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De Silva AP, Leslie K, Braat S, Grobler AC. Application of the Estimand Framework to Anesthesia Trials. Anesthesiology 2024; 141:13-23. [PMID: 38743905 DOI: 10.1097/aln.0000000000004966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
SUMMARY Events occurring after randomization, such as use of rescue medication, treatment discontinuation, or death, are common in randomized trials. These events can change either the existence or interpretation of the outcome of interest. However, appropriate handling of these intercurrent events is often unclear. The International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) E9(R1) addendum introduced the estimand framework, which aligns trial objectives with the design, conduct, statistical analysis, and interpretation of results. This article describes how the estimand framework can be used in anesthesia trials to precisely define the treatment effect to be estimated, key attributes of an estimand, common intercurrent events in anesthesia trials with strategies for handling them, and use of the estimand framework in a hypothetical anesthesia trial on postoperative delirium. When planning anesthesia trials, clearly defining the estimand is vital to ensure that what is being estimated is clearly understood, is clinically relevant, and helps answer the clinical questions of interest.
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Affiliation(s)
- Anurika P De Silva
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia; Methods and Implementation Support for Clinical and Health (MISCH) research Hub, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Kate Leslie
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | - Sabine Braat
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia; Methods and Implementation Support for Clinical and Health (MISCH) research, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Anneke C Grobler
- Department of Paediatrics, Melbourne Medical School, University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
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Siegler JE, Abdalkader M, Michel P, Nguyen TN. Therapeutic Trends of Cerebrovascular Disease during the COVID-19 Pandemic and Future Perspectives. J Stroke 2022; 24:179-188. [PMID: 35677974 PMCID: PMC9194541 DOI: 10.5853/jos.2022.00843] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 03/27/2022] [Indexed: 11/27/2022] Open
Abstract
As of May 2022, there have been more than 400 million cases (including re-infections) of the systemic acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), and nearly 5 million deaths worldwide. Not only has the coronavirus disease 2019 (COVID-19) pandemic been responsible for diagnosis and treatment delays of a wide variety of conditions, and overwhelmed the allocation of healthcare resources, it has impacted the epidemiology and management of cerebrovascular disease. In this narrative review, we summarize the changing paradigms and latest data regarding the complex relationship between COVID-19 and cerebrovascular disease. Paradoxically, although SARS-CoV-2 has been associated with many thrombotic complications—including ischemic stroke—there have been global declines in ischemic stroke and other cerebrovascular diseases. These epidemiologic shifts may be attributed to patient avoidance of healthcare institutions due to fear of contracting the novel human coronavirus, and also related to declines in other transmissible infectious illnesses which may trigger ischemic stroke. Despite the association between SARS-CoV-2 and thrombotic events, there are inconsistent data regarding targeted antithrombotics to prevent venous and arterial events. In addition, we provide recommendations for the conduct of stroke research and clinical trial planning during the ongoing COVID-19 pandemic, and for future healthcare crises.
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Affiliation(s)
- James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
- Correspondence: James E. Siegler Cooper Neurological Institute, Cooper University Hospital, 3 Cooper Plaza, Suite 320, Camden, NJ 08103, USA Tel: +1-501-912-4392 Fax: +1-856-964-0504 E-mail:
| | - Mohamad Abdalkader
- Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Patrik Michel
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Thanh N. Nguyen
- Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
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Yassi N, Zhao H, Churilov L, Campbell BCV, Wu T, Ma H, Cheung A, Kleinig T, Brown H, Choi P, Jeng JS, Ranta A, Wang HK, Cloud GC, Grimley R, Shah D, Spratt N, Cho DY, Mahawish K, Sanders L, Worthington J, Clissold B, Meretoja A, Yogendrakumar V, Ton MD, Dang DP, Phuong NTM, Nguyen HT, Hsu CY, Sharma G, Mitchell PJ, Yan B, Parsons MW, Levi C, Donnan GA, Davis SM. Tranexamic acid for intracerebral haemorrhage within 2 hours of onset: protocol of a phase II randomised placebo-controlled double-blind multicentre trial. Stroke Vasc Neurol 2021; 7:158-165. [PMID: 34848566 PMCID: PMC9067256 DOI: 10.1136/svn-2021-001070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
Rationale Haematoma growth is common early after intracerebral haemorrhage (ICH), and is a key determinant of outcome. Tranexamic acid, a widely available antifibrinolytic agent with an excellent safety profile, may reduce haematoma growth. Methods and design Stopping intracerebral haemorrhage with tranexamic acid for hyperacute onset presentation including mobile stroke units (STOP-MSU) is a phase II double-blind, randomised, placebo-controlled, multicentre, international investigator-led clinical trial, conducted within the estimand statistical framework. Hypothesis In patients with spontaneous ICH, treatment with tranexamic acid within 2 hours of onset will reduce haematoma expansion compared with placebo. Sample size estimates A sample size of 180 patients (90 in each arm) would be required to detect an absolute difference in the primary outcome of 20% (placebo 39% vs treatment 19%) under a two-tailed significance level of 0.05. An adaptive sample size re-estimation based on the outcomes of 144 patients will allow a possible increase to a prespecified maximum of 326 patients. Intervention Participants will receive 1 g intravenous tranexamic acid over 10 min, followed by 1 g intravenous tranexamic acid over 8 hours; or matching placebo. Primary efficacy measure The primary efficacy measure is the proportion of patients with haematoma growth by 24±6 hours, defined as either ≥33% relative increase or ≥6 mL absolute increase in haematoma volume between baseline and follow-up CT scan. Discussion We describe the rationale and protocol of STOP-MSU, a phase II trial of tranexamic acid in patients with ICH within 2 hours from onset, based in participating mobile stroke units and emergency departments.
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Affiliation(s)
- Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia .,Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Henry Zhao
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Teddy Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Henry Ma
- Department of Neurology, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Andrew Cheung
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Helen Brown
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Philip Choi
- Department of Neurology, Box Hill Hospital, Eastern Health, Box Hill, Victoria, Australia
| | - Jiann-Shing Jeng
- Stroke Centre and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Annemarei Ranta
- Department of Medicine, Dunedin School of Medicine, University of Otago, Wellington, New Zealand
| | - Hao-Kuang Wang
- Department of Neurosurgery, E-Da Hospital, Yanchao, Kaohsiung, Taiwan
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Clinical Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Rohan Grimley
- Department of Medicine, Sunshine Coast University Hospital, Nambour, Queensland, Australia
| | - Darshan Shah
- Department of Neurology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Der-Yang Cho
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan
| | - Karim Mahawish
- Department of Internal Medicine, Palmerston North Hospital, Palmerston North, New Zealand
| | - Lauren Sanders
- Department of Neurology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - John Worthington
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Ben Clissold
- Department of Neurology, Geelong Hospital, Geelong, Victoria, Australia
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Mai Duy Ton
- Stroke Center, Bach Mai Hospital, Hanoi, Viet Nam
| | - Duc Phuc Dang
- Stroke Department, 103 Military Hospital, Hanoi, Hanoi, Viet Nam
| | | | - Huy-Thang Nguyen
- Department of Cerebrovascular Disease, 115 Hospital, Ho Chi Minh City, Viet Nam
| | - Chung Y Hsu
- Department of Neurology, China Medical University, Taichung, Taiwan
| | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Sydney, New South Wales, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
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