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Bhide P, Chan DYL, Lanz D, Alqawasmeh O, Barry E, Baxter D, Gonzalez Carreras F, Choudhury Y, Cheong Y, Chung JPW, Collins B, Cong L, Doidge S, Heighway J, Patel D, Pardo MC, Rattos A, Wright A, Dodds J, Perez T, Khan KS, Thangaratinam S. Clinical effectiveness and safety of time-lapse imaging systems for embryo incubation and selection in in-vitro fertilisation treatment (TILT): a multicentre, three-parallel-group, double-blind, randomised controlled trial. Lancet 2024; 404:256-265. [PMID: 39033010 DOI: 10.1016/s0140-6736(24)00816-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/29/2024] [Accepted: 04/17/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Time-lapse imaging systems for embryo incubation and selection might improve outcomes of in-vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) treatment due to undisturbed embryo culture conditions, improved embryo selection, or both. However, the benefit remains uncertain. We aimed to evaluate the effectiveness of time-lapse imaging systems providing undisturbed culture and embryo selection, and time-lapse imaging systems providing only undisturbed culture, and compared each with standard care without time-lapse imaging. METHODS We conducted a multicentre, three-parallel-group, double-blind, randomised controlled trial in participants undergoing IVF or ICSI at seven IVF centres in the UK and Hong Kong. Embryologists randomly assigned participants using a web-based system, stratified by clinic in a 1:1:1 ratio to the time-lapse imaging system for undisturbed culture and embryo selection (time-lapse imaging group), time-lapse imaging system for undisturbed culture alone (undisturbed culture group), and standard care without time-lapse imaging (control group). Women were required to be aged 18-42 years and men (ie, their partners) 18 years or older. Couples had to be receiving their first, second, or third IVF or ICSI treatment and could not participate if using donor gametes. Participants and trial staff were masked to group assignment, embryologists were not. The primary outcome was live birth. We performed analyses using the intention-to-treat principle and reported the main analysis in participants with primary outcome data available (full analysis set). The trial is registered on the International Trials Registry (ISRCTN17792989) and is now closed. FINDINGS 1575 participants were randomly assigned to treatment groups (525 participants per group) between June 21, 2018, and Sept 30, 2022. The live birth rates were 33·7% (175/520) in the time-lapse imaging group, 36·6% (189/516) in the undisturbed culture group, and 33·0% (172/522) in the standard care group. The adjusted odds ratio was 1·04 (97·5% CI 0·73 to 1·47) for time-lapse imaging arm versus control and 1·20 (0·85 to 1·70) for undisturbed culture versus control. The risk reduction for the absolute difference was 0·7 percentage points (97·5% CI -5·85 to 7·25) between the time-lapse imaging and standard care groups and 3·6 percentage points (-3·02 to 10·22) between the undisturbed culture and standard care groups. 79 serious adverse events unrelated to the trial were reported (n=28 in time-lapse imaging, n=27 in undisturbed culture, and n=24 in standard care). INTERPRETATION In women undergoing IVF or ICSI treatment, the use of time-lapse imaging systems for embryo culture and selection does not significantly increase the odds of live birth compared with standard care without time-lapse imaging. FUNDING Barts Charity, Pharmasure Pharmaceuticals, Hong Kong OG Trust Fund, Hong Kong Health and Medical Research Fund, Hong Kong Matching Fund.
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Affiliation(s)
- Priya Bhide
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK; Homerton Fertility Centre, Homerton Healthcare NHS Foundation Trust, London, UK.
| | - David Y L Chan
- Assisted Reproductive Technology Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Doris Lanz
- Institute of Cancer Research, Clinical Trials and Statistics Unit, Sutton, UK
| | | | - Eleanor Barry
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Dominic Baxter
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | | | - Yasmin Choudhury
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Ying Cheong
- Human Development and Health, Institute of Life Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jacqueline Pui Wah Chung
- Assisted Reproductive Technology Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Bonnie Collins
- The Centre for Reproductive Medicine, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Luping Cong
- Assisted Reproductive Technology Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Sally Doidge
- Centre for Reproduction and Gynaecology Wales and the West, Plymouth, UK
| | - James Heighway
- Coalition for Epidemic Preparedness Innovations (CEPI), London, UK
| | - Deepali Patel
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - M Carmen Pardo
- Department of Statistics and OR, Complutense University of Madrid, Madrid, Spain
| | - Annabel Rattos
- Wolfson Fertility Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - Annie Wright
- Imperial Clinical Trials Unit, Imperial College, London, UK
| | - Julie Dodds
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Teresa Perez
- Department of Statistics and Data Science, Complutense University of Madrid, Madrid, Spain
| | - Khalid S Khan
- Department of Preventative Medicine and Public Health, University of Granada, Granada, Spain
| | - Shakila Thangaratinam
- Institute of Life Course and Medical Sciences, University of Liverpool, UK; Liverpool Women's NHS Foundation Trust, Liverpool, UK
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Ullman A, Takashima M, Gibson V, Comber E, Borello E, Bradford N, Byrnes J, Cole R, Eisenstat D, Henson N, Howard P, Irwin A, Keogh S, Kleidon T, Martin M, McCleary K, McLean J, Moloney S, Monagle P, Moore A, Newall F, Noyes M, Rowan G, St John A, Wood A, Wolf J, Ware R. Preventing adverse events during paediatric cancer treatment: protocol for a multi-site hybrid randomised controlled trial of catheter lock solutions (the CLOCK trial). BMJ Open 2024; 14:e085637. [PMID: 38986559 PMCID: PMC11243282 DOI: 10.1136/bmjopen-2024-085637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/24/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Central venous access devices (CVADs) are commonly used for the treatment of paediatric cancer patients. Catheter locking is a routine intervention that prevents CVAD-associated adverse events, such as infection, occlusion and thrombosis. While laboratory and clinical data are promising, tetra-EDTA (T-EDTA) has yet to be rigorously evaluated or introduced in cancer care as a catheter lock. METHODS AND ANALYSIS This is a protocol for a two-arm, superiority type 1 hybrid effectiveness-implementation randomised controlled trial conducted at seven hospitals across Australia and New Zealand. Randomisation will be in a 3:2 ratio between the saline (heparinised saline and normal saline) and T-EDTA groups, with randomly varied blocks of size 10 or 20 and stratification by (1) healthcare facility; (2) CVAD type and (3) duration of dwell since insertion. Within the saline group, there will be a random allocation between normal and heparin saline. Participants can be re-recruited and randomised on insertion of a new CVAD. Primary outcome for effectiveness will be a composite of CVAD-associated bloodstream infections (CABSI), CVAD-associated thrombosis or CVAD occlusion during CVAD dwell or at removal. Secondary outcomes will include CABSI, CVAD-associated-thrombosis, CVAD failure, incidental asymptomatic CVAD-associated-thrombosis, other adverse events, health-related quality of life, healthcare costs and mortality. To achieve 90% power (alpha=0.05) for the primary outcome, data from 720 recruitments are required. A mixed-methods approach will be employed to explore implementation contexts from the perspective of clinicians and healthcare purchasers. ETHICS AND DISSEMINATION Ethics approval has been provided by Children's Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC) (HREC/22/QCHQ/81744) and the University of Queensland HREC (2022/HE000196) with subsequent governance approval at all sites. Informed consent is required from the substitute decision-maker or legal guardian prior to participation. In addition, consent may also be obtained from mature minors, depending on the legislative requirements of the study site. The primary trial and substudies will be written by the investigators and published in peer-reviewed journals. The findings will also be disseminated through local health and clinical trial networks by investigators and presented at conferences. TRIAL REGISTRATION NUMBER ACTRN12622000499785.
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Affiliation(s)
- Amanda Ullman
- The University of Queensland, Brisbane, Queensland, Australia
| | - Mari Takashima
- The University of Queensland, Brisbane, Queensland, Australia
| | - Victoria Gibson
- The University of Queensland, Brisbane, Queensland, Australia
- Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Elouise Comber
- The University of Queensland, Brisbane, Queensland, Australia
| | - Eloise Borello
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Natalie Bradford
- Cancer and Palliative Care Outcomes Centre, Queensland University of Technology, South Brisbane, Queensland, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, Griffith University, Brisbane, Queensland, Australia
| | - Roni Cole
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - David Eisenstat
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Nicole Henson
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Philippa Howard
- The University of Queensland, Brisbane, Queensland, Australia
| | - Adam Irwin
- University Of Queensland Centre for Clinical Research, Herston, Queensland, Australia
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children, London, UK
| | - Samantha Keogh
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Tricia Kleidon
- Queensland Children's Hospital, Queensland Health, South Brisbane, Queensland, Australia
- Alliance for Vascular Access Teaching and Research Group, Menzies Health Institute Queensland, Nathan, Queensland, Australia
| | - Michelle Martin
- Monash Children's Hospital, Clayton, New South Wales, Australia
| | - Karen McCleary
- Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia
| | - Jordana McLean
- Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Susan Moloney
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Paul Monagle
- Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Andrew Moore
- Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Fiona Newall
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Michelle Noyes
- Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Gemma Rowan
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Amanda St John
- Monash Children's Hospital, Clayton, New South Wales, Australia
| | - Andrew Wood
- Starship Children's Health, Auckland, Auckland, New Zealand
| | - Joshua Wolf
- St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Robert Ware
- Menzies Health Institute Queensland, Griffith University, Nathan, Queensland, Australia
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Humphreys S, von Ungern-Sternberg BS, Taverner F, Davidson A, Skowno J, Hallett B, Sommerfield D, Hauser N, Williams T, Spall S, Pham T, Atkins T, Jones M, King E, Burgoyne L, Stephens P, Vijayasekaran S, Slee N, Burns H, Franklin D, Hough J, Schibler A. High-flow nasal oxygen for children's airway surgery to reduce hypoxaemic events: a randomised controlled trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:535-543. [PMID: 38788748 DOI: 10.1016/s2213-2600(24)00115-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 03/13/2024] [Accepted: 04/03/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Tubeless upper airway surgery in children is a complex procedure in which surgeons and anaesthetists share the same operating field. These procedures are often interrupted for rescue oxygen therapy. The efficacy of nasal high-flow oxygen to decrease the frequency of rescue interruptions in children undergoing upper airway surgery is unknown. METHODS In this multicentre randomised trial conducted in five tertiary hospitals in Australia, children aged 0-16 years who required tubeless upper airway surgery were randomised (1:1) by a web-based randomisation tool to either nasal high-flow oxygen delivery or standard oxygen therapy (oxygen flows of up to 6 L/min). Randomisation was stratified by site and age (<1 year, 1-4 years, and 5-16 years). Subsequent tubeless upper airway surgery procedures in the same child could be included if there were more than 2 weeks between the procedures, and repeat surgical procedures meeting this condition were considered to be independent events. The oxygen therapy could not be masked, but the investigators remained blinded until outcome data were locked. The primary outcome was successful anaesthesia without interruption of the surgical procedure for rescue oxygenation. A rescue oxygenation event was defined as an interruption of the surgical procedure to deliver positive pressure ventilation using either bag mask technique, insertion of an endotracheal tube, or laryngeal mask to improve oxygenation. There were ten secondary outcomes, including the proportion of procedures with a hypoxaemic event (SpO2 <90%). Analyses were done on an intention-to-treat (ITT) basis. Safety was assessed in all enrolled participants. This trial is registered in the Australian New Zealand Clinical Trials Registry, ACTRN12618000949280, and is completed. FINDINGS From Sept 4, 2018, to April 12, 2021, 581 procedures in 487 children were randomly assigned to high-flow oxygen (297 procedures) or standard care (284 procedures); after exclusions, 528 procedures (267 assigned to high-flow oxygen and 261 assigned to standard care) in 483 children (293 male and 190 female) were included in the ITT analysis. The primary outcome of successful anaesthesia without interruption for tubeless airway surgery was achieved in 236 (88%) of 267 procedures on high-flow oxygen and in 229 (88%) of 261 procedures on standard care (adjusted risk ratio [RR] 1·02, 95% CI 0·96-1·08, p=0·82). There were 51 (19%) procedures with a hypoxaemic event in the high-flow oxygen group and 57 (22%) in the standard care group (RR 0·86, 95% CI 0·58-1·24). Of the other prespecified secondary outcomes, none showed a significant difference between groups. Adverse events of epistaxis, laryngospasm, bronchospasm, hypoxaemia, bradycardia, cardiac arrest, hypotension, or death were similar in both study groups. INTERPRETATION Nasal high-flow oxygen during tubeless upper airway surgery did not reduce the proportion of interruptions of the procedures for rescue oxygenation compared with standard care. There were no differences in adverse events between the intervention groups. These results suggest that both approaches, nasal high-flow or standard oxygen, are suitable alternatives to maintain oxygenation in children undergoing upper airway surgery. FUNDING Thrasher Research Fund, the Australian and New Zealand College of Anaesthetists, the Society for Paediatric Anaesthesia in New Zealand and Australia.
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Affiliation(s)
- Susan Humphreys
- Department of Anaesthesia, Queensland Children's Hospital, Brisbane, QLD, Australia; The University of Queensland, Brisbane, QLD, Australia
| | - Britta S von Ungern-Sternberg
- Division of Emergency Medicine, Anaesthesia, and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia; University of Western Australia, Perth, WA, Australia
| | - Fiona Taverner
- Department of Children's Anaesthesia, Women's and Children's Hospital, Adelaide, SA, Australia; University of Adelaide, Adelaide, SA, Australia
| | - Andrew Davidson
- Department of Anaesthesia, Royal Children's Hospital, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Justin Skowno
- Department of Anaesthesia, The Children's Hospital at Westmead, Sydney, NSW, Australia; School of Child and Adolescent Health, University of Sydney, Sydney, NSW, Australia
| | - Ben Hallett
- Department of Anaesthesia, Royal Children's Hospital, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - David Sommerfield
- Division of Emergency Medicine, Anaesthesia, and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia; University of Western Australia, Perth, WA, Australia
| | - Neil Hauser
- Division of Emergency Medicine, Anaesthesia, and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia; University of Western Australia, Perth, WA, Australia
| | - Tara Williams
- Department of Anaesthesia, Queensland Children's Hospital, Brisbane, QLD, Australia; The University of Queensland, Brisbane, QLD, Australia
| | - Susan Spall
- Department of Anaesthesia, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Trang Pham
- Department of Anaesthesia, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Tiffany Atkins
- Institute for Evidence-Based Healthcare, Bond University, Robina, QLD, Australia
| | - Mark Jones
- Institute for Evidence-Based Healthcare, Bond University, Robina, QLD, Australia
| | - Emma King
- Department of Children's Anaesthesia, Women's and Children's Hospital, Adelaide, SA, Australia
| | - Laura Burgoyne
- Department of Children's Anaesthesia, Women's and Children's Hospital, Adelaide, SA, Australia; University of Adelaide, Adelaide, SA, Australia
| | - Philip Stephens
- Department of Anaesthesia, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Shyan Vijayasekaran
- Division of Emergency Medicine, Anaesthesia, and Pain Medicine, Perth Children's Hospital, Perth, WA, Australia; University of Western Australia, Perth, WA, Australia
| | - Nicola Slee
- Department of Ear, Nose, and Throat Surgery, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Hannah Burns
- Department of Ear, Nose, and Throat Surgery, Queensland Children's Hospital, Brisbane, QLD, Australia; The University of Queensland, Brisbane, QLD, Australia
| | - Donna Franklin
- The University of Queensland, Brisbane, QLD, Australia; Children's Critical Care Research Collaborative Group, Griffith University, Gold Coast University Hospital, Southport, QLD, Australia; Wesley Research Institute, Brisbane, QLD, Australia; Menzies Health Institute Queensland, Southport, QLD, Australia
| | - Judith Hough
- Australia Catholic University, Department of Physiotherapy, Brisbane, QLD, Australia
| | - Andreas Schibler
- Critical Care Research Group, St Andrew's War Memorial Hospital, Wesley Research Institute, Brisbane, QLD, Australia; College of Medicine & Dentistry, James Cook University, Townsville, QLD, Australia.
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Ramakrishnan S, Jeffers H, Langford-Wiley B, Davies J, Thulborn SJ, Mahdi M, A'Court C, Binnian I, Bright S, Cartwright S, Glover V, Law A, Fox R, Jones A, Davies C, Copping D, Russell RE, Bafadhel M. Blood eosinophil-guided oral prednisolone for COPD exacerbations in primary care in the UK (STARR2): a non-inferiority, multicentre, double-blind, placebo-controlled, randomised controlled trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:67-77. [PMID: 37924830 DOI: 10.1016/s2213-2600(23)00298-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/04/2023] [Accepted: 08/07/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Systemic glucocorticoids are recommended for use in chronic obstructive pulmonary disease (COPD) exacerbations; however, there is increased harm associated with their use. We hypothesised that the use of eosinophil biomarker-directed oral prednisolone therapy at the time of an exacerbation of COPD was effective at reducing prednisolone use without affecting adverse outcomes. METHODS The studying acute exacerbations and response (STARR2) study was a multicentre, randomised, double-blind, placebo-controlled trial conducted in 14 primary care practices in the UK. We included adults (aged ≥40 years), who were current or former smokers (with at least a 10 pack year smoking history) with a diagnosis of COPD, defined as a post-bronchodilator FEV1/forced vital capacity ratio of less than 0·7 previously recorded by the primary care physician, and a history of at least one exacerbation in the previous 12 months requiring systemic corticosteroids with or without antibiotics. All study staff and participants were masked to study group allocation and to treatment allocation. Participants were randomly assigned (1:1) to blood eosinophil-directed treatment (BET; to receive oral prednisolone 30 mg once daily if eosinophil count was high [≥2%] or placebo if eosinophil count was low [<2%]) or to standard care treatment (ST; to receive prednisolone 30 mg once daily irrespective of the point-of-care eosinophil result). Treatment was prescribed for 14 days and all patients also received antibiotics. The primary outcome was the rate of treatment failure, defined as any need for re-treatment with antibiotics or steroids, hospitalisation for any cause, or death, assessed at 30 days after exacerbation in the modified intention-to-treat population. Participants were eligible for re-randomisation at further exacerbations (with a maximum of four exacerbations per participant). A safety analysis was conducted on all randomly assigned participants. Although designed as a superiority trial, after identification of an error in the randomisation code before data lock the study converted to show non-inferiority. An upper margin of 1·105 for the 95% CI was defined as the non-inferiority margin. This study was registered with EudraCT, 2017-001586-24, and is complete. FINDINGS Between Nov 6, 2017, and April 30, 2020, 308 participants were recruited from 14 general practices. 144 exacerbations (73 in the BET group and 71 in the ST group) from 93 participants (mean age 70 years [range 46-84] and mean percent predicted FEV1 60·9% [SD 19·4]; 52 [56%] male and 41 [44%] female; ethnicity data was not collected]) were included in the modified intention-to-treat analysis. There were 14 (19%) treatment failures at 30 days post-exacerbation in the BET group and 23 (32%) in the ST group; we found a large non-significant estimated effect between BET and ST (RR 0·60 [95% CI 0·33-1·04]; p=0·070) in reducing treatment failures after a COPD exacerbation. The non-inferiority analysis supported that BET was non-inferior to ST. Frequency of adverse events were similar between the study groups; glycosuria (2/102 [2%] in BET group and 1/101 [1%] in the ST group) and hospital admission for COPD exacerbation (2/102 [2%] in BET group and 1/101 [1%] in the ST group) were the two most common adverse events in both groups. No deaths occurred in the study. INTERPRETATION Blood eosinophil-directed prednisolone therapy at the time of an acute exacerbation of COPD is non-inferior to standard care and can be used to safely reduce systemic glucocorticoid use in clinical practice. FUNDING National Institute for Health and Care Research.
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Affiliation(s)
- Sanjay Ramakrishnan
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Helen Jeffers
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Beverly Langford-Wiley
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Joanne Davies
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Samantha J Thulborn
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Mahdi Mahdi
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | | | | | | | | | | | - Alison Law
- White Horse Medical Practice, Faringdon, UK; Montgomery House Surgery, Bicester, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, UK
| | | | | | | | - Richard Ek Russell
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK; King's Centre of Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Mona Bafadhel
- Respiratory Medicine Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; King's Centre of Lung Health, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, UK.
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Kusec A, Murphy FC, Peers PV, Bennett R, Carmona E, Korbacz A, Lawrence C, Cameron E, Bateman A, Watson P, Allanson J, duToit P, Manly T. Mood, Activity Participation, and Leisure Engagement Satisfaction (MAPLES): results from a randomised controlled pilot feasibility trial for low mood in acquired brain injury. BMC Med 2023; 21:445. [PMID: 37974189 PMCID: PMC10655452 DOI: 10.1186/s12916-023-03128-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/24/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Acquired brain injury (ABI) is linked to increased depression risk. Existing therapies for depression in ABI (e.g., cognitive behavioural therapy) have mixed efficacy. Behavioural activation (BA), an intervention that encourages engaging in positively reinforcing activities, shows promise. The primary aims were to assess feasibility, acceptability, and potential efficacy of two 8-week BA groups. METHODS Adults (≥ 18 years) recruited from local ABI services, charities, and self-referral via social media were randomised to condition. The Activity Planning group (AP; "traditional" BA) trained participants to plan reinforcing activities over 8 weeks. The Activity Engagement group (AE; "experiential" BA) encouraged engagement in positive activities within session only. Both BA groups were compared to an 8-week Waitlist group (WL). The primary outcomes, feasibility and acceptability, were assessed via recruitment, retention, attendance, and qualitative feedback on groups. The secondary outcome, potential efficacy, was assessed via blinded assessments of self-reported activity levels, depression, and anxiety (at pre- and post-intervention and 1 month follow-up) and were compared across trial arms. Data were collected in-person and remotely due to COVID-19. RESULTS N = 60 participants were randomised to AP (randomised n = 22; total n = 29), AE (randomised n = 22; total n = 28), or re-randomised following WL (total n = 16). Whether in-person or remote, AP and AE were rated as similarly enjoyable and helpful. In exploring efficacy, 58.33% of AP members had clinically meaningful activity level improvements, relative to 50% AE and 38.5% WL. Both AP and AE groups had depression reductions relative to WL, but only AP participants demonstrated anxiety reductions relative to AE and WL. AP participants noted benefits of learning strategies to increase activities and learning from other group members. AE participants valued social discussion and choice in selecting in-session activities. CONCLUSIONS Both in-person and remote group BA were feasible and acceptable in ABI. Though both traditional and experiential BA may be effective, these may have different mechanisms. TRIAL REGISTRATION Clinicaltrials.gov, NCT03874650. Protocol version 2.3, May 26 2020.
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Affiliation(s)
- Andrea Kusec
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK.
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
| | - Fionnuala C Murphy
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Polly V Peers
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Ron Bennett
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
- Patient and Public Involvement Representative, University of Cambridge, Cambridge, UK
| | - Estela Carmona
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Aleksandra Korbacz
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Cara Lawrence
- School of Allied Health, Anglia Ruskin University, Cambridge, UK
| | - Emma Cameron
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Andrew Bateman
- School of Health and Social Care, University of Essex, Colchester, UK
| | - Peter Watson
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Judith Allanson
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Pieter duToit
- School of Health and Social Care, University of Essex, Colchester, UK
- The Disabilities Trust, Fen House, Ely, UK
| | - Tom Manly
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
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Goulao B, Duncan A, Innes K, Ramsay CR, Kahan BC. Using re-randomisation designs to increase the efficiency and applicability of retention studies within trials: a case study. Trials 2023; 24:299. [PMID: 37118802 PMCID: PMC10148456 DOI: 10.1186/s13063-023-07323-y] [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: 06/06/2022] [Accepted: 04/22/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Poor retention in randomised trials can lead to serious consequences to their validity. Studies within trials (SWATs) are used to identify the most effective interventions to increase retention. Many interventions could be applied at any follow-up time point, but SWATs commonly assess interventions at a single time point, which can reduce efficiency. METHODS The re-randomisation design allows participants to be re-enrolled and re-randomised whenever a new retention opportunity occurs (i.e. a new follow-up time point where the intervention could be applied). The main advantages are as follows: (a) it allows the estimation of an average effect across time points, thus increasing generalisability; (b) it can be more efficient than a parallel arm trial due to increased sample size; and (c) it allows subgroup analyses to estimate effectiveness at different time points. We present a case study where the re-randomisation design is used in a SWAT. RESULTS In our case study, the host trial is a dental trial with two available follow-up points. The Sticker SWAT tests whether adding the trial logo's sticker to the questionnaire's envelope will result in a higher response rate compared with not adding the sticker. The primary outcome is the response rate to postal questionnaires. The re-randomisation design could double the available sample size compared to a parallel arm trial, resulting in the ability to detect an effect size around 28% smaller. CONCLUSION The re-randomisation design can increase the efficiency and generalisability of SWATs for trials with multiple follow-up time points.
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Affiliation(s)
- Beatriz Goulao
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland.
| | - Anne Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Karen Innes
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
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7
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Yelland LN, Sullivan TR, Gibson RA, Simmonds LA, Thakkar SK, Huang F, Devaraj S, Best KP, Zolezzi IS, Makrides M. Identifying women who may benefit from higher dose omega-3 supplementation during pregnancy to reduce their risk of prematurity: exploratory analyses from the ORIP trial. BMJ Open 2023; 13:e070220. [PMID: 37068907 PMCID: PMC10111924 DOI: 10.1136/bmjopen-2022-070220] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
OBJECTIVES The risk factors for prematurity are multifactorial and include low omega-3 status. Omega-3 supplementation in pregnancy has been found to reduce prematurity risk, particularly among women with low omega-3 levels. This study aimed to identify maternal characteristics that predict whether women with a singleton pregnancy will benefit from omega-3 supplementation to reduce their risk of prematurity. DESIGN Exploratory analyses of a multicentre, double-blind randomised trial. SETTING 6 tertiary care centres in four states in Australia. PARTICIPANTS 5328 singleton pregnancies in 5305 women recruited before 20 weeks of gestation. INTERVENTIONS Fish oil capsules containing 900 mg omega-3 long-chain polyunsaturated fatty acids per day versus vegetable oil capsules consumed from enrolment until 34 weeks' gestation. OUTCOME MEASURES Early preterm birth (EPTB, <34 weeks' gestation) and preterm birth (PTB, <37 weeks' gestation) analysed using logistic regression models with interactions between treatment group and a range of maternal biological, clinical and demographic characteristics. RESULTS Omega-3 supplementation reduced the odds of EPTB for women with low total omega-3 status in early pregnancy (OR=0.30, 95% CI 0.10-0.93). No additional maternal characteristics influenced whether omega-3 supplementation reduced the odds of EPTB. For PTB, women were more likely to benefit from omega-3 supplementation if they were multiparous (OR=0.65, 95% CI 0.49-0.87) or avoided alcohol in the lead up to pregnancy (OR=0.62, 95% CI 0.45-0.86). CONCLUSIONS Our results support previous findings that women with low total omega-3 levels in early pregnancy are most likely to benefit from taking omega-3 supplements to reduce their risk of EPTB. Understanding how other maternal characteristics influence the effectiveness of omega-3 supplementation on reducing PTB requires further investigation. TRIAL REGISTRATION NUMBER ACTRN12613001142729.
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Affiliation(s)
- Lisa N Yelland
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Thomas R Sullivan
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Robert A Gibson
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Agriculture, Food and Wine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lucy A Simmonds
- College of Business, Government and Law, Flinders University, Adelaide, South Australia, Australia
| | - Sagar K Thakkar
- Scientific Affairs, Nestlé Product Technology Center-Nutrition, Société des Produits Nestlé S.A, Vevey, Switzerland
| | - Fang Huang
- Nestlé Research, Société des Produits Nestlé S.A, Beijing, China
| | | | - Karen P Best
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Irma Silva Zolezzi
- Nestlé Product Technology Center-Nutrition, Société des Produits Nestlé S.A, Vevey, Switzerland
| | - Maria Makrides
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
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Lange KM, Kasza J, Sullivan TR, Yelland LN. Partially clustered designs for clinical trials: Unifying existing designs using consistent terminology. Clin Trials 2023; 20:99-110. [PMID: 36628406 PMCID: PMC10021130 DOI: 10.1177/17407745221146987] [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: 01/12/2023]
Abstract
INTRODUCTION Clinical trial designs based on the assumption of independent observations are well established. Clustered clinical trial designs, where all observational units belong to a cluster and outcomes within clusters are expected to be correlated, have also received considerable attention. However, many clinical trials involve partially clustered data, where only some observational units belong to a cluster. Examples of such trials occur in neonatology, where participants include infants from both singleton and multiple births, and ophthalmology, where one or two eyes per participant may need treatment. Partial clustering can also arise in trials of group-based treatments (e.g. group education or counselling sessions) or treatments administered individually by a discrete number of health care professionals (e.g. surgeons or physical therapists), when this is compared to an unclustered control arm. Trials involving partially clustered data have received limited attention in the literature and the current lack of standardised terminology may be hampering the development and dissemination of methods for designing and analysing these trials. METHODS AND EXAMPLES In this article, we present an overarching definition of partially clustered trials, bringing together several existing trial designs including those for group-based treatments, clustering due to facilitator effects and the re-randomisation design. We define and describe four types of partially clustered trial designs, characterised by whether the clustering occurs pre-randomisation or post-randomisation and, in the case of pre-randomisation clustering, by the method of randomisation that is used for the clustered observations (individual randomisation, cluster randomisation or balanced randomisation within clusters). Real life examples are provided to highlight the occurrence of partially clustered trials across a variety of fields. To assess how partially clustered trials are currently reported, we review published reports of partially clustered trials. DISCUSSION Our findings demonstrate that the description of these trials is often incomplete and the terminology used to describe the trial designs is inconsistent, restricting the ability to identify these trials in the literature. By adopting the definitions and terminology presented in this article, the reporting of partially clustered trials can be substantially improved, and we present several recommendations for reporting these trial designs in practice. Greater awareness of partially clustered trials will facilitate more methodological research into their design and analysis, ultimately improving the quality of these trials.
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Affiliation(s)
- Kylie M Lange
- School of Public Health, The University of Adelaide, Adelaide, SA, Australia.,Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Thomas R Sullivan
- School of Public Health, The University of Adelaide, Adelaide, SA, Australia.,Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Lisa N Yelland
- School of Public Health, The University of Adelaide, Adelaide, SA, Australia.,Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
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9
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Kahan BC, Li F, Copas AJ, Harhay MO. Estimands in cluster-randomized trials: choosing analyses that answer the right question. Int J Epidemiol 2023; 52:107-118. [PMID: 35834775 PMCID: PMC9908044 DOI: 10.1093/ije/dyac131] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 06/07/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Cluster-randomized trials (CRTs) involve randomizing groups of individuals (e.g. hospitals, schools or villages) to different interventions. Various approaches exist for analysing CRTs but there has been little discussion around the treatment effects (estimands) targeted by each. METHODS We describe the different estimands that can be addressed through CRTs and demonstrate how choices between different analytic approaches can impact the interpretation of results by fundamentally changing the question being asked, or, equivalently, the target estimand. RESULTS CRTs can address either the participant-average treatment effect (the average treatment effect across participants) or the cluster-average treatment effect (the average treatment effect across clusters). These two estimands can differ when participant outcomes or the treatment effect depends on the cluster size (referred to as 'informative cluster size'), which can occur for reasons such as differences in staffing levels or types of participants between small and large clusters. Furthermore, common estimators, such as mixed-effects models or generalized estimating equations with an exchangeable working correlation structure, can produce biased estimates for both the participant-average and cluster-average treatment effects when cluster size is informative. We describe alternative estimators (independence estimating equations and cluster-level analyses) that are unbiased for CRTs even when informative cluster size is present. CONCLUSION We conclude that careful specification of the estimand at the outset can ensure that the study question being addressed is clear and relevant, and, in turn, that the selected estimator provides an unbiased estimate of the desired quantity.
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Affiliation(s)
- Brennan C Kahan
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Fan Li
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Prevention Science, Yale University School of Public Health, New Haven, CT, USA
| | - Andrew J Copas
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, PAIR (Palliative and Advanced Illness Research) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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10
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Tackney MS, Woods D, Shpitser I. Nonmyopic and pseudo-nonmyopic approaches to optimal sequential design in the presence of covariates. J STAT COMPUT SIM 2022; 93:581-603. [PMID: 36968627 PMCID: PMC10035582 DOI: 10.1080/00949655.2022.2113788] [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: 03/22/2022] [Accepted: 08/12/2022] [Indexed: 10/14/2022]
Abstract
In sequential experiments, subjects become available for the study over a period of time, and covariates are often measured at the time of arrival. We consider the setting where the sample size is fixed but covariate values are unknown until subjects enrol. Given a model for the outcome, a sequential optimal design approach can be used to allocate treatments to minimize the variance of the estimator of the treatment effect. We extend existing optimal design methodology so it can be used within a nonmyopic framework, where treatment allocation for the current subject depends not only on the treatments and covariates of the subjects already enrolled in the study, but also the impact of possible future treatment assignments within a specified horizon. The nonmyopic approach requires recursive formulae and suffers from the curse of dimensionality. We propose a pseudo-nonmyopic approach which has a similar aim to the nonmyopic approach, but does not involve recursion and instead relies on simulating trajectories of future possible decisions. Our simulation studies show that, for the simple case of a logistic regression with a single binary covariate and a binary treatment, and a more realistic case with four binary covariates, binary treatment and treatment-covariate interactions, the nonmyopic and pseudo-nonmyopic approaches provide no competitive advantage over the myopic approach, both in terms of the size of the estimated treatment effect and also the efficiency of the designs. Results are robust to the size of the horizon used in the nonmyopic approach, and the number of simulated trajectories used in the pseudo-nonmyopic approach.
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11
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Kahan BC, White IR, Hooper R, Eldridge S. Re-randomisation trials in multi-episode settings: Estimands and independence estimators. Stat Methods Med Res 2022; 31:1342-1354. [PMID: 35422159 PMCID: PMC9251752 DOI: 10.1177/09622802221094140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Often patients may require treatment on multiple occasions. The re-randomisation design can be used in such multi-episode settings, as it allows patients to be re-enrolled and re-randomised for each new treatment episode they experience. We propose a set of estimands that can be used in multi-episode settings, focusing on issues unique to multi-episode settings, namely how each episode should be weighted, how the patient's treatment history in previous episodes should be handled, and whether episode-specific effects or average effects across all episodes should be used. We then propose independence estimators for each estimand, and show the manner in which many re-randomisation trials have been analysed in the past (a simple comparison between all intervention episodes vs. all control episodes) corresponds to a per-episode added-benefit estimand, that is, the average effect of the intervention across all episodes, over and above any benefit conferred from the intervention in previous episodes. We show this estimator is generally unbiased, and describe when other estimators will be unbiased. We conclude that (i) consideration of these estimands can help guide the choice of which analysis method is most appropriate; and (ii) the re-randomisation design with an independence estimator can be a useful approach in multi-episode settings.
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Affiliation(s)
- Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of
London, London, UK
- MRC Clinical Trials Unit at
UCL, London, UK
| | | | - Richard Hooper
- Pragmatic Clinical Trials Unit, Queen Mary University of
London, London, UK
| | - Sandra Eldridge
- Pragmatic Clinical Trials Unit, Queen Mary University of
London, London, UK
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12
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Li V, Leurent B, Barkhof F, Braisher M, Cafferty F, Ciccarelli O, Eshaghi A, Gray E, Nicholas JM, Parmar M, Peryer G, Robertson J, Stallard N, Wason J, Chataway J. Designing Multi-arm Multistage Adaptive Trials for Neuroprotection in Progressive Multiple Sclerosis. Neurology 2022; 98:754-764. [PMID: 35321926 PMCID: PMC9109150 DOI: 10.1212/wnl.0000000000200604] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/10/2022] [Indexed: 11/24/2022] Open
Abstract
There are few treatments shown to slow disability progression in progressive multiple sclerosis (PMS). One challenge has been efficiently testing the pipeline of candidate therapies from preclinical studies in clinical trials. Multi-arm multistage (MAMS) platform trials may accelerate evaluation of new therapies compared to traditional sequential clinical trials. We describe a MAMS design in PMS focusing on selection of interim and final outcome measures, sample size, and statistical considerations. The UK MS Society Expert Consortium for Progression in MS Clinical Trials reviewed recent phase II and III PMS trials to inform interim and final outcome selection and design measures. Simulations were performed to evaluate trial operating characteristics under different treatment effect, recruitment rate, and sample size assumptions. People with MS formed a patient and public involvement group and contributed to the trial design, ensuring it would meet the needs of the MS community. The proposed design evaluates 3 experimental arms compared to a common standard of care arm in 2 stages. Stage 1 (interim) outcome will be whole brain atrophy on MRI at 18 months, assessed for 123 participants per arm. Treatments with sufficient evidence for slowing brain atrophy will continue to the second stage. The stage 2 (final) outcome will be time to 6-month confirmed disability progression, based on a composite clinical score comprising the Expanded Disability Status Scale, Timed 25-Foot Walk test, and 9-Hole Peg Test. To detect a hazard ratio of 0.75 for this primary final outcome with 90% power, 600 participants per arm are required. Assuming one treatment progresses to stage 2, the trial will recruit ≈1,900 participants and last ≈6 years. This is approximately two-thirds the size and half the time of separate 2-arm phase II and III trials. The proposed MAMS trial design will substantially reduce duration and sample size compared to traditional clinical trials, accelerating discovery of effective treatments for PMS. The design was well-received by people with multiple sclerosis. The practical and statistical principles of MAMS trial design may be applicable to other neurodegenerative conditions to facilitate efficient testing of new therapies.
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Affiliation(s)
- Vivien Li
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - Baptiste Leurent
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - Frederik Barkhof
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - Marie Braisher
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - Fay Cafferty
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - Olga Ciccarelli
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - Arman Eshaghi
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - Emma Gray
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - Jennifer M Nicholas
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - Mahesh Parmar
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - Guy Peryer
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - Jenny Robertson
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - Nigel Stallard
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - James Wason
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
| | - Jeremy Chataway
- From the Florey Institute of Neuroscience and Mental Health (V.L.), University of Melbourne; Department of Neurology (V.L.), Royal Melbourne Hospital, Australia; Department of Medical Statistics (B.L., J.M.N.) and International Statistics and Epidemiology Group (B.L.), London School of Hygiene and Tropical Medicine, UK; Department of Radiology and Nuclear Medicine, Neuroscience Campus Amsterdam (F.B.), VU University Medical Center, Amsterdam, the Netherlands; Queen Square Institute of Neurology and Centre for Medical Image Computing (F.B.), Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre (M.B., O.C.), and NMR Unit, Department of Neuroinflammation (A.E.), Faculty of Brain Sciences, UCL Queen Square Institute of Neurology; MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology (F.C., M.P., J.C.), and Department of Computer Science, Centre for Medical Image Computing (A.E.), University College London; National Institute for Health Research (F.B., O.C., J.C.), University College London Hospitals Biomedical Research Centre; UK Multiple Sclerosis Society (E.G., G.P., J.R.), London; Faculty of Medicine and Health Sciences (G.P.), University of East Anglia, Norwich; Statistics and Epidemiology, Division of Health Sciences (N.S.), Warwick Medical School, University of Warwick, Coventry; and Population Health Sciences Institute (J.W.), Newcastle University, UK
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Abbott RA, Cordaro A, Lloyd B, Cannings-John R, Wootton M, Kirby N, Pickles T, McQueen A, Westmoreland M, Ziaj S, Martin-Clavijo A, Wernham A, Matin R, Thomas-Jones E. Observational study to estimate the proportion of surgical site infection following excision of ulcerated skin tumours (OASIS study). Clin Exp Dermatol 2022; 47:882-888. [PMID: 34855996 DOI: 10.1111/ced.15037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Ulceration is a recognized risk factor for surgical site infection (SSI); however, the proportion of patients developing SSI after excision of an ulcerated skin cancer is unknown. AIM To determine the proportion of participants with SSI after surgical excision of an ulcerated skin cancer. A secondary aim was to assess feasibility outcomes to inform the design of a randomized controlled trial to investigate the benefits and harms of perioperative antibiotics following excision of ulcerated tumours. METHODS This was a multicentre, prospective, observational study of patients undergoing excision of an ulcerated skin cancer between March 2019 and March 2020. Prior to surgical excision, surface swabs of the ulcerated tumours of participants recruited from one centre were undertaken to determine organism growth. At 4 weeks after surgery, all participants were e-mailed or posted the Wound Healing Questionnaire (WHQ) to determine whether they had developed SSI. RESULTS In total, 148 participants were recruited 105 (70.9%) males; mean ± SD age 77.1 ± 12.3 years. Primary outcome data were available for 116 (78.4%) participants, of whom 35 (30.2%) were identified as having an SSI using the WHQ with a cutoff score of 8, and 47 (40.5%) were identified with a cutoff score of 6. Using the modified WHQ in participants with wounds left to heal by secondary intention, 33 (28.4%) and 43 (37.1%) were identified to have SSI respectively. CONCLUSION This prospective evaluation of SSI identified with the WHQ following excision of ulcerated skin cancers demonstrated a high proportion with SSI. The WHQ was acceptable to patients; however, further evaluation is required to ensure validity in assessing skin wounds.
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Affiliation(s)
- R A Abbott
- Department of Dermatology, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - A Cordaro
- Department of Dermatology, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - B Lloyd
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - M Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, Cardiff, UK
| | - N Kirby
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - T Pickles
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - A McQueen
- Department of Dermatology, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - M Westmoreland
- Department of Dermatology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Ziaj
- Department of Dermatology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Martin-Clavijo
- Department of Dermatology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Wernham
- Department of Dermatology, Manor Hospital, Walsall Healthcare NHS Trust, Wallsall, UK
- Department of Dermatology, Leicester Royal Infirmary, Leicester University Hospitals NHS Trust, Leicester, UK
| | - R Matin
- Department of Dermatology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - E Thomas-Jones
- Centre for Trials Research, Cardiff University, Cardiff, UK
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14
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Wilkinson J, Stocking K. Study design flaws and statistical challenges in evaluating fertility treatments. REPRODUCTION AND FERTILITY 2022; 2:C9-C21. [PMID: 35128452 PMCID: PMC8812412 DOI: 10.1530/raf-21-0015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/21/2021] [Indexed: 12/16/2022] Open
Abstract
Health interventions should be tested before being introduced into clinical practice, to find out whether they work and whether they are harmful. However, research studies will only provide reliable answers to these questions if they are appropriately designed and analysed. But these are not trivial tasks. We review some methodological challenges that arise when evaluating fertility interventions and explain the implications for a non-statistical audience. These include flexibility in outcomes and analyses; use of surrogate outcomes instead of live birth; use of inappropriate denominators; evaluating cumulative outcomes and time to live birth; allowing each patient or couple to contribute to a research study more than once. We highlight recurring errors and present solutions. We conclude by highlighting the importance of collaboration between clinical and methodological experts, as well as people with experience of subfertility, for realising high-quality research. Lay summary We do research to find out whether fertility treatments are beneficial and to make sure they don't cause harm. However, research will only provide reliable answers if it is done properly. It is not unusual for researchers to make mistakes when they are designing research studies and analysing the data that we get from them. In this review, we describe some of the mistakes people make when they do research about fertility treatments and explain how to avoid them. These include challenges which arise due to the large number of things that can be measured and reported when looking to see if fertility treatments work; failure to check whether the treatment increases the number of live births; failing to include all study participants in calculations;challenges in studies where participants may have more than one treatment attempt. We conclude by highlighting the importance of collaboration between clinical and methodological experts, as well as people with experience of fertility problems.
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Affiliation(s)
- Jack Wilkinson
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
| | - Katie Stocking
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
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15
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Kahan BC, White IR, Eldridge S, Hooper R. Independence estimators for re-randomisation trials in multi-episode settings: a simulation study. BMC Med Res Methodol 2021; 21:235. [PMID: 34717559 PMCID: PMC8557515 DOI: 10.1186/s12874-021-01433-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 08/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Re-randomisation trials involve re-enrolling and re-randomising patients for each new treatment episode they experience. They are often used when interest lies in the average effect of an intervention across all the episodes for which it would be used in practice. Re-randomisation trials are often analysed using independence estimators, where a working independence correlation structure is used. However, research into independence estimators in the context of re-randomisation has been limited. METHODS We performed a simulation study to evaluate the use of independence estimators in re-randomisation trials. We focussed on a continuous outcome, and the setting where treatment allocation does not affect occurrence of subsequent episodes. We evaluated different treatment effect mechanisms (e.g. by allowing the treatment effect to vary across episodes, or to become less effective on re-use, etc), and different non-enrolment mechanisms (e.g. where patients who experience a poor outcome are less likely to re-enrol for their second episode). We evaluated four different independence estimators, each corresponding to a different estimand (per-episode and per-patient approaches, and added-benefit and policy-benefit approaches). RESULTS We found that independence estimators were unbiased for the per-episode added-benefit estimand in all scenarios we considered. We found independence estimators targeting other estimands (per-patient or policy-benefit) were unbiased, except when there was differential non-enrolment between treatment groups (i.e. when different types of patients from each treatment group decide to re-enrol for subsequent episodes). We found the use of robust standard errors provided close to nominal coverage in all settings where the estimator was unbiased. CONCLUSIONS Careful choice of estimand can ensure re-randomisation trials are addressing clinically relevant questions. Independence estimators are a useful approach, and should be considered as the default estimator until the statistical properties of alternative estimators are thoroughly evaluated.
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Affiliation(s)
- Brennan C Kahan
- MRC Clinical Trials Unit at UCL, London, UK.
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK.
| | | | - Sandra Eldridge
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Richard Hooper
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
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16
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Walker AS, White IR, Turner RM, Hsu LY, Yeo TW, White NJ, Sharland M, Thwaites GE. Personalised randomised controlled trial designs-a new paradigm to define optimal treatments for carbapenem-resistant infections. THE LANCET. INFECTIOUS DISEASES 2021; 21:e175-e181. [PMID: 33894130 DOI: 10.1016/s1473-3099(20)30791-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 04/30/2020] [Accepted: 09/11/2020] [Indexed: 10/21/2022]
Abstract
Antimicrobial resistance is impacting treatment decisions for, and patient outcomes from, bacterial infections worldwide, with particular threats from infections with carbapenem-resistant Enterobacteriaceae, Acinetobacter baumanii, or Pseudomonas aeruginosa. Numerous areas of clinical uncertainty surround the treatment of these highly resistant infections, yet substantial obstacles exist to the design and conduct of treatment trials for carbapenem-resistant bacterial infections. These include the lack of a widely acceptable optimised standard of care and control regimens, varying antimicrobial susceptibilities and clinical contraindications making specific intervention regimens infeasible, and diagnostic and recruitment challenges. The current single comparator trials are not designed to answer the urgent public health question, identified as a high priority by WHO, of what are the best regimens out of the available options that will significantly reduce morbidity, costs, and mortality. This scenario has an analogy in network meta-analysis, which compares multiple treatments in an evidence synthesis to rank the best of a set of available treatments. To address these obstacles, we propose extending the network meta-analysis approach to individual randomisation of patients. We refer to this approach as a Personalised RAndomised Controlled Trial (PRACTical) design that compares multiple treatments in an evidence synthesis, to identify, overall, which is the best treatment out of a set of available treatments to recommend, or how these different treatments rank against each other. In this Personal View, we summarise the design principles of personalised randomised controlled trial designs. Specifically, of a network of different potential regimens for life-threatening carbapenem-resistant infections, each patient would be randomly assigned only to regimens considered clinically reasonable for that patient at that time, incorporating antimicrobial susceptibility, toxicity profile, pharmacometric properties, availability, and physician assessment. Analysis can use both direct and indirect comparisons across the network, analogous to network meta-analysis. This new trial design will maximise the relevance of the findings to each individual patient, and enable the top-ranked regimens from any personalised randomisation list to be identified, in terms of both efficacy and safety.
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Affiliation(s)
- A Sarah Walker
- MRC Clinical Trials Unit at University College London, London, UK; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ian R White
- MRC Clinical Trials Unit at University College London, London, UK
| | - Rebecca M Turner
- MRC Clinical Trials Unit at University College London, London, UK
| | - Li Yang Hsu
- National University of Singapore, Saw Swee Hock School of Public Health, Singapore
| | - Tsin Wen Yeo
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Nicholas J White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Guy E Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; and Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.
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Bhide P, Srikantharajah A, Lanz D, Dodds J, Collins B, Zamora J, Chan D, Thangaratinam S, Khan KS. TILT: Time-Lapse Imaging Trial-a pragmatic, multi-centre, three-arm randomised controlled trial to assess the clinical effectiveness and safety of time-lapse imaging in in vitro fertilisation treatment. Trials 2020; 21:600. [PMID: 32611445 PMCID: PMC7329433 DOI: 10.1186/s13063-020-04537-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/19/2020] [Indexed: 11/19/2022] Open
Abstract
Background Subfertility is a common problem for which in vitro fertilisation (IVF) treatment is commonly recommended. Success rates following IVF are suboptimal and have remained static over the last few years. This imposes a considerable financial burden on overstretched healthcare resources. Time-lapse imaging (TLI) of developing embryos in IVF treatment is hypothesised to improve the success rates of treatment. This may be either by providing undisturbed culture conditions or by improving the predictive accuracy for optimal embryo selection from a cohort of available embryos. However, the current best evidence for its effectiveness is inconclusive. Methods The time-lapse imaging trial is a pragmatic, multi-centre, three-arm parallel-group randomised controlled trial using re-randomisation. The primary objective of the trial is to determine if the use of TLI or undisturbed culture in IVF treatment results in a higher live birth rate when compared to current standard methods of embryo incubation and assessment. Secondary outcomes include measures of clinical efficacy and safety. The trial will randomise 1575 participants to detect an increase in live birth from 26.5 to 35.25%. Discussion In the absence of high-quality evidence, there is no current national guidance, recommendation or policy for the use of TLI. The use of TLI is not consistently incorporated into standard IVF care. A large, pragmatic, multi-centre, trial will provide much needed definitive evidence regarding the effectiveness of TLI. If proven to be effective, its incorporation into standard care would translate into significant clinical and economic benefits. If not, it would allow allocation of resources to more effective interventions. Trial registration ISRCTN registry ISRCTN17792989. Prospectively registered on 18 April 2018
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Affiliation(s)
- Priya Bhide
- Barts Research Centre for Women's Health, Institute of Population Health Sciences, Queen Mary University of London, London, UK. .,Homerton Fertility Centre, Homerton University Hospital, London, UK.
| | | | - Doris Lanz
- Barts Research Centre for Women's Health, Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Julie Dodds
- Barts Research Centre for Women's Health, Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Bonnie Collins
- Centre for Reproductive Medicine, St Bartholomew's Hospital, London, UK
| | - Javier Zamora
- Barts Research Centre for Women's Health, Institute of Population Health Sciences, Queen Mary University of London, London, UK.,Clinical Biostatistics Unit, Hospital Ramón y Cajal (IRYCIS), CIBER Epidemiology and Public Health, Madrid, Spain
| | - David Chan
- Assisted Reproductive Technology Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, Hong Kong SAR
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, WHO Collaborating Centre for Women's Health, University of Birmingham, Birmingham, UK
| | - Khalid S Khan
- Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
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China L, Skene SS, Bennett K, Shabir Z, Hamilton R, Bevan S, Chandler T, Maini AA, Becares N, Gilroy D, Forrest EH, O’Brien A. ATTIRE: Albumin To prevenT Infection in chronic liveR failurE: study protocol for an interventional randomised controlled trial. BMJ Open 2018; 8:e023754. [PMID: 30344180 PMCID: PMC6196858 DOI: 10.1136/bmjopen-2018-023754] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Circulating prostaglandin E2 levels are elevated in acutely decompensated cirrhosis and have been shown to contribute to immune suppression. Albumin binds to and inactivates this immune-suppressive lipid mediator. Human albumin solution (HAS) could thus be repurposed as an immune-restorative drug in these patients.This is a phase III randomised controlled trial (RCT) to verify whether targeting a serum albumin level of ≥35 g/L in hospitalised patients with decompensated cirrhosis using repeated intravenous infusions of 20% HAS will reduce incidence of infection, renal dysfunction and mortality for the treatment period (maximum 14 days or discharge if <14 days) compared with standard medical care. METHODS AND ANALYSIS Albumin To prevenT Infection in chronic liveR failurE stage 2 is a multicentre, open-label, interventional RCT. Patients with decompensated cirrhosis admitted to the hospital with a serum albumin of <30 g/L are eligible, subject to exclusion criteria. Patients randomised to intravenous HAS will have this administered, according to serum albumin levels, for up to 14 days or discharge. The infusion protocol aims to increase serum albumin to near-normal levels.The composite primary endpoint is: new infection, renal dysfunction or mortality within the trial treatment period. Secondary endpoints include mortality at up to 6 months, incidence of other organ failures, cost-effectiveness and quality of life outcomes and time to liver transplant. The trial will recruit 866 patients at more than 30 sites across the UK. ETHICSANDDISSEMINATION Research ethics approval was given by the London-Brent research ethics committee (ref: 15/LO/0104). The clinical trials authorisation was issued by the medicines and healthcare products regulatory agency (ref: 20363/0350/001-0001). The trial is registered with the European Medicines Agency (EudraCT 2014-002300-24) and has been adopted by the National Institute for Health Research (ISRCTN 14174793). This manuscript refers to version 6.0 of the protocol. Results will be disseminated through peer-reviewed journals and international conferences. Recruitment of the first participant occurred on 25 January 2016.
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Affiliation(s)
- Louise China
- Division of Medicine, University College London, London, UK
| | - Simon S Skene
- School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Kate Bennett
- Comprehensive Clinical Trials Unit, UCL, London, UK
| | | | | | - Scott Bevan
- Comprehensive Clinical Trials Unit, UCL, London, UK
| | | | | | | | - Derek Gilroy
- Division of Medicine, University College London, London, UK
| | - Ewan H Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
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Re-randomization increased recruitment and provided similar treatment estimates as parallel designs in trials of febrile neutropenia. J Clin Epidemiol 2018; 97:14-19. [PMID: 29428873 PMCID: PMC5984235 DOI: 10.1016/j.jclinepi.2018.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/24/2018] [Accepted: 02/02/2018] [Indexed: 11/23/2022]
Abstract
Objective Re-randomization trials allow patients to be re-enrolled for multiple treatment episodes. However, it remains uncertain to what extent re-randomization improves recruitment compared to parallel group designs or whether treatment estimates might be affected. Study Design and Setting We evaluated trials included in a recent Cochrane review of granulocyte colony-stimulating factors for patients with febrile neutropenia. We assessed the recruitment benefits of re-randomization trials; compared treatment effect estimates between re-randomization and parallel group designs; and assessed whether re-randomization led to higher rates of non-compliance and loss to follow-up in subsequent episodes. Results We included 14 trials (5 re-randomization and 9 parallel group). The re-randomization trials recruited a median of 25% (range 16–66%) more episodes on average than they would have under a parallel-group design. Treatment effect estimates were similar between re-randomization and parallel group trials across all outcomes, though confidence intervals were wide. The re-randomization trials in this review reported no loss to follow-up and low rates of non-compliance (median 1.7%, range 0–8.9%). Conclusions In the setting of febrile neutropenia, re-randomization increased recruitment while providing similar estimates of treatment effect to parallel group trials, with minimal loss to follow-up or non-compliance. It appears to be safe and efficient alternative to parallel group designs in this setting.
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Said HM, Gupta S, Vricella LK, Wand K, Nguyen T, Gross G. Effect of ambient light on the time needed to complete a fetal biophysical profile: A randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2017; 217:59-65. [PMID: 28854376 DOI: 10.1016/j.ejogrb.2017.08.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/16/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The objective of this study is to determine whether ambient light serves as a fetal stimulus to decrease the amount of time needed to complete a biophysical profile. STUDY DESIGN This is a randomized controlled trial of singleton gestations undergoing a biophysical profile. Patients were randomized to either ambient light or a darkened room. The primary outcome was the time needed to complete the biophysical profile. Secondary outcomes included total and individual component biophysical profile scores and scores less than 8. A subgroup analysis of different maternal body mass indices was also performed. RESULTS 357 biophysical profile studies were analyzed. 182 studies were performed with ambient light and 175 were performed in a darkened room. There was no difference in the median time needed to complete the biophysical profile based on exposure to ambient light (6.1min in darkened room versus 6.6min with ambient light; P=0.73). No difference was found in total or individual component biophysical profile scores. Subgroup analysis by maternal body mass index did not demonstrate shorter study times with ambient light exposure in women who were normal weight, overweight or obese. CONCLUSION Ambient light exposure did not decrease the time needed to complete the biophysical profile. There was no evidence that ambient light altered fetal behavior observed during the biophysical profile.
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Affiliation(s)
- Heather M Said
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO, United States.
| | - Shweta Gupta
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Laura K Vricella
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Katy Wand
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Thinh Nguyen
- Johns Hopkins All Children's Hospital, Saint. Petersburg, FL, United States
| | - Gilad Gross
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO, United States
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Kahan BC. Using re-randomization to increase the recruitment rate in clinical trials - an assessment of three clinical areas. Trials 2016; 17:595. [PMID: 27964743 PMCID: PMC5154140 DOI: 10.1186/s13063-016-1736-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 11/23/2016] [Indexed: 11/17/2022] Open
Abstract
Background Patient recruitment in clinical trials is often challenging, and as a result, many trials are stopped early due to insufficient recruitment. The re-randomization design allows patients to be re-enrolled and re-randomized for each new treatment episode that they experience. Because it allows multiple enrollments for each patient, this design has been proposed as a way to increase the recruitment rate in clinical trials. However, it is unknown to what extent recruitment could be increased in practice. Methods We modelled the expected recruitment rate for parallel-group and re-randomization trials in different settings based on estimates from real trials and datasets. We considered three clinical areas: in vitro fertilization, severe asthma exacerbations, and acute sickle cell pain crises. We compared the two designs in terms of the expected time to complete recruitment, and the sample size recruited over a fixed recruitment period. Results Across the different scenarios we considered, we estimated that re-randomization could reduce the expected time to complete recruitment by between 4 and 22 months (relative reductions of 19% and 45%), or increase the sample size recruited over a fixed recruitment period by between 29% and 171%. Re-randomization can increase recruitment most for trials with a short follow-up period, a long trial recruitment duration, and patients with high rates of treatment episodes. Conclusions Re-randomization has the potential to increase the recruitment rate in certain settings, and could lead to quicker and more efficient trials in these scenarios.
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Affiliation(s)
- Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, 58 Turner St, London, E1 2AB, UK.
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Parmar MKB, Sydes MR, Morris TP. How do you design randomised trials for smaller populations? A framework. BMC Med 2016; 14:183. [PMID: 27884190 PMCID: PMC5123370 DOI: 10.1186/s12916-016-0722-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/19/2016] [Indexed: 11/10/2022] Open
Abstract
How should we approach trial design when we can get some, but not all, of the way to the numbers required for a randomised phase III trial?We present an ordered framework for designing randomised trials to address the problem when the ideal sample size is considered larger than the number of participants that can be recruited in a reasonable time frame. Staying with the frequentist approach that is well accepted and understood in large trials, we propose a framework that includes small alterations to the design parameters. These aim to increase the numbers achievable and also potentially reduce the sample size target. The first step should always be to attempt to extend collaborations, consider broadening eligibility criteria and increase the accrual time or follow-up time. The second set of ordered considerations are the choice of research arm, outcome measures, power and target effect. If the revised design is still not feasible, in the third step we propose moving from two- to one-sided significance tests, changing the type I error rate, using covariate information at the design stage, re-randomising patients and borrowing external information.We discuss the benefits of some of these possible changes and warn against others. We illustrate, with a worked example based on the Euramos-1 trial, the application of this framework in designing a trial that is feasible, while still providing a good evidence base to evaluate a research treatment.This framework would allow appropriate evaluation of treatments when large-scale phase III trials are not possible, but where the need for high-quality randomised data is as pressing as it is for common diseases.
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Affiliation(s)
- Mahesh K B Parmar
- London Hub for Trials Methodology Research, MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, UK
| | - Matthew R Sydes
- London Hub for Trials Methodology Research, MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, UK
| | - Tim P Morris
- London Hub for Trials Methodology Research, MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, UK. .,Medical Statistics Dept., London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
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Cho G, Anie KA, Buckton J, Kiilu P, Layton M, Alexander L, Hemmaway C, Sutton D, Amos C, Doré CJ, Kahan B, Meredith S. SWIM (sickle with ibuprofen and morphine) randomised controlled trial fails to recruit: lessons learnt. BMJ Open 2016; 6:e011276. [PMID: 27288381 PMCID: PMC4908891 DOI: 10.1136/bmjopen-2016-011276] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Sickle With Ibuprofen and Morphine (SWIM) trial was designed to assess whether co-administration of ibuprofen (a non-steroidal anti-inflammatory drug) resulted in a reduction of opioid consumption delivered by patient-controlled analgesia (PCA) for acute pain in sickle cell disease. DESIGN A randomised, placebo-controlled, double-blind trial. SETTING UK multicentre trial in acute hospital setting. PARTICIPANTS Adults with sickle cell disease of any gender and phenotype aged 16 years and over. INTERVENTIONS Oral ibuprofen at a dose of 800 mg three times daily or placebo in addition to opioids (morphine or diamorphine) administered via PCA pump for up to 4 days. MAIN OUTCOME MEASURES The primary outcome measure was opioid consumption over 4 days following randomisation. RESULTS The SWIM trial closed early because it failed to randomise to its target of 316 patients within a reasonable time. CONCLUSIONS The key issues identified include the unanticipated length of time between informed consent and randomisation, difficulties in randomisation of patients in busy emergency departments, availability of trained staff at weekends and out of hours, fewer centres than expected using PCA routinely for sickle cell pain treatment, lack of research staff and support for participation, and the trial design. There are implications for future UK trials in sickle cell disease. TRIAL REGISTRATION NUMBER ISRCTN97241637, NCT00880373; Pre-results.
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Affiliation(s)
- Gavin Cho
- Haematology and Sickle Cell Centre, London North West Healthcare NHS Trust, Central Middlesex Hospital, London, UK
| | - Kofi A Anie
- Haematology and Sickle Cell Centre, London North West Healthcare NHS Trust, Central Middlesex Hospital, London, UK
- Faculty of Medicine, Imperial College London, London, UK
| | - Jacky Buckton
- Haematology and Sickle Cell Centre, London North West Healthcare NHS Trust, Central Middlesex Hospital, London, UK
| | - Patricia Kiilu
- Haematology and Sickle Cell Centre, London North West Healthcare NHS Trust, Central Middlesex Hospital, London, UK
| | - Mark Layton
- Department of Haematology, Imperial College London, Hammersmith Hospital Campus, London, UK
| | - Lydia Alexander
- Department of Haematology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Claire Hemmaway
- Department of Haematology, Barking, Havering and Redbridge University Hospitals NHS Trust, Queen's Hospital, Romford, Essex, UK
| | - Dorothy Sutton
- Department of Haematology, Barking, Havering and Redbridge University Hospitals NHS Trust, Queen's Hospital, Romford, Essex, UK
| | - Claire Amos
- MRC Clinical Trials Unit, University College London, London, UK
| | - Caroline J Doré
- MRC Clinical Trials Unit, University College London, London, UK
| | - Brennan Kahan
- MRC Clinical Trials Unit, University College London, London, UK
| | - Sarah Meredith
- MRC Clinical Trials Unit, University College London, London, UK
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