials? Nat Rev Rheumatol 2023; 19:666-674. [PMID: 37666996 DOI: 10.1038/s41584-023-01007-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2023] [Indexed: 09/06/2023]
Abstract
Immune-mediated inflammatory diseases (IMIDs) are responsible for substantial global disease burden and associated health-care costs. Traditional models of research and service delivery silo their management within organ-based medical disciplines. Very often patients with disease in one organ have comorbid involvement in another, suggesting shared pathogenic pathways. Moreover, different IMIDs are often treated with the same drugs (including glucocorticoids, immunoregulators and biologics). Unlocking the cellular basis of these diseases remains a major challenge, leading us to ask why, if these diseases have so much in common, they are not investigated in a common manner. A tissue-based, cellular understanding of inflammation might pave the way for cross-disease, cross-discipline basket trials (testing one drug across two or more diseases) to reduce the risk of failure of early-phase drug development in IMIDs. This new approach will enable rapid assessment of the efficacy of new therapeutic agents in cross-disease translational research in humans.
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Affiliation(s)
- Tom Hosack
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Tom Thomas
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Rahul Ravindran
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
| | - Hans Holm Uhlig
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
- Biomedical Research Centre, University of Oxford, Oxford, UK
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Simon Piers Leigh Travis
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
- Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Christopher Dominic Buckley
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK.
- Biomedical Research Centre, University of Oxford, Oxford, UK.
- Institute for Inflammation and Aging, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Msaouel P, Lee J, Thall PF. Interpreting Randomized Controlled Trials. Cancers (Basel) 2023; 15:4674. [PMID: 37835368 PMCID: PMC10571666 DOI: 10.3390/cancers15194674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
This article describes rationales and limitations for making inferences based on data from randomized controlled trials (RCTs). We argue that obtaining a representative random sample from a patient population is impossible for a clinical trial because patients are accrued sequentially over time and thus comprise a convenience sample, subject only to protocol entry criteria. Consequently, the trial's sample is unlikely to represent a definable patient population. We use causal diagrams to illustrate the difference between random allocation of interventions within a clinical trial sample and true simple or stratified random sampling, as executed in surveys. We argue that group-specific statistics, such as a median survival time estimate for a treatment arm in an RCT, have limited meaning as estimates of larger patient population parameters. In contrast, random allocation between interventions facilitates comparative causal inferences about between-treatment effects, such as hazard ratios or differences between probabilities of response. Comparative inferences also require the assumption of transportability from a clinical trial's convenience sample to a targeted patient population. We focus on the consequences and limitations of randomization procedures in order to clarify the distinctions between pairs of complementary concepts of fundamental importance to data science and RCT interpretation. These include internal and external validity, generalizability and transportability, uncertainty and variability, representativeness and inclusiveness, blocking and stratification, relevance and robustness, forward and reverse causal inference, intention to treat and per protocol analyses, and potential outcomes and counterfactuals.
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Affiliation(s)
- Pavlos Msaouel
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- David H. Koch Center for Applied Research of Genitourinary Cancers, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Juhee Lee
- Department of Statistics, University of California Santa Cruz, Santa Cruz, CA 95064, USA;
| | - Peter F. Thall
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
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Chevret S, Bouadma L, Dupuis C, Burdet C, Timsit JF. Which severe COVID-19 patients could benefit from high dose dexamethasone? A Bayesian post-hoc reanalysis of the COVIDICUS randomized clinical trial. Ann Intensive Care 2023; 13:75. [PMID: 37634234 PMCID: PMC10460760 DOI: 10.1186/s13613-023-01168-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/31/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND The respective benefits of high and low doses of dexamethasone (DXM) in patients with severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) and acute respiratory failure (ARF) are controversial, with two large triple-blind RCTs reaching very important difference in the effect-size. In the COVIDICUS trial, no evidence of additional benefit of high-dose dexamethasone (DXM20) was found. We aimed to explore whether some specific patient phenotypes could benefit from DXM20 compared to the standard of care 6 mg dose of DXM (DXMSoC). METHODS We performed a post hoc exploratory Bayesian analysis of 473 patients who received either DXMSoc or DXM20 in the COVIDICUS trial. The outcome was the 60 day mortality rate of DXM20 over DXMSoC, with treatment effect measured on the hazard ratio (HR) estimated from Cox model. Bayesian analyses allowed to compute the posterior probability of a more than trivial benefit (HR < 0.95), and that of a potential harm (HR > 1.05). Bayesian measures of interaction then quantified the probability of interaction (Pr Interact) that the HR of death differed across the subsets by 20%. Primary analyses used noninformative priors, centred on HR = 1.00. Sensitivity analyses used sceptical and enthusiastic priors, based on null (HR = 1.00) or benefit (HR = 0.95) effects. RESULTS Overall, the posterior probability of a more than trivial benefit and potential harm was 29.0 and 51.1%, respectively. There was some evidence of treatment by subset interaction (i) according to age (Pr Interact, 84%), with a 86.5% probability of benefit in patients aged below 70 compared to 22% in those aged above 70; (ii) according to the time since symptoms onset (Pr Interact, 99%), with a 99.9% probability of a more than trivial benefit when lower than 7 days compared to a < 0.1% probability when delayed by 7 days or more; and (iii) according to use of remdesivir (Pr Interact, 91%), with a 90.1% probability of benefit in patients receiving remdesivir compared to 19.1% in those who did not. CONCLUSIONS In this exploratory post hoc Bayesian analysis, compared with standard-of-care DXM, high-dose DXM may benefit patients aged less than 70 years with severe ARF that occurred less than 7 days after symptoms onset. The use of remdesivir may also favour the benefit of DXM20. Further analysis is needed to confirm these findings. TRIAL REGISTRATION NCT04344730, date of registration April 14, 2020 ( https://clinicaltrials.gov/ct2/show/NCT04344730?term=NCT04344730&draw=2&rank=1 ); EudraCT: 2020-001457-43 ( https://www.clinicaltrialsregister.eu/ctr-search/search?query=2020-001457-43 ).
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Affiliation(s)
- Sylvie Chevret
- ECSTRRA, UMR 1153, Saint Louis Hospital, University Paris Cité, Paris, France
| | - Lila Bouadma
- Medical and Infectious Diseases ICU, APHP Bichat Hospital, 75018, Paris, France
- Université Paris Cité, IAME, INSERM, UMR 1137, 75018, Paris, France
| | - Claire Dupuis
- Université Paris Cité, IAME, INSERM, UMR 1137, 75018, Paris, France
- Intensive Care Unit, Gabriel Montpied Hospital, CHU de Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Charles Burdet
- Université Paris Cité, IAME, INSERM, UMR 1137, 75018, Paris, France
- Epidemiology, Biostatistics and Clinical Research Department, AP-HP, Bichat Hospital, 75018, Paris, France
| | - Jean-François Timsit
- Medical and Infectious Diseases ICU, APHP Bichat Hospital, 75018, Paris, France.
- Université Paris Cité, IAME, INSERM, UMR 1137, 75018, Paris, France.
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Haines RW, Fowler AJ, Liang K, Pearse RM, Larsson AO, Puthucheary Z, Prowle JR. Comparison of Cystatin C and Creatinine in the Assessment of Measured Kidney Function during Critical Illness. Clin J Am Soc Nephrol 2023; 18:997-1005. [PMID: 37256861 PMCID: PMC10564373 DOI: 10.2215/cjn.0000000000000203] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 05/26/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Incomplete recovery of kidney function is an important adverse outcome in survivors of critical illness. However, unlike eGFR creatinine, eGFR cystatin C is not confounded by muscle loss and may improve identification of persistent kidney dysfunction. METHODS To assess kidney function during prolonged critical illness, we enrolled 38 mechanically ventilated patients with an expected length of stay of >72 hours near admission to intensive care unit (ICU) in a single academic medical center. We assessed sequential kidney function using creatinine, cystatin C, and iohexol clearance measurements. The primary outcome was difference between eGFR creatinine and eGFR cystatin C at ICU discharge using Bayesian regression modeling. We simultaneously measured muscle mass by ultrasound of the rectus femoris to assess the confounding effect on serum creatinine generation. RESULTS Longer length of ICU stay was associated with greater difference between eGFR creatinine and eGFR cystatin C at a predicted rate of 2 ml/min per 1.73 m 2 per day (95% confidence interval [CI], 1 to 2). By ICU discharge, the posterior mean difference between creatinine and cystatin C eGFR was 33 ml/min per 1.73 m 2 (95% credible interval [CrI], 24 to 42). In 27 patients with iohexol clearance measured close to ICU discharge, eGFR creatinine was on average two-fold greater than the iohexol gold standard, and posterior mean difference was 59 ml/min per 1.73 m 2 (95% CrI, 49 to 69). The posterior mean for eGFR cystatin C suggested a 22 ml/min per 1.73 m 2 (95% CrI, 13 to 31) overestimation of measured GFR. Each day in ICU resulted in a predicted 2% (95% CI, 1% to 3%) decrease in muscle area. Change in creatinine-to-cystatin C ratio showed good longitudinal, repeated measures correlation with muscle loss, R =0.61 (95% CI, 0.50 to 0.72). CONCLUSIONS eGFR creatinine systematically overestimated kidney function after prolonged critical illness. Cystatin C better estimated true kidney function because it seemed unaffected by the muscle loss from prolonged critical illness. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Skeletal Muscle Wasting and Renal Dysfunction After Critical Illness Trauma - Outcomes Study (KRATOS), NCT03736005 .
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Affiliation(s)
- Ryan W. Haines
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Alex J. Fowler
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Kaifeng Liang
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
| | - Rupert M. Pearse
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Anders O. Larsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Zudin Puthucheary
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - John R. Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
- Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, United Kingdom
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Azzolina D, Comoretto R, Da Dalt L, Bressan S, Gregori D. A SuperLearner-enforced approach for the estimation of treatment effect in pediatric trials. Digit Health 2023; 9:20552076231191967. [PMID: 37559827 PMCID: PMC10408313 DOI: 10.1177/20552076231191967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/18/2023] [Indexed: 08/11/2023] Open
Abstract
Background Randomized Clinical Trials (RCT) represent the gold standard among scientific evidence. RCTs are tailored to control selection bias and the confounding effect of baseline characteristics on the effect of treatment. However, trial conduction and enrolment procedures could be challenging, especially for rare diseases and paediatric research. In these research frameworks, the treatment effect estimation could be compromised. A potential countermeasure is to develop predictive models on the probability of the baseline disease based on previously collected observational data. Machine learning (ML) algorithms have recently become attractive in clinical research because of their flexibility and improved performance compared to standard statistical methods in developing predictive models. Objective This manuscript proposes an ML-enforced treatment effect estimation procedure based on an ensemble SuperLearner (SL) approach, trained on historical observational data, to control the confounding effect. Methods The REnal SCarring Urinary infEction trial served as a motivating example. Historical observational study data have been simulated through 10,000 Monte Carlo (MC) runs. Hypothetical RCTs have been also simulated, for each MC run, assuming different treatment effects of antibiotics combined with steroids. For each MC simulation, the SL tool has been applied to the simulated observational data. Furthermore, the average treatment effect (ATE), has been estimated on the trial data and adjusted for the SL predicted probability of renal scar. Results The simulation results revealed an increased power in ATE estimation for the SL-enforced estimation compared to the unadjusted estimates for all the algorithms composing the ensemble SL.
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Affiliation(s)
- Danila Azzolina
- Department of Environmental and Preventive Science, University of Ferrara, Ferrara, Italy
| | - Rosanna Comoretto
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Liviana Da Dalt
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Silvia Bressan
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
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Costa T, Premi E, Liloia D, Cauda F, Manuello J. Unleashing the Power of Bayesian Re-Analysis: Enhancing Insights into Lecanemab (Clarity AD) Phase III Trial Through Informed t-Test. J Alzheimers Dis 2023; 95:1059-1065. [PMID: 37638445 DOI: 10.3233/jad-230589] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Clinical trials targeting Alzheimer's disease (AD) aim to alleviate clinical symptoms and alter the course of this complex neurodegenerative disorder. However, the conventional approach of null hypothesis significance testing (NHST) commonly employed in such trials has inherent limitations in assessing clinical significance and capturing nuanced evidence of effectiveness on a continuous scale. OBJECTIVE In this study, we conducted a re-analysis of the phase III trial of lecanemab, a recently proposed humanized IgG1 monoclonal antibody with high affinity for Aβ soluble protofibrils, using a Bayesian approach with informed t-test priors. METHODS To achieve this, we carefully selected trial data and derived effect size estimates for the primary endpoint, the Clinical Dementia Rating Scale-Sum of Boxes (CDR-SB). Subsequently, a series of Bayes Factor analyses were performed to compare evidence supporting the null hypothesis (no treatment effect) versus the alternative hypothesis (presence of an effect). Drawing on relevant literature and the lecanemab phase III trial, we incorporated different minimal clinically important difference (MCID) values for the primary endpoint CDR-SB as prior information. RESULTS Our findings, based on a standard prior, revealed anecdotal evidence favoring the null hypothesis. Additional robustness checks yielded consistent results. However, when employing informed priors, we observed varying evidence across different MCID values, ultimately indicating no support for the effectiveness of lecanemab over placebo. CONCLUSION Our study underscores the value of Bayesian analysis in clinical trials while emphasizing the importance of incorporating MCID and effect size granularity to accurately assess treatment efficacy.
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Affiliation(s)
- Tommaso Costa
- GCS-fMRI, Koelliker Hospital and Department of Psychology, University of Turin, Turin, Italy
- FOCUSLAB, Department of Psychology, University of Turin, Turin, Italy
- Neuroscience Institute of Turin, Turin, Italy
| | - Enrico Premi
- Stroke Unit, Department of Neurological and Vision Sciences, ASST Spedali Civili, Brescia, Italy
| | - Donato Liloia
- GCS-fMRI, Koelliker Hospital and Department of Psychology, University of Turin, Turin, Italy
- FOCUSLAB, Department of Psychology, University of Turin, Turin, Italy
| | - Franco Cauda
- GCS-fMRI, Koelliker Hospital and Department of Psychology, University of Turin, Turin, Italy
- FOCUSLAB, Department of Psychology, University of Turin, Turin, Italy
- Neuroscience Institute of Turin, Turin, Italy
| | - Jordi Manuello
- GCS-fMRI, Koelliker Hospital and Department of Psychology, University of Turin, Turin, Italy
- FOCUSLAB, Department of Psychology, University of Turin, Turin, Italy
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