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Johansen E, Nielsen H, Gillespie D, Aabenhus R, Hansen MP. The optimal antibiotic treatment duration for community-acquired pneumonia in adults diagnosed in general practice in Denmark (CAP-D): an open-label, pragmatic, randomised controlled trial. Trials 2024; 25:627. [PMID: 39334468 PMCID: PMC11429885 DOI: 10.1186/s13063-024-08477-z] [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: 05/27/2024] [Accepted: 09/17/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Use of antibiotics is the main driver of antimicrobial resistance which is considered one of the biggest threats to human health. In Denmark, most antibiotics are prescribed in general practice. Acute lower respiratory tract infections, including community-acquired pneumonia (CAP), are among the most frequent indications for antibiotic prescribing. Phenoxymethylpenicillin is established as first-line treatment in general practice in Denmark. However, the treatment duration with phenoxymethylpenicillin is mostly based on traditions. Both 5 and 7 days of treatment is recommended in Danish guidelines, and when asking the general practitioners about what treatment duration, they prescribe the variation is even bigger. Several hospital-based studies have proven short course (≤ 6 days) antibiotic treatment non-inferior to long course (≥ 7 days) treatment of CAP. No evidence exists on the optimal treatment duration for CAP in non-hospitalised patients. This randomised controlled trial aim to investigate the optimal treatment duration with phenoxymethylpenicillin for CAP in adults diagnosed in general practice in Denmark. METHODS This is an open-label, pragmatic, randomised controlled, five-arm DURATIONS trial. Participants will be recruited from at least 24 general practices in Denmark. Eligible participants are adults, with no pre-existing lung disease, presenting with symptoms of CAP, and in whom the general practitioner finds it relevant to treat with antibiotics. The study will compare treatment with phenoxymethylpenicillin 1.2 MIE q.i.d. in 3, 4, 5, 6, and 7 days. DISCUSSION This study will provide evidence for the optimal antibiotic treatment duration of CAP in general practice and inform future guidelines on CAP in all countries using phenoxymethylpenicillin for the treatment of acute respiratory tract infections in adults. The results of this study might also be used to guide treatment recommendations in other countries using phenoxymethylpenicillin. Moreover, a (potential) reduction in antibiotic use might lower the development of antimicrobial resistance, increase patient treatment adherence, reduce risks of adverse events, and lower the economical exp TRIAL REGISTRATION: ClinicalTrials.gov: NCT06295120. Registered 28 February 2024. The Scientific Ethics Committee for the North Denmark Region: N-20230039.
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Affiliation(s)
- Eskild Johansen
- Center for General Practice, Aalborg University, Aalborg, Denmark.
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - David Gillespie
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - Rune Aabenhus
- The Research Unit for General Practice, Copenhagen, Denmark
- Section of General Practice, Institute of Public Health, Copenhagen University, Copenhagen, Denmark
| | - Malene Plejdrup Hansen
- Center for General Practice, Aalborg University, Aalborg, Denmark
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
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Parker CC, Clarke NW, Cook AD, Petersen PM, Catton CN, Cross WR, Kynaston H, Persad RA, Saad F, Logue J, Payne H, Amos C, Bower L, Raman R, Sayers I, Worlding J, Parulekar WR, Parmar MKB, Sydes MR. Randomised Trial of No, Short-term, or Long-term Androgen Deprivation Therapy with Postoperative Radiotherapy After Radical Prostatectomy: Results from the Three-way Comparison of RADICALS-HD (NCT00541047). Eur Urol 2024:S0302-2838(24)02515-6. [PMID: 39217077 DOI: 10.1016/j.eururo.2024.07.026] [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: 03/26/2024] [Revised: 05/31/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND AND OBJECTIVE The use and duration of androgen deprivation therapy (ADT) with postoperative radiotherapy (RT) have been uncertain. RADICALS-HD compared adding no ("None"), 6-months ("Short"), or 24-mo ("Long") ADT to study efficacy in the long term. METHODS Participants with prostate cancer were indicated for postoperative RT and agreed randomisation between all durations. ADT was allocated for 0, 6, or 24 mo. The primary outcome measure (OM) was metastasis-free survival (MFS). The secondary OMs included freedom from distant metastasis, overall survival, and initiation of nonprotocol ADT. Sample size was determined by two-way comparisons. Analyses followed standard time-to-event approaches and intention-to-treat principles. KEY FINDINGS AND LIMITATIONS Between 2007 and 2015, 492 participants were randomised one of three groups: 166 None, 164 Short, and 162 Long. The median age at randomisation was 66 yr; Gleason scores at surgery were as follows: <7 = 64 (13%), 3+4 = 229 (47%), 4+3 = 127 (26%), and 8+ = 72 (15%); T3b was 112 (23%); and T4 was 5 (1%). The median follow-up was 9.0 yr and, with MFS events reported for 89 participants (32 None, 31 Short, and 26 Long), there was no evidence of difference in MFS overall (logrank p = 0.98), and, for Long versus None, hazard ratio = 0.948 (95% confidence interval 0.54-1.68). After 10 yr, 80% None, 77% Short, and 81% Long patients were alive without metastatic disease. The three-way randomisation was not powered to conventional levels for assessment, yet provides a fair comparison. CONCLUSIONS AND CLINICAL IMPLICATIONS Long-term outcomes after radical prostatectomy are usually favourable. In those indicated for postoperative RT and considered suitable for no, short-term, or long-term ADT, there was no evidence of improvement with addition of ADT. Future research should focus on patients at a higher risk of metastases in whom improvements are required more urgently.
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Affiliation(s)
- Chris C Parker
- Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK
| | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal Hospitals, Manchester, UK; The University of Manchester, Manchester, UK
| | - Adrian D Cook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Peter M Petersen
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Charles N Catton
- Department of Radiation Oncology, Princess Margaret, Cancer Centre, University Health Network, Toronto, ON, Canada
| | - William R Cross
- Department of Urology, St James's University Hospital, Leeds, UK
| | - Howard Kynaston
- Division of Cancer & Genetics, Cardiff University Medical School, Cardiff, UK
| | - Raj A Persad
- Department of Urology, Bristol Urological Institute, Bristol, UK
| | - Fred Saad
- Department of Urology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | | | | | - Claire Amos
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Lorna Bower
- The Institute of Cancer Research, Sutton, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rakesh Raman
- Kent Oncology Centre, Kent & Canterbury Hospital, Canterbury, UK
| | - Ian Sayers
- Deanesly Centre, New Cross Hospital, Wolverhampton, UK
| | - Jane Worlding
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Wendy R Parulekar
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Mahesh K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK.
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Strohbehn GW, Stadler WM, Boonstra PS, Ratain MJ. Optimizing the doses of cancer drugs after usual dose finding. Clin Trials 2024; 21:340-349. [PMID: 38148731 DOI: 10.1177/17407745231213882] [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] [Indexed: 12/28/2023]
Abstract
Since the middle of the 20th century, oncology's dose-finding paradigm has been oriented toward identifying a drug's maximum tolerated dose, which is then carried forward into phase 2 and 3 trials and clinical practice. For most modern precision medicines, however, maximum tolerated dose is far greater than the minimum dose needed to achieve maximal benefit, leading to unnecessary side effects. Regulatory change may decrease maximum tolerated dose's predominance by enforcing dose optimization of new drugs. Dozens of already approved cancer drugs require re-evaluation, however, introducing a new methodologic and ethical challenge in cancer clinical trials. In this article, we assess the history and current landscape of cancer drug dose finding. We provide a set of strategic priorities for postapproval dose optimization trials of the future. We discuss ethical considerations for postapproval dose optimization trial design and review three major design strategies for these unique trials that would both adhere to ethical standards and benefit patients and funders. We close with a discussion of financial and reporting considerations in the realm of dose optimization. Taken together, we provide a comprehensive, bird's eye view of the postapproval dose optimization trial landscape and offer our thoughts on the next steps required of methodologies and regulatory and funding regimes.
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Affiliation(s)
- Garth W Strohbehn
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
- Division of Medical Oncology, Lieutenant Colonel Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Walter M Stadler
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Philip S Boonstra
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL, USA
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, USA
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Bryant AK, Lewy JR, Bressler RD, Chopra Z, Gyori DJ, Bazzell BG, Moeller JA, Jacobson SI, Fendrick AM, Kerr EA, Ramnath N, Green MD, Hofer TP, Vaishnav P, Strohbehn GW. Projected environmental and public health benefits of extended-interval dosing: an analysis of pembrolizumab use in a US national health system. Lancet Oncol 2024; 25:802-810. [PMID: 38821085 PMCID: PMC11177338 DOI: 10.1016/s1470-2045(24)00200-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Health care is a major source of greenhouse gas emissions, leading to climate change and public health harms. Changes are needed to improve the environmental sustainability of health-care practices, but such changes should not sacrifice patient outcomes or financial sustainability. Alternative dosing strategies that reduce the frequency with which specialty drugs are administered, without sacrificing patient outcomes, are an attractive possibility for improving environmental sustainability. We sought to inform environmentally sustainable cancer care by estimating and comparing the environmental and financial effects of alternative, clinically equivalent strategies for pembrolizumab administration. METHODS We conducted a retrospective analysis using a cohort of patients from the Veterans Health Administration (VHA) in the USA who received one or more pembrolizumab doses between May 1, 2020, and Sept 30, 2022. Using baseline, real-world administration of pembrolizumab, we generated simulated pembrolizumab use data under three near-equivalent counterfactual pembrolizumab administration strategies defined by combinations of weight-based dosing, pharmacy-level vial sharing and dose rounding, and extended-interval dosing (ie, every 6 weeks). For each counterfactual dosing strategy, we estimated greenhouse gas emissions related to pembrolizumab use across the VHA cohort using a deterministic environmental impact model that estimated greenhouse gas emissions due to patient travel, drug manufacture, and medical waste as the primary outcome measure. FINDINGS We identified 7813 veterans who received at least one dose of pembrolizumab-containing therapy in the VHA during the study period. 59 140 pembrolizumab administrations occurred in the study period, of which 46 255 (78·2%) were dosed at 200 mg every 3 weeks, 12 885 (21·8%) at 400 mg every 6 weeks, and 14 955 (25·3%) were coadministered with infusional chemotherapies. Adoption of weight-based, extended-interval pembrolizumab dosing (4 mg/kg every 6 weeks) and pharmacy-level stewardship strategies (ie, dose rounding and vial sharing) for all pembrolizumab infusions would have resulted in 24·7% fewer administration events than baseline dosing (44 533 events vs 59 140 events) and an estimated 200 metric tons less CO2 emitted per year as a result of pembrolizumab use within the VHA (650 tons vs 850 tons of CO2, a relative reduction of 24%), largely due to reductions in distance travelled by patients to receive treatment. Similar results were observed when weight-based and extended-interval dosing were applied only to pembrolizumab monotherapy and pembrolizumab in combination with oral therapies. INTERPRETATION Alternative pembrolizumab administration strategies might have environmental advantages over the current dosing and compounding paradigms. Specialty medication dosing can be optimised for health-care spending and environmental sustainability without sacrificing clinical outcomes. FUNDING None.
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Affiliation(s)
- Alex K Bryant
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA; Department of Radiation Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Lung Precision Oncology Program, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Jacqueline R Lewy
- University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - R Daniel Bressler
- School of International and Public Affairs, Columbia Climate School, and Center for Environmental Economics and Policy, Columbia University, New York, NY, USA
| | - Zoey Chopra
- University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA; Department of Economics, University of Michigan, Ann Arbor, MI, USA
| | - Derek J Gyori
- Division of Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA
| | - Brian G Bazzell
- Division of Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA
| | - Julie A Moeller
- Division of Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA
| | | | - A Mark Fendrick
- Division of General Internal Medicine, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Center for Value-Based Insurance Design, University of Michigan, Ann Arbor, MI, USA
| | - Eve A Kerr
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA; Division of General Internal Medicine, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Nithya Ramnath
- Lung Precision Oncology Program, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Division of Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA; Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Michael D Green
- Department of Radiation Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Lung Precision Oncology Program, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA; Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA
| | - Timothy P Hofer
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA; Division of General Internal Medicine, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA
| | - Parth Vaishnav
- School for Environment and Sustainability, University of Michigan, Ann Arbor, MI, USA
| | - Garth W Strohbehn
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA; Lung Precision Oncology Program, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Division of Oncology, Charles S Kettles VA Medical Center, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA; Center for Global Health Equity, University of Michigan, Ann Arbor, MI, USA.
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Lin Z, Chen Z, Li Y. Analgesic efficacy of an opioid-free postoperative pain management strategy versus a conventional opioid-based strategy following laparoscopic radical gastrectomy: an open-label, randomized, controlled, non-inferiority trial. World J Surg Oncol 2024; 22:54. [PMID: 38360661 PMCID: PMC10868092 DOI: 10.1186/s12957-023-03298-x] [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: 10/09/2023] [Accepted: 12/29/2023] [Indexed: 02/17/2024] Open
Abstract
OBJECTIVE In patients undergoing laparoscopic radical gastrectomy, the use of subcostal transversus abdominis plane block (STAPB) for completely opioid-free postoperative pain management lacks convincing clinical evidence. METHODS This study included 112 patients who underwent laparoscopic radical gastrectomy at the 900TH Hospital of the Joint Logistics Support Force from October 2020 to March 2022. Patients were randomly divided into (1:1) continuous opioid-free STAPB (C-STAPB) group and conventional group. In the C-STAPB group, 0.2% ropivacaine (bilateral, 20 ml per side) was injected intermittently every 12 h through a catheter placed on the transverse abdominis plane for postoperative pain management. The conventional group was treated with a conventional intravenous opioid pump (2.5 μg/kg sufentanil and 10 mg tropisetron, diluted to 100 ml with 0.9% NS). The primary outcomes were the accumulative area under the curve of the numeric rating scale (NRS) score at 24 and 48 h postoperatively at rest and during movement. The secondary outcomes were postoperative recovery outcomes, postoperative daily food intake, and postoperative complications. RESULTS After exclusion (n = 16), a total of 96 patients (C-STAPB group, n = 46; conventional group, n = 49) were included. We found there were no significant differences in the cumulative AUC of NRS score PACU-24 h and PACU-48 h between the C-STAPB group and conventional group at rest [(mean difference, 1.38; 95% CI, - 2.21 to 4.98, P = 0.447), (mean difference, 1.22; 95% CI, - 6.20 to 8.65, P = 0.744)] and at movement [(mean difference, 2.90; 95% CI, - 3.65 to 9.46; P = 0.382), (mean difference, 4.32; 95% CI, - 4.46 to 13.1; P = 0.331)]. The 95% CI upper bound of the difference between rest and movement in the C-STAPB group was less than the inferior margin value (9.5 and 14 points), indicating the non-inferiority of the analgesic effect of C-STPAB. The C-STAPB group had faster postoperative recovery profiles including earlier bowel movement, defecation, more volume of food intake postoperative, and lower postoperative nausea and vomiting compared to conventional groups (P < 0.001). CONCLUSIONS After laparoscopic radical gastrectomy, the analgesic effect of C-STAPBP is not inferior to the traditional opioid-based pain management model. TRIAL REGISTRATION ChiCTR2100051784.
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Affiliation(s)
- Zhimin Lin
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, 350001, People's Republic of China
- The 900th, Hospital of Joint Logistic Support Force, PLA, Fuzhou, 350001, People's Republic of China
- Affiliated Hospital of Putian University, 999th Dongzhen East Road, Licheng District, Putian, 351100, People's Republic of China
| | - Zhongbiao Chen
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, 350001, People's Republic of China
- The 900th, Hospital of Joint Logistic Support Force, PLA, Fuzhou, 350001, People's Republic of China
| | - Yongliang Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, 350001, People's Republic of China.
- Affiliated Hospital of Putian University, 999th Dongzhen East Road, Licheng District, Putian, 351100, People's Republic of China.
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Boonstra PS, Tabarrok A, Strohbehn GW. Targeted randomization dose optimization trials enable fractional dosing of scarce drugs. PLoS One 2023; 18:e0287511. [PMID: 37903093 PMCID: PMC10615276 DOI: 10.1371/journal.pone.0287511] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 06/07/2023] [Indexed: 11/01/2023] Open
Abstract
Administering drug at a dose lower than that used in pivotal clinical trials, known as fractional dosing, can stretch scarce resources. Implementing fractional dosing with confidence requires understanding a drug's dose-response relationship. Clinical trials aimed at describing dose-response in scarce, efficacious drugs risk underdosing, leading dose-finding trials to not be pursued despite their obvious potential benefit. We developed a new set of response-adaptive randomized dose-finding trials and demonstrate, in a series of simulated trials across diverse dose-response curves, these designs' efficiency in identifying the minimum dose that achieves satisfactory efficacy. Compared to conventional designs, these trials have higher probabilities of identifying lower doses while reducing the risks of both population- and subject-level underdosing. We strongly recommend that, upon demonstration of a drug's efficacy, pandemic drug development swiftly proceeds with response-adaptive dose-finding trials. This unified strategy ensures that scarce effective drugs produce maximum social benefits.
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Affiliation(s)
- Philip S. Boonstra
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, United States of America
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Alex Tabarrok
- Department of Economics, George Mason University, Fairfax, Virginia, United States of America
| | - Garth W. Strohbehn
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, United States of America
- Veterans Affairs Center for Clinical Management and Research, Ann Arbor, Michigan, United States of America
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
- Division of Medical Oncology, LTC Charles S Kettles VA Medical Center, Ann Arbor, Michigan, United States of America
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
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Wang D, Liao C, Tian Y, Zheng T, Ye H, Yu Z, Jiang J, Su J, Chen S, Zheng X. Analgesic efficacy of an opioid-free postoperative pain management strategy versus a conventional opioid-based strategy following open major hepatectomy: an open-label, randomised, controlled, non-inferiority trial. EClinicalMedicine 2023; 63:102188. [PMID: 37692074 PMCID: PMC10485032 DOI: 10.1016/j.eclinm.2023.102188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/12/2023] [Accepted: 08/15/2023] [Indexed: 09/12/2023] Open
Abstract
Background Convincing clinical evidence regarding completely opioid-free postoperative pain management using erector spinae plane block (ESPB) in patients undergoing open major hepatectomy (OMH) is lacking. Herein, we aimed to compare the postoperative analgesic efficacy of the visualised continuous opioid-free ESPB (VC-ESPB) and conventional intravenous opioid-based postoperative pain management in hepatocellular carcinoma (HCC) patients undergoing OMH. Methods This open-label, randomised, controlled, non-inferiority trial enrolled patients with HCC undergone open major hepatectomy in Fujian Provincial Hospital and compared the postoperative analgesic efficacy of VC-ESPB (VC-ESPB group) and conventional intravenous opioid-based pain management regimen (conventional group). Patients were randomly assigned (1:1) to VC-ESPB group and conventional group. Patients were not masked to treatment allocation. The VC-ESPB group was treated with intermittent injections of 0.25% ropivacaine (bilateral, 30 mL each side) given every 12 h through catheters placed in the space of erector spinae and an opioid-free intravenous pump (10-mg tropisetron diluted to 100 mL with 0.9% normal saline [NS]) for postoperative pain management. The conventional group did not receive ESPB and was treated with a conventional intravenous opioid-based pump (2.5-μg/kg sufentanil and 10-mg tropisetron diluted to 100 mL with 0.9% NS). Patients in the VC-ESPB group underwent magnetic resonance imaging (MRI) to identify local anaesthetic diffusion after ESPB was performed under ultrasound guidance. The primary outcome was postoperative analgesic efficacy, which was indicated by the cumulative area under the curve (AUC) of the pain visual analogue scale scores (range, 0-10; a higher score indicates more pain) obtained at rest and at movement until 48 h postoperatively after leaving the post-anaesthesia care unit (PACU). Herein, an AUC of 26.5 was set as the noninferiority margin, which needed to be satisfied for both cumulative AUCPACU-48 h at rest and cumulative AUCPACU-48 h at movement. Per protocol participants were included in primary and safety analyses. This trial was registered with ChiCTR.org.cn (ChiCTR1900026583). Findings Between October 30, 2019, and May 1, 2023, 106 patients were enrolled and randomly assigned to the VC-ESPB group (n = 53) and the conventional group (n = 53). After the dropout (n = 5), a total of 101 patients (VC-ESPB group, n = 50; conventional group, n = 51) were analysed. Both the level of cumulative AUCPACU-48 h (at rest: 160.08 ± 38.00 vs. 164.94 ± 31.00; difference [90% CI], -4.861 [-16.308, 6.585]) and cumulative AUCPACU-48 h (at movement: 209.64 ± 28.98 vs. 212.59 ± 33.11; difference [90% CI], -2.948 [-13.236, 7.339]) were similar between the VC-ESPB and control groups within the first postoperative 48 h. The upper limit of the 90% CIs for the difference in cumulative ACUPACU-48 h at rest and at movement did not reach the upper inferiority margin (26.5). During the first postoperative 48 h, the rate of nonsteroidal anti-inflammatory drug rescue analgesia was similar between the VC-ESPB group and conventional group (n = 16, 32.0% vs. n = 11, 21.6%; P = 0.236). Treatment-related death was not observed in the VC-ESPB group (n = 0, 0%) and conventional group (n = 0, 0%). In VC-ESPB group, local site paralysis (n = 1, 2.0%) was observed in one patient and rash (n = 1, 2.0%) was observed in another patient. One patient in the conventional group was observed with rash preoperatively (n = 1, 2.0%). The VC-ESPB group had significantly lower rates of postoperative nausea (n = 2, 4.0%, vs. n = 9, 17.6%, P = 0.028), vomiting (n = 1, 2.0% vs. n = 8, 15.7%, P = 0.031) and lower incidence of major complications (n = 4, 8.0% vs. n = 6, 11.8%; P = 0.033). Interpretation This study demonstrates the noninferiority of VC-ESPB when compared with the conventional opioid-based approach for postoperative pain management after OMH, suggesting that it is feasible to achieve opioid-free postoperative pain management for OMH. Funding The Joint Funds for the Innovation of Science and Technology, Fujian Province, China; the Youth Scientific Research Project of Fujian Provincial Health Commission; the Fujian Research and Training Grants for Young and Middle-aged Leaders in Healthcare; and the Key Clinical Specialty Discipline Construction Program of Fujian, China.
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Affiliation(s)
- Danfeng Wang
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, China
| | - Chengyu Liao
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Yifeng Tian
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Ting Zheng
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, China
| | - Huazhen Ye
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, China
| | - Zenggui Yu
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, China
| | - Jundan Jiang
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, China
| | - Jiawei Su
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Radiology, Fujian Provincial Hospital, Fuzhou, China
| | - Shi Chen
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Xiaochun Zheng
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, China
- Fujian Provincial Key Laboratory of Emergency Medicine, Fuzhou, Fujian, China
- Fujian Emergency Medical Center, Fujian Provincial Key Laboratory of Critical Care Medicine, Fujian Provincial Co-Constructed Laboratory of “Belt and Road”, Fuzhou, China
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8
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Serra A, Mozgunov P, Davies G, Jaki T. Determining the minimum duration of treatment in tuberculosis: An order restricted non-inferiority trial design. Pharm Stat 2023; 22:938-962. [PMID: 37415394 DOI: 10.1002/pst.2320] [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: 07/26/2022] [Revised: 04/22/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
Tuberculosis (TB) is one of the biggest killers among infectious diseases worldwide. Together with the identification of drugs that can provide benefits to patients, the challenge in TB is also the optimisation of the duration of these treatments. While conventional duration of treatment in TB is 6 months, there is evidence that shorter durations might be as effective but could be associated with fewer side effects and may be associated with better adherence. Based on a recent proposal of an adaptive order-restricted superiority design that employs the ordering assumptions within various duration of the same drug, we propose a non-inferiority (typically used in TB trials) adaptive design that effectively uses the order assumption. Together with the general construction of the hypothesis testing and expression for type I and type II errors, we focus on how the novel design was proposed for a TB trial concept. We consider a number of practical aspects such as choice of the design parameters, randomisation ratios, and timings of the interim analyses, and how these were discussed with the clinical team.
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Affiliation(s)
| | - Pavel Mozgunov
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Geraint Davies
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Thomas Jaki
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Faculty of Informatics and Data Science, University of Regensburg, Regensburg, Germany
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9
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Ghorani E, Quartagno M, Blackhall F, Gilbert DC, O'Brien M, Ottensmeier C, Pizzo E, Spicer J, Williams A, Badman P, Parmar MKB, Seckl MJ. REFINE-Lung implements a novel multi-arm randomised trial design to address possible immunotherapy overtreatment. Lancet Oncol 2023; 24:e219-e227. [PMID: 37142383 DOI: 10.1016/s1470-2045(23)00095-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/14/2023] [Accepted: 02/20/2023] [Indexed: 05/06/2023]
Abstract
Increasing evidence suggests that some immunotherapy dosing regimens for patients with advanced cancer could result in overtreatment. Given the high costs of these agents, and important implications for quality of life and toxicity, new approaches are needed to identify and reduce unnecessary treatment. Conventional two-arm non-inferiority designs are inefficient in this context because they require large numbers of patients to explore a single alternative to the standard of care. Here, we discuss the potential problem of overtreatment with anti-PD-1 directed agents in general and introduce REFINE-Lung (NCT05085028), a UK multicentre phase 3 study of reduced frequency pembrolizumab in advanced non-small-cell lung cancer. REFINE-Lung uses a novel multi-arm multi-stage response over continuous interventions (MAMS-ROCI) design to determine the optimal dose frequency of pembrolizumab. Along with a similarly designed basket study of patients with renal cancer and melanoma, REFINE-Lung and the MAMS-ROCI design could contribute to practice-changing advances in patient care and form a template for future immunotherapy optimisation studies across cancer types and indications. This new trial design is applicable to many new or existing agents for which optimisation of dose, frequency, or duration of therapy is desirable.
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Affiliation(s)
- Ehsan Ghorani
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, London, UK
| | - Matteo Quartagno
- Institute for Clinical Trials and Methodology, University College London, London, UK
| | - Fiona Blackhall
- Christie National Health Service Foundation Trust, Manchester, UK
| | - Duncan C Gilbert
- Institute for Clinical Trials and Methodology, University College London, London, UK
| | - Mary O'Brien
- Royal Marsden Hospital, Imperial College London, London, UK
| | - Christian Ottensmeier
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK; Clatterbridge Cancer Center NHS Foundation Trust, Liverpool, UK
| | - Elena Pizzo
- Department of Applied Health Research, University College London, London, UK
| | - James Spicer
- King's College London, Guy's Hospital, London, UK
| | - Alex Williams
- Imperial College Trials Unit-Cancer, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Philip Badman
- Imperial College Trials Unit-Cancer, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Mahesh K B Parmar
- Institute for Clinical Trials and Methodology, University College London, London, UK.
| | - Michael J Seckl
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, London, UK.
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10
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McDonald EG, Prosty C, Hanula R, Bortolussi-Courval É, Albuquerque AM, Tong SYC, Hamilton F, Lee TC. Observational versus randomized controlled trials to inform antibiotic treatment durations: a narrative review. Clin Microbiol Infect 2023; 29:165-170. [PMID: 36108947 DOI: 10.1016/j.cmi.2022.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Studies comparing shorter and longer antibiotic treatment durations are increasingly common. Randomized controlled trials (RCTs) are an ideal methodological approach to study antibiotic treatment durations; however, these trials can be logistically and financially challenging to conduct. OBJECTIVES In this narrative review, we sought to compare the strengths and limitations of observational study data with those of RCT data in evaluating antibiotic treatment durations. We used uncomplicated Gram-negative bacteraemia as an illustrative case example because several published RCTs and observational studies have been conducted in similar patient populations. SOURCES We searched MEDLINE for articles comparing treatment durations for gram-negative bacteremia from inception to June 9th, 2022. We included studies reporting on all-cause mortality and/or relapse at day 28-30. Data comparing short- versus long-course therapy were pooled by Bayesian random effects meta-analyses to assess the odds ratios (OR) of all-cause mortality and relapse at 30 days, stratified by study design. Parameters were summarized with median and 95% highest-density credible intervals (CrI). Posterior probabilities of OR > 1.0 were estimated. Observational studies were further examined to determine if and how they addressed potential sources of bias. CONTENT We identified 1671 unique records and included 10 studies (seven observational and three RCTs). With respect to 30-day mortality, the Bayesian posterior probability that a longer course of therapy was better (i.e. OR >1.0) was 42% in RCTs (OR, 0.94; 95% CrI, 0.51-1.68) and 91% in observational studies (OR, 1.25; 95% CrI, 0.88-1.73). No observational study fully addressed all potential sources of bias. IMPLICATIONS On the basis of our findings, we discuss future directions for antibiotic treatment duration trials, including approaches to limit sources of bias in observation data and novel trial designs.
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Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, McGill University Health Centre, Montréal, Québec, Canada; Clinical Practice Assessment Unit, Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada; Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada.
| | - Connor Prosty
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Ryan Hanula
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Émilie Bortolussi-Courval
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Arthur M Albuquerque
- School of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Fergus Hamilton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom; Infection Science, North Bristol NHS Trust, Bristol, United Kingdom
| | - Todd C Lee
- Clinical Practice Assessment Unit, Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada; Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada; Division of Infectious Diseases, McGill University Health Centre, Montréal, Québec, Canada
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11
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Zantek ND, Steiner ME, VanBuren JM, Lewis RJ, Berry NS, Viele K, Krachey E, Dean JM, Nelson S, Spinella PC. Design and logistical considerations for the randomized adaptive non-inferiority storage-duration-ranging CHIlled Platelet Study. Clin Trials 2023; 20:36-46. [PMID: 36541257 DOI: 10.1177/17407745221126423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Platelet transfusion is a potentially life-saving therapy for actively bleeding patients, ranging from those undergoing planned surgical procedures to those suffering unexpected traumatic injuries. Platelets are currently stored at room temperature (20°C-24°C) with a maximum storage duration of 7 days after donation. The CHIlled Platelet Study trial will compare the efficacy and safety of standard room temperature-stored platelets with platelets that are cold-stored (1°C-6°C), that is, chilled, with a maximum of storage up to 21 days in adult and pediatric patients undergoing complex cardiac surgical procedures. METHODS/RESULTS CHIlled Platelet Study will use a Bayesian adaptive design to identify the range of cold storage durations for platelets that are non-inferior to standard room temperature-stored platelets. If cold-stored platelets are non-inferior at durations greater than 7 days, a gated superiority analysis will identify durations for which cold-stored platelets may be superior to standard platelets. We present example simulations of the CHIlled Platelet Study design and discuss unique challenges in trial implementation. The CHIlled Platelet Study trial has been funded and will be implemented in approximately 20 clinical centers. Early randomization to enable procurement of cold-stored platelets with different storage durations will be required, as well as a platelet tracking system to eliminate platelet wastage and maximize trial efficiency and economy. DISCUSSION The CHIlled Platelet Study trial will determine whether cold-stored platelets are non-inferior to platelets stored at room temperature, and if so, will determine the maximum duration (up to 21 days) of storage that maintains non-inferiority. TRIAL REGISTRATION ClinicalTrials.gov, NCT04834414.
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Affiliation(s)
- Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - John M VanBuren
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Roger J Lewis
- Harbor-UCLA Medical Center, Torrance, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Berry Consultants, Austin, TX, USA
| | | | | | | | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | - Philip C Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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12
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Merrick S, Nankivell M, Quartagno M, Clarke CS, Joharatnam-Hogan N, Waddell T, O'Carrigan B, Seckl M, Ghorani E, Banks E, Edmonds K, Bray G, Woodward R, Bennett R, Badrock J, Hudson W, Langley RE, Vasudev N, Pickering L, Gilbert DC. REFINE (REduced Frequency ImmuNE checkpoint inhibition in cancers): A multi-arm phase II basket trial testing reduced intensity immunotherapy across different cancers. Contemp Clin Trials 2023; 124:107030. [PMID: 36519749 PMCID: PMC7614585 DOI: 10.1016/j.cct.2022.107030] [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: 07/25/2022] [Revised: 10/13/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) have revolutionised treating advanced cancers. ICI are administered intravenously every 2-6 weeks for up to 2 years, until cancer progression/unacceptable toxicity. Physiological efficacy is observed at lower doses than those used as standard of care (SOC). Pharmacodynamic studies indicate sustained target occupancy, despite a pharmacological half-life of 2-3 weeks. Reducing frequency of administration may be possible without compromising outcomes. The REFINE trial aims to limit individual patient exposure to ICI whilst maintaining efficacy, with potential benefits in quality of life and reduced drug treatment/attendance costs. METHODS/DESIGN REFINE is a randomised phase II, multi-arm, multi-stage (MAMS) adaptive basket trial investigating extended interval administration of ICIs. Eligible patients are those responding to conventionally dosed ICI at 12 weeks. In stage I, patients (n = 160 per tumour-specific cohort) will be randomly allocated (1:1) to receive maintenance ICI at SOC vs extended dose interval. REFINE is currently recruiting UK patients with locally advanced or metastatic renal cell carcinoma (RCC) who have tolerated and responded to initial nivolumab/ipilimumab, randomised to receive maintenance nivolumab SOC (480 mg 4 weekly) vs extended interval (480 mg 8 weekly). Additional tumour cohorts are planned. Subject to satisfactory outcomes (progression-free survival) stage II will investigate up to 5 different treatment intervals. Secondary outcome measures include overall survival, quality-of-life, treatment-related toxicity, mean incremental pathway costs and quality-adjusted life-years per patient. REFINE is funded by the Jon Moulton Charity Trust and Medical Research Council, sponsored by University College London (UCL), and coordinated by the MRC CTU at UCL. Trial Registration ISRCTN79455488. NCT04913025 EUDRACT #: 2021-002060-47. CTA 31330/0008/001-0001; MREC approval: 21/LO/0593. REFINE Protocol version 4.0.
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Affiliation(s)
- Sophie Merrick
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Matthew Nankivell
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Matteo Quartagno
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Caroline S Clarke
- University College London (UCL) Research Department of Primary Care and Population Health, Upper 3rd Floor, UCL Medical School, Royal Free Campus, London NW3 2PF, UK
| | - Nalinie Joharatnam-Hogan
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Tom Waddell
- The Christie NHS Foundation Trust, Wilmslow Road, Manchester M20 4BX, UK
| | - Brent O'Carrigan
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus Hill's Road, Cambridge CB2 0QQ, UK
| | - Michael Seckl
- Imperial College London, Division of Cancer, 2nd floor U201 Hammersmith Hospital Campus, London W12 0NN, UK
| | - Ehsan Ghorani
- Imperial College London, Division of Cancer, 2nd floor U201 Hammersmith Hospital Campus, London W12 0NN, UK
| | - Emma Banks
- Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds LS9 7TF, UK
| | - Kim Edmonds
- Royal Marsden Hospital, 203 Fulham Rd, Chelsea, London SW3 6JJ, UK
| | - George Bray
- University College London (UCL) Research Department of Primary Care and Population Health, Upper 3rd Floor, UCL Medical School, Royal Free Campus, London NW3 2PF, UK
| | - Rose Woodward
- Action Kidney Cancer, 11th Floor, 3 Piccadilly Place, Manchester M1 3BN, UK
| | - Rachel Bennett
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Jonathan Badrock
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Will Hudson
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Ruth E Langley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK
| | - Naveen Vasudev
- Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds LS9 7TF, UK
| | - Lisa Pickering
- Royal Marsden Hospital, 203 Fulham Rd, Chelsea, London SW3 6JJ, UK
| | - Duncan C Gilbert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, 2nd Floor 90 High Holborn, London WC1V 6LJ, UK.
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13
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Bouche G, Langley R, Rush H, Parmar M, Gilbert DC. Testing alternative schedules of adjuvant immune checkpoint blockers - The need for well-designed clinical trials. Eur J Cancer 2023; 178:88-90. [PMID: 36427393 DOI: 10.1016/j.ejca.2022.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/24/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Gauthier Bouche
- MRC Clinical Trials Unit at UCL, UCL, London, United Kingdom; The Anticancer Fund, Meise, Belgium.
| | - Ruth Langley
- MRC Clinical Trials Unit at UCL, UCL, London, United Kingdom
| | - Hannah Rush
- MRC Clinical Trials Unit at UCL, UCL, London, United Kingdom
| | - Mahesh Parmar
- MRC Clinical Trials Unit at UCL, UCL, London, United Kingdom
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14
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Abstract
OBJECTIVE A deep understanding of the relationship between a scarce drug's dose and clinical response is necessary to appropriately distribute a supply-constrained drug along these lines. SUMMARY OF KEY DATA The vast majority of drug development and repurposing during the COVID-19 pandemic - an event that has made clear the ever-present scarcity in healthcare systems -has been ignorant of scarcity and dose optimisation's ability to help address it. CONCLUSIONS Future pandemic clinical trials systems should obtain dose optimisation data, as these appear necessary to enable appropriate scarce resource allocation according to societal values.
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Affiliation(s)
- Garth Strohbehn
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care, Ann Arbor, Michigan, USA
| | - Govind Persad
- Sturm College of Law, University of Denver, Denver, Colorado, USA
| | - William F Parker
- Maclean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - Srinivas Murthy
- Paediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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15
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Allerton F, Pouwels KB, Bazelle J, Caddy S, Cauvin A, De Risio L, Swann J, Warland J, Kent A. Prospective trial of different antimicrobial treatment durations for presumptive canine urinary tract infections. BMC Vet Res 2021; 17:299. [PMID: 34488771 PMCID: PMC8422737 DOI: 10.1186/s12917-021-02974-y] [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: 02/02/2021] [Accepted: 07/20/2021] [Indexed: 12/03/2022] Open
Abstract
Background Avoidance of unnecessary antimicrobial administration is a key tenet of antimicrobial stewardship; knowing the optimal duration of therapy obviates over-treatment. However, little research has been performed to establish course lengths for common canine infections. In clinical practice, antimicrobial therapy is frequently prescribed in dogs presenting lower urinary tract signs (haematuria, pollakiuria and dysuria/stranguria). The proposed length of treatment in International Consensus guidelines has decreased with each iteration, but these recommendations remain arbitrary and largely extrapolated from experience in people. Methods The objective of this prospective, multi-centre study is to find the shortest course duration that is non-inferior to the standard duration of 7 days of amoxicillin/clavulanate in terms of clinical outcomes for female dogs with lower urinary tract signs consistent with a urinary tract infection. An electronic data capture platform will be used by participating veterinarians working in clinical practice in the United Kingdom. Eligible dogs must be female, aged between 6 months and 10 years and have lower urinary tract signs of up to seven days’ duration. Enrolment will be offered in cases where the case clinician intends to prescribe antimicrobial therapy. Automatic pseudo-randomisation to treatment group will be based on the day of presentation (Monday-Friday); all antimicrobial courses will be completed on the Sunday after presentation generating different treatment durations. Follow-up data will be collected 1, 8 and 22–26 days after completion of the antimicrobial course to ensure effective safety netting, and to monitor short-term outcome and recurrence rates. Informed owner consent will be obtained in all cases. The study is approved by the Ethical Review Board of the University of Nottingham and has an Animal Test Certificate from the Veterinary Medicine’s Directorate. Discussion This study has been designed to mirror current standards of clinical management; conclusions should therefore, be widely applicable and guide practising veterinarians in their antimicrobial decision-making process. A duration-response curve will be created allowing determination of the optimal treatment duration for the management of female dogs with lower urinary tract signs. It is hoped that these results will contribute valuable information to improve future antimicrobial stewardship as part of a wider one-health perspective. Supplementary Information The online version contains supplementary material available at 10.1186/s12917-021-02974-y.
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Affiliation(s)
- Fergus Allerton
- Willows Veterinary Centre and Referral Service; part of Linnaeus Veterinary Limited, Highlands Road, Shirley, Solihull, UK.
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial, Oxford, UK.,Resistance at University of Oxford in partnership with Public Health England, Oxford, UK
| | - Julien Bazelle
- Davies Veterinary Specialists; part of Linnaeus Veterinary Limited, Manor Farm Business Park, Higham Gobion, Hitchin, UK
| | - Sarah Caddy
- Cambridge Institute for Therapeutic Immunology and Infectious Disease, Jeffery Cheah Biomedical Centre, Puddicomb Way, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Luisa De Risio
- Linnaeus Veterinary Limited, Friars gate, Shirley, Solihull, UK
| | - James Swann
- Columbia Stem Cell Initiative, Columbia University, 650 West 168th Street, NY, 10032, New York, USA
| | - James Warland
- Wellcome-MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, University of Cambridge, Puddicombe Way, Cambridge, UK
| | - Andrew Kent
- Willows Veterinary Centre and Referral Service; part of Linnaeus Veterinary Limited, Highlands Road, Shirley, Solihull, UK
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