Best practices in phase III clinical trials on DMTs for multiple sclerosis: a systematic analysis and appraisal of published trials

BACKGROUND

Great advances have been made in the field of multiple sclerosis (MS) therapy due to the publication of numerous randomised clinical trials (RCTs). In this study, we carried out a critical appraisal of phase III RCTs of disease-modifying therapies (DMTs) for MS published after 2010, intending to identify critical areas of improvement.

METHODS

We performed a systematic search of published RCTs on MS from January 2010 until December 2021. RCTs were assessed using an ad-hoc tool. This tool was developed based on existing generic methodological instruments and MS-specific guidelines and methodological papers. It included 14 items grouped in 5 domains: methodological quality, adequacy and measurement of outcomes, adverse event reporting, applicability and relevance of results, and transparency and conflict of interest.

RESULTS

We identified 31 phase III RCTs. Most of them were fully compliant in terms of sample size (87%), randomisation (68%), blinding (61%), participant selection (68%), adverse event reporting (84%) and clinical relevance (52%). Only a few were compliant in terms of participant description (6%), comparison (42%), attrition bias (26%), adequacy of outcome measures (26%), applicability (23%), transparency (36%) and conflict of interest (6%). None were compliant in terms of analysis and reporting of outcomes. The most common limitations related to the absence of comorbidity data, unjustified use of placebo, inadequacy of outcomes design and absence of protocol and/or prospective registration.

CONCLUSIONS

RCTs for DMTs in MS have relevant and frequent limitations. These should be addressed to enhance their quality, transparency and external validity.

Neurotological emergencies: a narrative review

INTRODUCTION

Vestibular symptoms, including vertigo, dizziness, and gait unsteadiness, are a frequent reason of urgent medical assistance. Their causes are numerous and diverse, including neurological, otorhinolaryngological, and systemic diseases. Therefore, following a systematic approach is essential to differentiate striking but benign conditions from others that can compromise the patient's life. This study is intended to review vestibular disorders from a practical perspective and provide guidance to physicians involved in the emergency care of patients with vestibular symptoms.

MATERIALS AND METHODS

A narrative review was performed, revisiting the main causes of vestibular disorders.

RESULTS

Based on the speed of onset, duration, and history of similar episodes in the past, vestibular disorders can be categorized into three syndromic entities (acute, recurrent, and chronic vestibular syndromes). The most representative conditions pertaining to each group were reviewed (including their diagnosis and treatment) and a practical algorithm was proposed for their correct management in the acute care setting.

CONCLUSIONS

Carrying out a correct categorization of the vestibular disorders is essential to avoid diagnostic pitfalls. This review provides useful tools for clinicians to approach their patients with vestibular symptoms at the emergency room.

Evidence of publication bias in multiple sclerosis clinical trials: a comparative analysis of published and unpublished studies registered in ClinicalTrials.gov

BACKGROUND

Complete and timely publication of clinical trials ensures that patients and the medical community are fully informed when making treatment decisions. The aim of this study is to assess the publication of phase III and IV clinical trials on multiple sclerosis (MS) drugs that have been carried out between 2010 and 2019 and to identify the factors associated with their publication in peer-reviewed journals.

METHODS

An advanced search in ClinicalTrials.gov was performed and consecutive searches in PubMed, EMBASE and Google Scholar were conducted looking for the associated publications of all completed trials. Study design characteristics, results and other relevant information were extracted. Data was analysed following a case-control design. Clinical trials with associated publications in peer-reviewed journals were the cases and unpublished trials were the controls. A multivariate logistic regression analysis was performed to identify factors associated with trial publication.

RESULTS

One hundred and fifty clinical trials were included in the analysis. Ninety-six of them (64.0%) were published in peer-reviewed journals. In the multivariate analysis, factors associated with trial publication were a favourable primary outcome (OR 12.49, 95% CI 1.28 to 122.29) and reaching the originally estimated sample size (OR 41.97, 95% CI 1.96 to 900.48), while those associated with a lower odds of publication were having 20% or more patients lost to follow-up (OR 0.03, 95% CI 0.01 to 0.52) and evaluating drugs intended to improve treatment tolerability (OR 0.01, 95% CI 0.00 to 0.74).

CONCLUSIONS

Phase III and IV clinical trials on MS drugs are prone to under-reporting and publication bias. Efforts must be made to promote a complete and accurate dissemination of data in MS clinical research.

Cancer-associated spinal cord infarction: A systematic review and analysis of survival predictors

OBJECTIVE

The association between spinal cord infarction (SCI) and cancer is an infrequent condition but requires an accurate diagnosis to establish the appropriate treatment. Clinical features and prognosis of cancer-associated SCI have never been assessed. The aim of this systematic review is to describe the characteristics and outcomes of patients with cancer-associated SCI. Illustratively, a case of ovarian cancer-related SCI is presented.

MATERIAL AND METHODS

Two authors independently analysed three different bibliographic databases looking for cancer-associated SCI case reports and case series. Data regarding age, sex, cardiovascular risk factors (CVRF), history of known cancer, infarction localization, spinal cord syndrome, Zalewski criteria classification, mechanism of ischemia, diagnostic tests, treatment and functional outcome were registered. A statistical analysis was carried out to identify factors related to mortality and survival time.

RESULTS

A total of 48 articles met the inclusion criteria and 52 patients were identified. The median age was 62 years. The most frequent neoplasm was intravascular large B-cell lymphoma. The median survival time was 17.4 weeks and the cumulative probability of survival at 12 months was 16.3%. In the group of deceased patients there was a higher proportion of malignant neoplasms than in those who survived (94.7% vs. 5.3%, p < 0.01). There were no statistically significant differences in terms of mortality or survival time depending on age, previously known cancer or CVRF.

CONCLUSION

Cancer-associated SCI entails a poor outcome. Mortality is increased in patients with malignant neoplasm. No other prognosis factors could be identified.