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Milanović S, Dedic N, Lew R, Burton D, Koblan KS, Camilleri M, Hopkins SC. TAAR1 agonist ulotaront delays gastric emptying of solids in patients with schizophrenia and concurrent metabolic syndrome with prediabetes. Diabetes Obes Metab 2024; 26:2466-2475. [PMID: 38533552 DOI: 10.1111/dom.15569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/05/2024] [Accepted: 03/08/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Metabolic syndrome (MetS), which can be induced or exacerbated by the current class of antipsychotic drugs, is highly prevalent in patients with schizophrenia and presents significant challenges to lifetime disease management. Supported by initial clinical results, trace amine-associated receptor 1 (TAAR1) agonists have emerged as potential novel treatments for schizophrenia. Notably, non-clinical studies have also shown weight-lowering and glucoregulatory effects of TAAR1 agonists, including the investigational agent ulotaront. However, the translatability of these findings to humans has not been adequately assessed. Given that delayed gastric emptying (GE) was identified as a potential mechanism contributing to the metabolic benefits of TAAR1 agonists in rodents, the aim of this study was to evaluate the effect of ulotaront on GE in patients with schizophrenia and concurrent MetS with prediabetes. METHODS Patients with schizophrenia were randomized to receive a single oral dose of ulotaront (150 mg) and their previous antipsychotic (PA) in an open-label, crossover, two-sequence design (NCT05402111). Eligible participants fulfilled at least three of five MetS criteria and had prediabetes defined by elevated glycated haemoglobin (5.7-6.4%) and/or fasting homeostatic model assessment of insulin resistance (i.e. ≥2.22). Following an overnight fast and 4 h post-dose, participants ingested a 99mTc-sulphur colloid radiolabelled egg meal (320 kcal, 30% fat). GE was measured by scintigraphy over 4 h. Endpoints included GE of solids half-time (T1/2) and percentage gastric retention at 1, 2 and 4 h. RESULTS Thirty-one adults were randomized and 27 completed the study. Ulotaront significantly delayed GE of solids [median GE T1/2 ulotaront at 139 min (119, 182) vs. the participant's PA of 124 min (109, 132), p = .006]. A significant increase in gastric retention was seen in the ulotaront versus the PA group at 1 h (80% vs. 75%, p = .015), 2 h (61% vs. 50%, p = .023) and 4 h (17% vs. 7%, p = .002) post-meal. CONCLUSION Ulotaront delayed the GE of solids in patients with schizophrenia and concurrent MetS with prediabetes. Additional studies are needed to assess whether treatment with TAAR1 agonists is associated with weight loss and glucoregulatory improvement.
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Affiliation(s)
| | - Nina Dedic
- Sumitomo Pharma America, Inc., Marlborough, Massachusetts, USA
| | - Robert Lew
- Sumitomo Pharma America, Inc., Marlborough, Massachusetts, USA
| | | | | | | | - Seth C Hopkins
- Sumitomo Pharma America, Inc., Marlborough, Massachusetts, USA
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2
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Piacentino D, Ogirala A, Lew R, Loftus G, Worden M, Koblan KS, Hopkins SC. A Novel Method for Deriving Adverse Event Prevalence in Randomized Controlled Trials: Potential for Improved Understanding of Benefit-Risk Ratio and Application to Drug Labels. Adv Ther 2024; 41:152-169. [PMID: 37855974 PMCID: PMC10796692 DOI: 10.1007/s12325-023-02695-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 09/21/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Adverse event (AE) data in randomized controlled trials (RCTs) allow quantification of a drug's safety risk relative to placebo and comparison across medications. The standard US label for Food and Drug Administration-approved drugs typically lists AEs by MedDRA Preferred Term that occur at ≥ 2% in drug and with greater incidence than in placebo. We suggest that the drug label can be more informative for both patients and physicians if it includes, in addition to AE incidence (percent of subjects who reported the AE out of the total subjects in treatment), the absolute prevalence (percent of subject-days spent with an AE out of the total subject-days spent in treatment) and expected duration (days required for AE incidence to be reduced by half). We also propose a new method to analyze AEs in RCTs using drug-placebo difference in AE prevalence to improve safety signal detection. METHODS AE data from six RCTs in schizophrenia were analyzed (five RCTs of the dopamine D2 receptor-based antipsychotic lurasidone and one RCT of the novel trace amine-associated receptor 1 [TAAR1] agonist ulotaront). We determined incidence, absolute prevalence, and expected duration of AEs for lurasidone and ulotaront vs respective placebo. We also calculated areas under the curve of drug-placebo difference in AE prevalence and mean percent contribution of each AE to this difference. RESULTS A number of AEs with the same incidence had different absolute prevalence and expected duration. When accounting for these two parameters, AEs that did not appear in the 2% incidence tables of the drug label turned out to contribute substantially to drug tolerability. The percent contribution of a drug-related AE to the overall side effect burden increased the drug-placebo difference in AE prevalence, whereas the percent contribution of a placebo-related AE decreased such difference, revealing a continuum of risk between drug and placebo. AE prevalence curves for drug were generally greater than those for placebo. Ulotaront exhibited a small drug-placebo difference in AE prevalence curves due to a relatively low incidence and short duration of AEs in the ulotaront treatment arm as well as the emergence of disease-related AEs in the placebo arm. CONCLUSION Reporting AE absolute prevalence and expected duration for each RCT and incorporating them in the drug label is possible, is clinically relevant, and allows standardized comparison of medications. Our new metric, the drug-placebo difference in AE prevalence, facilitates signal detection in RCTs. We piloted this metric in RCTs of several neuropsychiatric indications and drugs, offering a new way to compare AE burden and tolerability among treatments using existing clinical trial information.
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Affiliation(s)
- Daria Piacentino
- Sumitomo Pharma America, Inc. (Formerly Sunovion Pharmaceuticals, Inc.), 84 Waterford Drive, Marlborough, MA, 01752, USA
| | - Ajay Ogirala
- Sumitomo Pharma America, Inc. (Formerly Sunovion Pharmaceuticals, Inc.), 84 Waterford Drive, Marlborough, MA, 01752, USA
| | - Robert Lew
- Sumitomo Pharma America, Inc. (Formerly Sunovion Pharmaceuticals, Inc.), 84 Waterford Drive, Marlborough, MA, 01752, USA
| | - Gregory Loftus
- Sumitomo Pharma America, Inc. (Formerly Sumitovant Biopharma Inc.), Marlborough, MA, USA
| | - MaryAlice Worden
- Sumitomo Pharma America, Inc. (Formerly Sunovion Pharmaceuticals, Inc.), 84 Waterford Drive, Marlborough, MA, 01752, USA
| | - Kenneth S Koblan
- Sumitomo Pharma America, Inc. (Formerly Sunovion Pharmaceuticals, Inc.), 84 Waterford Drive, Marlborough, MA, 01752, USA
| | - Seth C Hopkins
- Sumitomo Pharma America, Inc. (Formerly Sunovion Pharmaceuticals, Inc.), 84 Waterford Drive, Marlborough, MA, 01752, USA.
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Ferguson RE, Leatherman SM, Woods P, Hau C, Lew R, Cushman WC, Brophy MT, Fiore L, Ishani A. Practical issues in pragmatic trials: the implementation of the Diuretic Comparison Project. Clin Trials 2023; 20:276-283. [PMID: 36992530 DOI: 10.1177/17407745231160553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
BACKGROUND/AIMS The US Department of Veterans Affairs Point of Care Clinical Trial Program conducts studies that utilize informatics infrastructure to integrate clinical trial protocols into routine care delivery. The Diuretic Comparison Project compared hydrochlorothiazide to chlorthalidone in reduction of major cardiovascular events in subjects with hypertension. Here we describe the cultural, technical, regulatory, and logistical challenges and solutions that enabled successful implementation of this large pragmatic comparative effectiveness Point of Care clinical trial. METHODS Patients were recruited from 72 Veterans Affairs Healthcare Systems using centralized processes for subject identification, obtaining informed consent, data collection, safety monitoring, site communication, and endpoint identification with minimal perturbation of the local clinical care ecosystem. Patients continued to be managed exclusively by their clinical care providers without protocol specified study visits, treatment recommendations, or data collection extraneous to routine care. Centralized study processes were operationalized through the application layer of the electronic health record via a data coordinating center staffed by clinical nurses, data scientists, and statisticians without site-based research coordinators. Study data was collected from the Veterans Affairs electronic health record supplemented by Medicare and National Death Index data. RESULTS The study exceeded its enrolled goal (13,523 subjects) and followed subjects for the 5-year study duration. The key determinant of program success was collaboration between researchers, regulators, clinicians, and administrative staff at the site level to customize study procedures to align with local clinical practice. This flexibility was enabled by designation of the study as minimal risk and determination that clinical care providers were not engaged in research by the Veterans Affairs Central Institutional Review Board. Cultural, regulatory, technical, and logistical problems were identified and solved through iterative collaboration between clinical and research entities. Paramount among these problems was customization of the Veterans Affairs electronic health record and data systems to accommodate study procedures. CONCLUSIONS Leveraging clinical care for large-scale clinical trials is feasible but requires a rethinking of traditional clinical trial design (and regulation) to better meet requirements of clinical care ecosystems. Study designs must accommodate site-specific practice variation to reduce the impact on clinical care. A tradeoff thus exists between designing trial processes tailored to expedite local study implementation versus those to produce a more refined response to the research question. The availability of a uniform and flexible electronic health record in the Department of Veterans Affairs played a major role in the success of the trial. Conducting Point of Care research in other healthcare systems without such research-friendly infrastructure presents a more formidable challenge.
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Affiliation(s)
- Ryan E Ferguson
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sarah M Leatherman
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Patricia Woods
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
| | - Cynthia Hau
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
| | - Robert Lew
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - William C Cushman
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mary T Brophy
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Louis Fiore
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
| | - Areef Ishani
- Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Szabo ST, Hopkins SC, Lew R, Loebel A, Roth T, Koblan KS. A multicenter, double-blind, placebo-controlled, randomized, Phase 1b crossover trial comparing two doses of ulotaront with placebo in the treatment of narcolepsy-cataplexy. Sleep Med 2023; 107:202-211. [PMID: 37209427 DOI: 10.1016/j.sleep.2023.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/09/2023] [Accepted: 04/16/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Ulotaront (SEP-363856) is a novel agonist at trace amine-associated receptor 1 and serotonin 5-HT1A receptors in clinical development for the treatment of schizophrenia. Previous studies demonstrated ulotaront suppresses rapid eye movement (REM) sleep in both rodents and healthy volunteers. We assessed acute and sustained treatments of ulotaront on REM sleep and symptoms of cataplexy and alertness in subjects with narcolepsy-cataplexy. METHODS In a multicenter, double-blind, placebo-controlled, randomized, 3-way crossover study, ulotaront was evaluated in 16 adults with narcolepsy-cataplexy. Two oral doses of ulotaront (25 mg and 50 mg) were administered daily for 2 weeks and compared with matching placebo (6-treatment sequence, 3-period, 3-treatment). RESULTS Acute treatment with both 25 mg and 50 mg of ulotaront reduced minutes spent in nighttime REM compared to placebo. A sustained 2-week administration of both doses of ulotaront reduced the mean number of short-onset REM periods (SOREMPs) during daytime multiple sleep latency test (MSLT) compared to placebo. Although cataplexy events decreased from the overall mean baseline during the 2-week treatment period, neither dose of ulotaront statistically separated from placebo (p = 0.76, 25 mg; p = 0.82, 50 mg), and no significant improvement in patient and clinician measures of sleepiness from baseline to end of the 2-week treatment period occurred in any treatment group. CONCLUSIONS Acute and sustained treatment with ulotaront reduced nighttime REM duration and daytime SOREMPs, respectively. The effect of ulotaront on suppression of REM did not demonstrate a statistical or clinically meaningful effect in narcolepsy-cataplexy. REGISTRATION ClinicalTrials.gov identifier: NCT05015673.
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Affiliation(s)
- Steven T Szabo
- Sunovion Pharmaceuticals Inc., 84 Waterford Drive, Marlborough, MA, 01752, USA.
| | - Seth C Hopkins
- Sunovion Pharmaceuticals Inc., 84 Waterford Drive, Marlborough, MA, 01752, USA.
| | - Robert Lew
- Sunovion Pharmaceuticals Inc., 84 Waterford Drive, Marlborough, MA, 01752, USA.
| | - Antony Loebel
- Sunovion Pharmaceuticals Inc., 84 Waterford Drive, Marlborough, MA, 01752, USA.
| | - Thomas Roth
- Sleep Disorders and Research Center, Henry Ford Hospital, 2799 West Grand Boulevard Detroit, MI, 48202, USA.
| | - Kenneth S Koblan
- Sunovion Pharmaceuticals Inc., 84 Waterford Drive, Marlborough, MA, 01752, USA.
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Szmulewicz A, Madenci A, Ferguson R, Liang MH, Lew R, Katz IR, Hernán MA. Estimating the per-protocol effect of lithium on suicidality in a randomized trial of individuals with depression or bipolar disorder. J Psychopharmacol 2023:2698811231166460. [PMID: 37039306 DOI: 10.1177/02698811231166460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
BACKGROUND The CSP590 randomized trial was designed to estimate the effect of lithium on suicidality. After a third of the intended number of participants were enrolled, the hazard ratio of suicidality was 1.10 (95% CI: 0.77, 1.55). Based on this, the trial was stopped for futility. However, only 17% of patients adhered to the specified protocol. AIMS The objective was to estimate the per-protocol effect of lithium on suicidality, that is, the effect of adhering to the treatment strategies as specified in the protocol. METHODS We stopped individuals' follow-up if/when they showed evidence of nonadherence. We then conducted the analysis in the restricted sample, adjusting for prognostic factors that predict adherence via inverse probability weighting. The primary outcome was the 12-month risk of suicidality (including death from suicide, suicide attempt, interrupted attempt, hospitalization specifically to prevent suicide). RESULTS The estimated 12-month risk of suicidality was 18.8% for lithium, and 24.3% for placebo. The risk ratio was 0.78 (95% CI: 0.43, 1.37) and the risk difference -5.5 percentage points (95% CI: -17.5, 5.5). Results were consistent across sensitivity analyses. CONCLUSIONS With one-third of the targeted sample size, lithium effects (compared with placebo) ranging between a 17.5% reduction and a 5.5% increase in the risk of suicidality were highly compatible with the data. Thus, a protective effect of lithium on suicidality among patients with bipolar disorder or major depressive disorder cannot be ruled out. Trials should incorporate adequate per-protocol analyses into the decision-making processes for stopping trials for futility.
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Affiliation(s)
- Alejandro Szmulewicz
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Arin Madenci
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ryan Ferguson
- Boston Cooperative Studies Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Matthew H Liang
- Boston Cooperative Studies Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Section of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Section of Rheumatology, VA Boston Healthcare System, Boston, MA, USA
| | - Robert Lew
- Boston Cooperative Studies Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Ira R Katz
- Department of Psychiatry, Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, PA, USA
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Miguel A Hernán
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Abstract
Schizophrenia is a chronic, heterogeneous, severe psychiatric disorder characterized by a spectrum of symptomology and is associated with substantial morbidity and mortality. For the last 70 years, available treatments have shared blockade of dopamine D2 receptors as their primary mechanism of action (MOA), the efficacy of which has been limited by incomplete resolution of all symptoms as well as treatment non-response in a select subset of patients. In addition, antipsychotics are associated with class-related side effects attributed to this primary MOA, including extrapyramidal symptoms (EPS). The need for non-D2 treatment options for patients which offer a novel risk/benefit profile is therefore apparent. There has been substantial investment in the research and development of non-D2 drug candidates. However, none of these programs have received successful regulatory approval by the FDA (as of Oct 2022). In this article, the scale of industry-sponsored clinical trials for D2-based investigational pharmacological treatments in schizophrenia was quantified and compared with investigational compounds with non-D2 MOAs. In a dataset of 545 clinical trials identified in ClinicalTrials.gov from January 2002 to July 2022, total enrollments in trials of non-D2-based compounds for the treatment of schizophrenia summed to approximately 34,000 patients, compared with 27,144 patients for D2-based compounds. These data indicate that there remains substantial and ongoing investment in the development of novel non-D2 options for schizophrenia, with a success rate measured by regulatory approval that is well-below recent benchmarks for the broader category of CNS drugs. Improved trial design, conduct, endpoints, and analyses/methods may influence signal detection and reliability to support development and registration of non-D2 compounds.
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Affiliation(s)
| | - Robert Lew
- Sunovion Pharmaceuticals Inc, Marlborough, MA, USA
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Schreiber R, Campbell U, Quinton MS, Hardy LW, Fang QK, Lew R. In vitro and in vivo pharmacological characterization of dasotraline, a dual dopamine and norepinephrine transporter inhibitor in vivo. Biomed Pharmacother 2022; 153:113359. [PMID: 35785702 DOI: 10.1016/j.biopha.2022.113359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 06/21/2022] [Accepted: 06/28/2022] [Indexed: 11/02/2022] Open
Abstract
Inhibitors of dopamine transporters (DAT), norepinephrine transporters (NET) and serotonin transporters (SERT) are effective treatments for neuropsychiatric diseases. Dasotraline [(1R,4 S)- 4-(3,4-dichlorophenyl)- 1,2,3,4-tetrahydro-1-naphthalenamine, also known as SEP-225289) was evaluated for its inhibitory potency at DAT, NET and SERT using in vitro and in vivo assays. In vitro radiometric functional uptake studies showed preferential inhibition by dasotraline of hDAT (IC50 =3 nM) and hNET (IC50 =4 nM relative to hSERT(IC50 =15 nM). In mouse ex vivo occupancy studies, dasotraline demonstrated total plasma concentration-dependent occupancy at DAT, NET and SERT. Determination of the TO50 (50% transporter occupancy) were 32, 109 and 276 ng/ml, respectively. In SPECT imaging studies in baboons, dasotraline (0.2 mg/kg iv) displaced radiotracer binding to DAT by 87% but only 20% at NET and SERT. Rat microdialysis studies were performed in prefrontal cortex and striatum. Dasotraline produced sustained (>4 h) increases in dopamine and norepinephrine concentrations. Dasotraline was also more potent at increasing synaptic dopamine in the striatum, and norepinephrine in the prefrontal cortex than serotonin in these regions. In summary, dasotraline preferentially inhibits DAT and NET relative to SERT. Together, the occupancy and neurochemical profile of dasotraline provide a mechanistic basis for the treatment of diseases that have an underlying causality involving dopamine and norepinephrine dysfunction.
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Affiliation(s)
- Rudy Schreiber
- Faculty of Psychology and Neuroscience, Section Neuropsychology and Psychopharmacology, Maastricht University, The Netherlands.
| | - Una Campbell
- Sunovion Pharmaceuticals, 84 Waterford Drive, Marlborough, MA 01752, USA
| | - Maria S Quinton
- Neuroscience Translational Medicine, Takeda Pharmaceuticals U.S.A., Inc., 350 Massachusetts Avenue, Cambridge, MA 02139, USA
| | - Larry W Hardy
- PsychoGenics, 215 College Rd, Paramus, NJ 07652, USA
| | - Q Kevin Fang
- Sunovion Pharmaceuticals, 84 Waterford Drive, Marlborough, MA 01752, USA
| | - Robert Lew
- Sunovion Pharmaceuticals, 84 Waterford Drive, Marlborough, MA 01752, USA
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Petrakis I, Springer SA, Davis C, Ralevski E, Gu L, Lew R, Hermos J, Nuite M, Gordon AJ, Kosten TR, Nunes EV, Rosenheck R, Saxon AJ, Swift R, Goldberg A, Ringer R, Ferguson R. Rationale, design and methods of VA-BRAVE: a randomized comparative effectiveness trial of two formulations of buprenorphine for treatment of opioid use disorder in veterans. Addict Sci Clin Pract 2022; 17:6. [PMID: 35101115 PMCID: PMC8802273 DOI: 10.1186/s13722-022-00286-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background To address the US opioid epidemic, there is an urgent clinical need to provide persons with opioid use disorder (OUD) with effective medication treatments for OUD (MOUD). Formulations of sublingual buprenorphine/naloxone (SL-BUP/NLX) are considered the standard of care for OUD including within the Veterans Healthcare Administration (VHA). However, poor retention on MOUD undermines its effectiveness. Long-acting injectable monthly buprenorphine (INJ-BUP) (e.g., Sublocade®) has the potential to improve retention and therefore reduce opioid use and overdose. Designing and conducting studies for OUD pose unique challenges. The strategies and solutions to some of these considerations in designing Cooperative Studies Program (CSP) 2014, Buprenorphine for Treating Opioid Use Disorder in Veterans (VA-BRAVE), a randomized, 20-site, clinical effectiveness trial comparing INJ-BUP to SL-BUP/NLX conducted within the VHA may provide valuable guidance for others confronted with similar investigation challenges. Methods This 52-week, parallel group, open-label, randomized controlled trial (RCT) evaluates the comparative effectiveness of two current FDA-approved formulations of buprenorphine: (1) daily SL-BUP/NLX vs. (2) monthly (28-day) INJ-BUP for Veterans with moderate to severe OUD (n = 952). The primary outcomes are (1) retention in MOUD and (2) opioid abstinence. Secondary outcomes include measures of other drug use, psychiatric symptoms, medical outcomes including prevalence rates of HIV, hepatitis B and C as well as social outcomes (housing instability, criminal justice involvement), service utilization and cost-effectiveness. Special considerations in conducting a comparative effectiveness trial with this population and during COVID-19 pandemic were also included. Discussion The evaluation of the extended-release formulation of buprenorphine compared to the standard sublingual formulation in real-world VHA settings is of paramount importance in addressing the opioid epidemic. The extent to which this new treatment facilitates retention, decreases opioid use, and prevents severe sequelae of OUD has not been studied in any long-term trial to date. Positive findings in this trial could lead to widespread adoption of MOUD, and, if proven superior INJ-BUP, by clinicians throughout the VHA and beyond. This treatment has the potential to reduce opioid use among Veterans, improve medical, psychological, and social outcomes, and save lives at justifiable cost. Trial registration Registered at Clinicaltrials.gov NCT04375033
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Affiliation(s)
- Ismene Petrakis
- Department of Psychiatry, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA. .,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
| | - Sandra A Springer
- Section of Infectious Disease, Department of Internal Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.,Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Cynthia Davis
- US Department of Veteran Affairs, Cooperative Studies Program Coordinating Center (CSPCC), Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Ralevski
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.,Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lucy Gu
- Department of Psychiatry, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Robert Lew
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Jamaica Plain, Boston, MA, USA.,Department of Public Health, Boston University, Boston, MA, USA
| | - John Hermos
- Section of General Internal Medicine, Department of Medicine, School of Medicine, Boston University, Boston, MA, USA.,Department of Internal Medicine, VA Boston Healthcare System, Jamaica Plain, Boston, MA, USA
| | | | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Division of Epidemiology, Department of Internal Medicine, Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Thomas R Kosten
- Department of Psychiatry, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Department of Psychiatry, Baylor College of Medicine, Houston, TX, USA
| | - Edward V Nunes
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA
| | - Robert Rosenheck
- Department of Psychiatry, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Robert Swift
- Providence Veterans Affairs Medical Center, Providence, RI, USA.,Department of Psychiatry and Human Behavior, Center for Alcohol and Addiction Studies, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Alexa Goldberg
- US Department of Veteran Affairs, Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Robert Ringer
- US Department of Veteran Affairs, Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Ryan Ferguson
- US Department of Veteran Affairs, Cooperative Studies Program Coordinating Center (CSPCC), Boston, MA, USA.,Department of Public Health, Boston University, Boston, MA, USA
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9
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Katz IR, Rogers MP, Lew R, Thwin SS, Doros G, Ahearn E, Ostacher MJ, DeLisi LE, Smith EG, Ringer RJ, Ferguson R, Hoffman B, Kaufman JS, Paik JM, Conrad CH, Holmberg EF, Boney TY, Huang GD, Liang MH. Lithium Treatment in the Prevention of Repeat Suicide-Related Outcomes in Veterans With Major Depression or Bipolar Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2022; 79:24-32. [PMID: 34787653 PMCID: PMC8600458 DOI: 10.1001/jamapsychiatry.2021.3170] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Suicide and suicide attempts are persistent and increasing public health problems. Observational studies and meta-analyses of randomized clinical trials have suggested that lithium may prevent suicide in patients with bipolar disorder or depression. OBJECTIVE To assess whether lithium augmentation of usual care reduces the rate of repeated episodes of suicide-related events (repeated suicide attempts, interrupted attempts, hospitalizations to prevent suicide, and deaths from suicide) in participants with bipolar disorder or depression who have survived a recent event. DESIGN, SETTING, AND PARTICIPANTS This double-blind, placebo-controlled randomized clinical trial assessed lithium vs placebo augmentation of usual care in veterans with bipolar disorder or depression who had survived a recent suicide-related event. Veterans at 29 VA medical centers who had an episode of suicidal behavior or an inpatient admission to prevent suicide within 6 months were screened between July 1, 2015, and March 31, 2019. INTERVENTIONS Participants were randomized to receive extended-release lithium carbonate beginning at 600 mg/d or placebo. MAIN OUTCOMES AND MEASURES Time to the first repeated suicide-related event, including suicide attempts, interrupted attempts, hospitalizations specifically to prevent suicide, and deaths from suicide. RESULTS The trial was stopped for futility after 519 veterans (mean [SD] age, 42.8 [12.4] years; 437 [84.2%] male) were randomized: 255 to lithium and 264 to placebo. Mean lithium concentrations at 3 months were 0.54 mEq/L for patients with bipolar disorder and 0.46 mEq/L for patients with major depressive disorder. No overall difference in repeated suicide-related events between treatments was found (hazard ratio, 1.10; 95% CI, 0.77-1.55). No unanticipated safety concerns were observed. A total of 127 participants (24.5%) had suicide-related outcomes: 65 in the lithium group and 62 in the placebo group. One death occurred in the lithium group and 3 in the placebo group. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, the addition of lithium to usual Veterans Affairs mental health care did not reduce the incidence of suicide-related events in veterans with major depression or bipolar disorders who experienced a recent suicide event. Therefore, simply adding lithium to existing medication regimens is unlikely to be effective for preventing a broad range of suicide-related events in patients who are actively being treated for mood disorders and substantial comorbidities. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01928446.
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Affiliation(s)
- Ira R. Katz
- Department of Psychiatry, Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, Pennsylvania,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Malcolm P. Rogers
- Department of Psychiatry, VA Maine Healthcare System, Togus,Department of Psychiatry, Tufts University School of Medicine, Boston, Massachusetts
| | - Robert Lew
- Boston Cooperative Studies Coordinating Center, VA Boston Healthcare System, Boston, Massachusetts,Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Soe Soe Thwin
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts,Department of Sexual and Reproductive Health and Rights, World Health Organization, Geneva, Switzerland
| | - Gheorghe Doros
- Boston Cooperative Studies Coordinating Center, VA Boston Healthcare System, Boston, Massachusetts,Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Eileen Ahearn
- Department of Psychiatry, William S. Middleton VA Medical Center, Madison, Wisconsin,Department of Psychiatry, School of Medicine and Public Health, University of Wisconsin, Madison
| | - Michael J. Ostacher
- Department of Psychiatry, VA Palo Alto Healthcare System, Palo Alto, California,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Lynn E. DeLisi
- Department of Psychiatry, Cambridge Health Alliance, Cambridge Hospital, Cambridge, Massachusetts
| | - Eric G. Smith
- Department of Psychiatry, VA Bedford Healthcare System, Bedford, Massachusetts,Department of Psychiatry, University of Massachusetts Medical School, Worcester
| | - Robert J. Ringer
- Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, New Mexico
| | - Ryan Ferguson
- Boston Cooperative Studies Coordinating Center, VA Boston Healthcare System, Boston, Massachusetts,Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | | | - James S. Kaufman
- Department of Nephrology, VA New York Harbor Healthcare System, New York,Renal Division, New York University School of Medicine, New York
| | - Julie M. Paik
- New England Geriatric Research Education and Clinical Center and Renal Section, VA Boston Healthcare System, Boston, Massachusetts
| | - Chester H. Conrad
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts,Department of Cardiology, VA Boston Healthcare System, Boston, Massachusetts
| | - Erika F. Holmberg
- Boston Cooperative Studies Coordinating Center, VA Boston Healthcare System, Boston, Massachusetts
| | - Tamara Y. Boney
- Department of Psychiatry, Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia, Pennsylvania
| | - Grant D. Huang
- Cooperative Studies Program, Office of Research and Development Department of Veterans Affairs, Washington, DC
| | - Matthew H. Liang
- Boston Cooperative Studies Coordinating Center, VA Boston Healthcare System, Boston, Massachusetts,Department of Medicine, Section of Rheumatology, Inflammation and Immunity, Brigham and Women’s Hospital, Boston, Massachusetts,Department of Medicine, Section of Rheumatology, VA Boston Healthcare System, Boston, Massachusetts
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10
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Monach PA, Warner RL, Lew R, Tómasson G, Specks U, Stone JH, Fervenza FC, Hoffman GS, Kallenberg CGM, Langford CA, Seo P, St Clair EW, Spiera R, Johnson KJ, Merkel PA. Serum Biomarkers of Disease Activity in Longitudinal Assessment of Patients with ANCA-Associated Vasculitis. ACR Open Rheumatol 2021; 4:168-176. [PMID: 34792864 PMCID: PMC8843765 DOI: 10.1002/acr2.11366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/01/2021] [Accepted: 09/13/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Improved biomarkers of current disease activity and prediction of relapse are needed in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). For clinical relevance, biomarkers must perform well longitudinally in patients on treatment and in patients with nonsevere flares. METHODS Twenty-two proteins were measured in 347 serum samples from 74 patients with AAV enrolled in a clinical trial. Samples were collected at Month 6 after remission induction, then every 3 months until Month 18, or at the time of flare. Associations of protein concentrations with concurrent disease activity and with future flare were analyzed using mixed-effects models, Cox proportional hazards models, and conditional logistic regression. RESULTS Forty-two patients had flares during the 12-month follow-up period, and 32 remained in remission. Twenty-two patients had severe flares. Six experimental markers (CXCL13, IL-6, IL-8, IL-15, IL-18BP, and matrix metalloproteinase-3 [MMP-3]) and ESR were associated with disease activity using all three methods (P < 0.05, with P < 0.01 in at least one method). A rise in IL-8, IL-15, or IL-18BP was associated temporally with flare. Combining C-reactive protein (CRP), IL-18BP, neutrophil gelatinase-associated lipocalin (NGAL), and sIL-2Rα improved association with active AAV. CXCL13 and MMP-3 were increased during treatment with prednisone, independent of disease activity. Marker concentrations during remission were not predictive of future flare. CONCLUSION Serum biomarkers of inflammation and tissue damage and repair have been previously shown to be strongly associated with severe active AAV were less strongly associated with active AAV in a longitudinal study that included mild flares and varying treatment. Markers rising contemporaneously with flare or with an improved association in combination merit further study.
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Affiliation(s)
- Paul A Monach
- Boston University, Boston, Massachusetts.,VA Boston Healthcare System, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Robert Lew
- Boston University, Boston, Massachusetts
| | | | | | - John H Stone
- Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
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11
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Cole J, Htun N, Lew R, Freilich M, Quinn S, Layland J. COlchicine to Prevent PeriprocEdural myocardial Injury in Percutaneous Coronary Intervention (COPE-PCI): A descriptive cytokine pilot sub-study. Cardiovasc Revasc Med 2021; 39:84-89. [PMID: 34686461 DOI: 10.1016/j.carrev.2021.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND High levels of inflammation pre- and post-percutaneous coronary intervention (PCI) are associated with worse outcomes. Recent trials have suggested a benefit from treating inflammation with colchicine in coronary artery disease. In this randomised pilot COPE-PCI sub-study, we aimed to determine if administration of colchicine pre-PCI, would attenuate the inflammatory effect of PCI. METHODS PCI patients were randomised to colchicine or placebo, 6 to 24-hours pre-procedure. Study blood samples were taken immediately pre-PCI, and 24-hours post-procedure. Samples were tested for a broad array of inflammatory biomarkers including high-sensitive(hs)-CRP, leucocyte counts, and hs-troponin-. Periprocedural Myocardial Injury (PM-Injury) was defined as per the ESC Third Universal Definitions of Myocardial Infarction. RESULTS Thirty-six were randomised to colchicine and 39 to placebo. Treatment groups were similar for baseline variables. The median time from drug administration to pre-PCI blood sampling was 18-hours. Overall inflammation was low across the patient population, pre- & post-PCI hsCRP was <1.4 mg/L. Colchicine patients had numerically lower levels of pre-PCI cytokines: IL-1β (p = 0.01), IL-6 (p = 0.02), IL-10 (p = 0.01), IFNγ (p = 0.01), TNFα (p = 0.02) and WBC-count (p = 0.04). Post-PCI (38-hours post-drug) measures of inflammation were similar between treatment arms. Absolute troponin change (post-PCI - pre-PCI levels) was less in colchicine patients (p = 0.02). CONCLUSION The reduction in PCI-related myocardial injury that resulted from colchicine given on median 18 h pre-PCI, was associated with numerically lower levels of inflammation pre-PCI but no difference one day post-PCI in the colchicine vs placebo groups. CLINICAL TRIAL REGISTRATION The trial was publicly registered at www.anzctr.org.au, Trial ID: ACTRN12615000485538.
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Affiliation(s)
- Justin Cole
- Peninsula Heart Service, Peninsula Health, Australia; Peninsula Clinical School, Monash University, Australia
| | - Nay Htun
- Peninsula Heart Service, Peninsula Health, Australia; Peninsula Clinical School, Monash University, Australia
| | - Robert Lew
- Peninsula Heart Service, Peninsula Health, Australia
| | - Mark Freilich
- Peninsula Heart Service, Peninsula Health, Australia
| | - Stephen Quinn
- Department of Health Science and Biostatistics, Swinburne University of Technology, Australia
| | - Jamie Layland
- Peninsula Heart Service, Peninsula Health, Australia; Peninsula Clinical School, Monash University, Australia.
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Cole J, Htun N, Lew R, Freilich M, Quinn S, Layland J. Colchicine to Prevent Periprocedural Myocardial Injury in Percutaneous Coronary Intervention: The COPE-PCI Pilot Trial. Circ Cardiovasc Interv 2021; 14:e009992. [PMID: 34003667 DOI: 10.1161/circinterventions.120.009992] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Justin Cole
- Peninsula Heart Service, Peninsula Health, Frankston, Australia (J.C., N.H., R.L., M.F., J.L.).,Peninsula Clinical School, Monash University, Frankston, Australia (J.C., N.H., J.L.)
| | - Nay Htun
- Peninsula Heart Service, Peninsula Health, Frankston, Australia (J.C., N.H., R.L., M.F., J.L.).,Peninsula Clinical School, Monash University, Frankston, Australia (J.C., N.H., J.L.)
| | - Robert Lew
- Peninsula Heart Service, Peninsula Health, Frankston, Australia (J.C., N.H., R.L., M.F., J.L.)
| | - Mark Freilich
- Peninsula Heart Service, Peninsula Health, Frankston, Australia (J.C., N.H., R.L., M.F., J.L.)
| | - Stephen Quinn
- Department of Health Science and Biostatistics, Swinburne University of Technology, Hawthorn, Victoria, Australia (S.Q.)
| | - Jamie Layland
- Peninsula Heart Service, Peninsula Health, Frankston, Australia (J.C., N.H., R.L., M.F., J.L.).,Peninsula Clinical School, Monash University, Frankston, Australia (J.C., N.H., J.L.)
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13
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Bauer MS, Stolzmann K, Miller CJ, Kim B, Connolly SL, Lew R. Implementing the Collaborative Chronic Care Model in Mental Health Clinics: Achieving and Sustaining Clinical Effects. Psychiatr Serv 2021; 72:586-589. [PMID: 33730885 DOI: 10.1176/appi.ps.202000117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Collaborative chronic care models (CCMs) were established with implementation support in nine mental health clinics. This study sought to determine whether their clinical impact was maintained after implementation support ceased. METHODS Posttrial data were analyzed from a randomized stepped-wedge CCM implementation trial in general mental health clinics in nine Department of Veterans Affairs medical centers. Sites received 1 year of implementation support, which was associated with reduced mental health hospitalization rates compared with non-CCM clinics in the same medical centers. Hospitalization rates for the year after implementation support were analyzed by using repeated measures logistic regression comparing the same clinics. RESULTS Hospitalization rates for the postsupport year did not differ from comparison clinics either in the population that initially showed the difference or the population active in the clinics at the end of the year of implementation support. CONCLUSIONS Clinical effects of the CCM may wane after cessation of active implementation support.
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Affiliation(s)
- Mark S Bauer
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Christopher J Miller
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Bo Kim
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Samantha L Connolly
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Robert Lew
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
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Martin PI, Chao L, Krengel MH, Ho MD, Yee M, Lew R, Knight J, Hamblin MR, Naeser MA. Transcranial Photobiomodulation to Improve Cognition in Gulf War Illness. Front Neurol 2021; 11:574386. [PMID: 33551948 PMCID: PMC7859640 DOI: 10.3389/fneur.2020.574386] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 11/09/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction: Approximately 25-30% of veterans deployed to Kuwait, 1990-91, report persistent multi-symptom Gulf War Illness (GWI) likely from neurotoxicant exposures. Photobiomodulation (PBM) in red/near-infrared (NIR) wavelengths is a safe, non-invasive modality shown to help repair hypoxic/stressed cells. Red/NIR wavelengths are absorbed by cytochrome C oxidase in mitochondria, releasing nitric oxide (increasing local vasodilation), and increasing adenosine tri-phosphate production. We investigated whether PBM applied transcranially could improve cognition, and health symptoms in GWI. Materials and Methods: Forty-eight (40 M) participants completed this blinded, randomized, sham-controlled trial using Sham or Real, red/NIR light-emitting diodes (LED) applied transcranially. Fifteen, half-hour transcranial LED (tLED) treatments were twice a week (7.5 weeks, in-office). Goggles worn by participant and assistant maintained blinding for visible red. Pre-/Post- testing was at Entry, 1 week and 1 month post- 15th treatment. Primary outcome measures were neuropsychological (NP) tests; secondary outcomes, Psychosocial Questionnaires, including PTSD. Results: Primary Analyses (all participants), showed improvement for Real vs. Sham, for Digit Span Forwards (p < 0.01); and a trend for Trails 4, Number/Letter Sequencing (p < 0.10). For secondary outcomes, Real group reported more improvement on the SF-36V Plus, Physical Component Score (p < 0.08). Secondary Analyses included only subjects scoring below norm (50%ile) at Entry, on specific NP test/s. Real and Sham improved at 1 week after 15th treatment; however, at 1 month, only those receiving Real improved further: Digit Span Total, Forwards and Backwards; Trails 4, Number/Letter Sequencing; California Verbal Learning Test-II, long delay free recall; Continuous Performance Test-II, False Alarm Rate; and Color-Word Interference, Stroop, Trial 3, Inhibition; Sham group worsened, toward Entry values. Only those with more post-traumatic stress disorder (PTSD) symptomatology at Entry, receiving Real, continued to have additional PTSD reduction at 1 month; Sham regressed. Conclusion: This study was underpowered (n = 48), with large heterogeneity at Entry. This likely contributed to significance or trend to significance, for only two of the NP tests (Digit Span Forwards; Trails 4, Number/Letter Sequencing) and only one general health measure, the SF-36V Plus, Physical Component Score. More subjects receiving Real, self-reported increased concentration, relaxation and sleep. Controlled studies with newer, transcranial LED home treatment devices are warranted; this is expected to increase enrollment. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT01782378.
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Affiliation(s)
- Paula I. Martin
- VA Boston Healthcare System, Boston, MA, United States
- Department of Neurology, School of Medicine, Boston University, Boston, MA, United States
| | - Linda Chao
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
| | - Maxine H. Krengel
- VA Boston Healthcare System, Boston, MA, United States
- Department of Neurology, School of Medicine, Boston University, Boston, MA, United States
| | - Michael D. Ho
- VA Boston Healthcare System, Boston, MA, United States
| | - Megan Yee
- VA Boston Healthcare System, Boston, MA, United States
| | - Robert Lew
- VA Boston Healthcare System, Boston, MA, United States
- Department of Biostatistics, School of Public Health, Boston University, Boston, MA, United States
| | - Jeffrey Knight
- VA Boston Healthcare System, National Center for Posttraumatic Stress Disorder, Boston, MA, United States
| | - Michael R. Hamblin
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, United States
- Laser Research Center, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Margaret A. Naeser
- VA Boston Healthcare System, Boston, MA, United States
- Department of Neurology, School of Medicine, Boston University, Boston, MA, United States
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Cole J, Lew R, Quinn S, Htun N, Freilich M, Layland J. 806 COlchicine to Prevent PeriprocEdural Myocardial Injury in Percutaneous Coronary Intervention (COPE-PCI Trial). Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dedic N, Jones PG, Hopkins SC, Lew R, Shao L, Campbell JE, Spear KL, Large TH, Campbell UC, Hanania T, Leahy E, Koblan KS. SEP-363856, a Novel Psychotropic Agent with a Unique, Non-D2 Receptor Mechanism of Action. J Pharmacol Exp Ther 2019; 371:1-14. [DOI: 10.1124/jpet.119.260281] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/10/2019] [Indexed: 01/03/2023] Open
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Bauer MS, Miller CJ, Kim B, Lew R, Stolzmann K, Sullivan J, Riendeau R, Pitcock J, Williamson A, Connolly S, Elwy AR, Weaver K. Effectiveness of Implementing a Collaborative Chronic Care Model for Clinician Teams on Patient Outcomes and Health Status in Mental Health: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e190230. [PMID: 30821830 PMCID: PMC6484628 DOI: 10.1001/jamanetworkopen.2019.0230] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Collaborative chronic care models (CCMs) have extensive randomized clinical trial evidence for effectiveness in serious mental illnesses, but little evidence exists regarding their feasibility or effect in typical practice conditions. OBJECTIVE To determine the effectiveness of implementation facilitation in establishing the CCM in mental health teams and the impact on health outcomes of team-treated individuals. DESIGN, SETTING, AND PARTICIPANTS This quasi-experimental, randomized stepped-wedge implementation trial was conducted from February 2016 through February 2018, in partnership with the US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention. Nine facilities were enrolled from all VA facilities in the United States to receive CCM implementation support. All veterans (n = 5596) treated by designated outpatient general mental health teams were included for hospitalization analyses, and a randomly selected sample (n = 1050) was identified for health status interviews. Individuals with dementia were excluded. Clinicians (n = 62) at the facilities were surveyed, and site process summaries were rated for concordance with the CCM process. The CCM implementation start time was randomly assigned across 3 waves. Data analysis of this evaluable population was performed from June to September 2018. INTERVENTIONS Internal-external facilitation, combining a study-funded external facilitator and a facility-funded internal facilitator working with a designated team for 1 year. MAIN OUTCOMES AND MEASURES Facilitation was hypothesized to be associated with improvements in both implementation and intervention outcomes (hybrid type II trial). Implementation outcomes included the clinician Team Development Measure (TDM) and proportion of CCM-concordant team care processes. The study was powered for the primary health outcome, mental component score (MCS). Hospitalization rate was derived from administrative data. RESULTS The veteran population (n = 5596) included 881 women (15.7%), and the mean (SD) age was 52.2 (14.5) years. The interviewed sample (n = 1050) was similar but was oversampled for women (n = 210 [20.0%]). Facilitation was associated with improvements in TDM subscales for role clarity (53.4%-68.6%; δ = 15.3; 95% CI, 4.4-26.2; P = .01) and team primacy (50.0%-68.6%; δ = 18.6; 95% CI, 8.3-28.9; P = .001). The percentage of CCM-concordant processes achieved varied, ranging from 44% to 89%. No improvement was seen in veteran self-ratings, including the primary outcome. In post hoc analyses, MCS improved in veterans with 3 or more treated mental health diagnoses compared with others (β = 5.03; 95% CI, 2.24-7.82; P < .001). Mental health hospitalizations demonstrated a robust decrease during facilitation (β = -0.12; 95% CI, -0.16 to -0.07; P < .001); this finding withstood 4 internal validity tests. CONCLUSIONS AND RELEVANCE Implementation facilitation that engages clinicians under typical practice conditions can enhance evidence-based team processes; its effect on self-reported overall population health status was negligible, although health status improved for individuals with complex conditions and hospitalization rate declined. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02543840.
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Affiliation(s)
- Mark S. Bauer
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Christopher J. Miller
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Bo Kim
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Robert Lew
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Biostatistics, Boston University School of Medicine, Boston, Massachusetts
| | - Kelly Stolzmann
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
| | - Jennifer Sullivan
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Health Policy, Law, & Management, Boston University School of Public Health, Boston, Massachusetts
| | - Rachel Riendeau
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Anthropology, University of Iowa, Iowa City
| | - Jeffery Pitcock
- Behavioral Health Quality Enhancement Research Initiative Program, Central Arkansas Veterans Healthcare System, Little Rock
| | | | - Samantha Connolly
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - A. Rani Elwy
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Kendra Weaver
- US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention, Washington, DC
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Rybin D, Lew R, Pencina MJ, Fava M, Doros G. Placebo Response as a Latent Characteristic: Application to Analysis of Sequential Parallel Comparison Design Studies. J Am Stat Assoc 2018. [DOI: 10.1080/01621459.2017.1375930] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Denis Rybin
- Department of Biostatistics, Boston University, Boston, MA
| | - Robert Lew
- Department of Biostatistics, Boston University, Boston, MA
| | | | - Maurizio Fava
- Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University, Boston, MA
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Peper SM, Lew R, Mikuls T, Brophy M, Rybin D, Wu H, O'Dell J. Rheumatoid Arthritis Treatment After Methotrexate: The Durability of Triple Therapy Versus Etanercept. Arthritis Care Res (Hoboken) 2017; 69:1467-1472. [DOI: 10.1002/acr.23255] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 02/24/2017] [Accepted: 04/04/2017] [Indexed: 11/08/2022]
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Pomerantz H, Chren MM, Lew R, Weinstock MA. Validation and comparison of quality-of-life measures for topical 5-fluorouracil treatment: results from a randomized controlled trial. Clin Exp Dermatol 2017. [DOI: 10.1111/ced.13089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- H. Pomerantz
- Center for Dermatoepidemiology; VA Medical Center; Providence RI USA
- Departments of Dermatology and Epidemiology; Brown University; Providence RI USA
| | - M.-M. Chren
- Dermatology Service; San Francisco VA Medical Center; San Francisco CA USA
- Department of Dermatology; University of California; San Francisco CA USA
| | - R. Lew
- VA Cooperative Studies Coordinating Center; Boston MA USA
| | - M. A. Weinstock
- Center for Dermatoepidemiology; VA Medical Center; Providence RI USA
- Departments of Dermatology and Epidemiology; Brown University; Providence RI USA
- Department of Dermatology; Rhode Island Hospital; Providence RI USA
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Pomerantz H, Korgavkar K, Lee KC, Lew R, Weinstock MA. Validation of Photograph-Based Toxicity Score for Topical 5-Fluorouracil Cream Application. J Cutan Med Surg 2016; 20:458-66. [PMID: 27207349 DOI: 10.1177/1203475416643952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND An objective tool quantifying the toxicity of 5-fluorouracil (5-FU) from photographs was recently reported, and its reliability was confirmed. OBJECTIVE The aim of this study was to validate the photograph-based toxicity score. METHODS Photograph-based toxicity scores of participants assigned to the 5-FU arm of a randomized placebo-controlled trial were tested for correlations with their patient-reported symptom scores and baseline characteristics. RESULTS Each pair of individual and overall scores of patient-reported symptoms and photograph-based toxicity was correlated at 2 and 4 weeks (correlation coefficient range, 0.34-0.95; P < .001 for all). Older age, more actinic keratoses, previous topical 5-FU use, and more keratinocyte carcinomas on the face and ears in the previous 5 years were correlated with increased 5-FU toxicity at 2 weeks (P < .05). An increase in the total number of 5-FU applications during the trial was correlated with less severe toxicity at 2 weeks (P < .001), but with increased toxicity at 4 weeks (P < .001). CONCLUSION This study provides evidence for construct validity of the photograph-based 5-FU toxicity score. The tool can be used to objectively measure 5-FU toxicity in clinical or research setting, and it can be a prototype for toxicity measurements of other topical medications.
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Affiliation(s)
- Hyemin Pomerantz
- Center for Dermatoepidemiology, VA Medical Center, Providence, RI, USA Department of Dermatology, Brown University, Providence, RI, USA
| | - Kaveri Korgavkar
- Center for Dermatoepidemiology, VA Medical Center, Providence, RI, USA Department of Dermatology, Brown University, Providence, RI, USA
| | - Kachiu C Lee
- Center for Dermatoepidemiology, VA Medical Center, Providence, RI, USA Department of Dermatology, Brown University, Providence, RI, USA
| | - Robert Lew
- The Massachusetts Veterans Epidemiology Research and Information Center, Boston, MA, USA
| | - Martin A Weinstock
- Center for Dermatoepidemiology, VA Medical Center, Providence, RI, USA The Massachusetts Veterans Epidemiology Research and Information Center, Boston, MA, USA Department of Epidemiology, Brown University, Providence, RI, USA
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Bauer MS, Miller C, Kim B, Lew R, Weaver K, Coldwell C, Henderson K, Holmes S, Seibert MN, Stolzmann K, Elwy AR, Kirchner J. Partnering with health system operations leadership to develop a controlled implementation trial. Implement Sci 2016; 11:22. [PMID: 26912342 PMCID: PMC4765154 DOI: 10.1186/s13012-016-0385-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 02/16/2016] [Indexed: 11/30/2022] Open
Abstract
Background Outcome for mental health conditions is suboptimal, and care is fragmented. Evidence from controlled trials indicates that collaborative chronic care models (CCMs) can improve outcomes in a broad array of mental health conditions. US Department of Veterans Affairs leadership launched a nationwide initiative to establish multidisciplinary teams in general mental health clinics in all medical centers. As part of this effort, leadership partnered with implementation researchers to develop a program evaluation protocol to provide rigorous scientific data to address two implementation questions: (1) Can evidence-based CCMs be successfully implemented using existing staff in general mental health clinics supported by internal and external implementation facilitation? (2) What is the impact of CCM implementation efforts on patient health status and perceptions of care? Methods/design Health system operation leaders and researchers partnered in an iterative process to design a protocol that balances operational priorities, scientific rigor, and feasibility. Joint design decisions addressed identification of study sites, patient population of interest, intervention design, and outcome assessment and analysis. Nine sites have been enrolled in the intervention-implementation hybrid type III stepped-wedge design. Using balanced randomization, sites have been assigned to receive implementation support in one of three waves beginning at 4-month intervals, with support lasting 12 months. Implementation support consists of US Center for Disease Control’s Replicating Effective Programs strategy supplemented by external and internal implementation facilitation support and is compared to dissemination of materials plus technical assistance conference calls. Formative evaluation focuses on the recipients, context, innovation, and facilitation process. Summative evaluation combines quantitative and qualitative outcomes. Quantitative CCM fidelity measures (at the site level) plus health outcome measures (at the patient level; n = 765) are collected in a repeated measures design and analyzed with general linear modeling. Qualitative data from provider interviews at baseline and 1 year elaborate CCM fidelity data and provide insights into barriers and facilitators of implementation. Discussion Conducting a jointly designed, highly controlled protocol in the context of health system operational priorities increases the likelihood that time-sensitive questions of operational importance will be answered rigorously and that the outcomes will result in sustainable change in the health-care system. Trial registration NCT02543840 (https://www.clinicaltrials.gov/ct2/show/NCT02543840).
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Affiliation(s)
- Mark S Bauer
- VA Boston Healthcare System, Harvard Medical School, 150 South Huntington Avenue (152M), Boston, MA, 02130, USA.
| | - Christopher Miller
- VA Boston Healthcare System, Harvard Medical School, 150 South Huntington Avenue (152M), Boston, MA, 02130, USA.
| | - Bo Kim
- VA Boston Healthcare System, Harvard Medical School, 150 South Huntington Avenue (152M), Boston, MA, 02130, USA.
| | - Robert Lew
- VA Boston Healthcare System, Boston University School of Medicine, 150 South Huntington Avenue (MAVERIC), Boston, MA, 02130, USA.
| | - Kendra Weaver
- James H. Quillen VA Medical Center, Corner of Lamont & Veterans Way, Mountain Home, TN, 37684, USA.
| | - Craig Coldwell
- VA New England Healthcare System, Boston University School of Medicine, 200 Springs Road, Building 61 (136G), Bedford, MA, 01730, USA.
| | - Kathy Henderson
- Central Arkansas Veterans Healthcare System, University of Arkansas for Medical Sciences, 2200 Fort Roots Drive, Building 58, North Little Rock, AR, 72114, USA.
| | - Sally Holmes
- VA Boston Healthcare System, 150 South Huntington Avenue (152M), Boston, MA, 02130, USA.
| | | | - Kelly Stolzmann
- VA Boston Healthcare System, 150 South Huntington Avenue (152M), Boston, MA, 02130, USA.
| | - A Rani Elwy
- VA Boston Healthcare System, 150 South Huntington Avenue (152M), Boston, MA, 02130, USA.
| | - JoAnn Kirchner
- Central Arkansas Veterans Healthcare System, University of Arkansas for Medical Sciences, 2200 Fort Roots Drive, Building 58, North Little Rock, AR, 72114, USA.
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Pomerantz H, Hogan D, Eilers D, Swetter SM, Chen SC, Jacob SE, Warshaw EM, Stricklin G, Dellavalle RP, Sidhu-Malik N, Konnikov N, Werth VP, Keri J, Lew R, Weinstock MA. Long-term Efficacy of Topical Fluorouracil Cream, 5%, for Treating Actinic Keratosis: A Randomized Clinical Trial. JAMA Dermatol 2015; 151:952-60. [PMID: 25950503 DOI: 10.1001/jamadermatol.2015.0502] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Topical fluorouracil was demonstrated to be effective in reducing the number of actinic keratoses (AKs) for up to 6 months, but no randomized trials studied its long-term efficacy. OBJECTIVE To evaluate the long-term efficacy of a single course of fluorouracil cream, 5%, for AK treatment. DESIGN, SETTING, AND PARTICIPANTS The Veterans Affairs Keratinocyte Carcinoma Chemoprevention (VAKCC) trial was a randomized, double-blinded, placebo-controlled trial with patients from dermatology clinics at 12 VA medical centers recruited from 2009 to 2011 and followed up until 2013. Our study population comprised 932 veterans with 2 or more keratinocyte carcinomas in the 5 years prior to enrollment. The mean follow-up duration was 2.6 years in both treatment and control groups. INTERVENTIONS Participants applied either topical fluorouracil cream, 5% (n = 468), or vehicle control cream (n = 464) to the face and ears twice daily for up to 4 weeks. MAIN OUTCOMES AND MEASURES This study reports on AK counts and treatments, which were secondary outcomes of the VAKCC trial. Actinic keratoses on the face and ears were counted by study dermatologists at enrollment and at study visits every 6 months. The number of spot treatments for AKs on the face and ears at semiannual study visits and in between study visits was recorded. RESULTS The number of AKs on the face and ears per participant was not different between the fluorouracil and control groups at randomization (11.1 vs 10.6, P > .10). After randomization, the fluorouracil group had fewer AKs compared with the control group at 6 months (3.0 vs 8.1, P < .001) and for the overall study duration (P < .001). The fluorouracil group also had higher complete AK clearance rates (38% vs 17% at 6 months) and fewer spot treatments at 6-month intervals, at study visits, and in between study visits during the trial (P < .01 for all). The fluorouracil group took longer to require the first spot AK treatment (6.2 months) compared with the control group (6.0 months) (hazard ratio, 0.69; 95% CI, 0.60-0.79). The number of hypertrophic AKs was not different between the 2 groups overall (P = .60), although there were fewer hypertrophic AKs in the fluorouracil group at 6 months (0.23 vs 0.41) (P = .05). CONCLUSIONS AND RELEVANCE Our results indicate that a single course of fluorouracil cream, 5%, effectively reduces AK counts and the need for spot treatments for longer than 2 years. TRIAL REGISTRATION clinicaltrials.gov Identifier:NCT00847912.
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Affiliation(s)
- Hyemin Pomerantz
- Center for Dermatoepidemiology, Veterans Affairs (VA) Medical Center, Providence, Rhode Island2Department of Dermatology, Brown University, Providence, Rhode Island
| | - Daniel Hogan
- Dermatology, Bay Pines VA Healthcare System, Bay Pines, Florida4Department of Internal Medicine (Dermatology), NOVA Southeastern University College of Osteopathic Medicine, Davie, Florida
| | - David Eilers
- Dermatology, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Susan M Swetter
- Dermatology, VA Palo Alto Health Care System, Palo Alto, California7Department of Dermatology, Stanford University Medical Center, Palo Alto, California
| | - Suephy C Chen
- Dermatology, Atlanta VA Medical Center, Atlanta, Georgia9Department of Dermatology, Emory University, Atlanta, Georgia
| | - Sharon E Jacob
- Dermatology, VA San Diego Healthcare System, San Diego, California
| | - Erin M Warshaw
- Dermatology, Minneapolis VA Health Care System, Minneapolis, Minnesota12Department of Dermatology, University of Minnesota, Minneapolis, Minnesota
| | - George Stricklin
- Dermatology, Tennessee Valley Healthcare System, Nashville, Tennessee14Division of Dermatology, Vanderbilt University, Nashville, Tennessee
| | | | - Navjeet Sidhu-Malik
- Dermatology, Durham VA Medical Center, Durham, North Carolina17Department of Dermatology, Duke University, Durham, North Carolina
| | - Nellie Konnikov
- Dermatology, Boston VA Medical Center, Boston, Massachusetts
| | - Victoria P Werth
- Dermatology, Philadelphia VA Medical Center, Philadelphia, Pennsylvania20Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonette Keri
- Dermatology, Miami VA Hospital, Miami, Florida22Department of Dermatology and Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami
| | - Robert Lew
- VA Cooperative Studies Coordinating Center, Boston, Massachusetts
| | - Martin A Weinstock
- Center for Dermatoepidemiology, Veterans Affairs (VA) Medical Center, Providence, Rhode Island2Department of Dermatology, Brown University, Providence, Rhode Island24Department of Dermatology, Rhode Island Hospital, Providence25Department of Epidemiology
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Jones PG, Hewitt MC, Campbell JE, Quinton MS, Engel S, Lew R, Campbell U, Burdi DF. Pharmacological evaluation of a novel phosphodiesterase 10A inhibitor in models of antipsychotic activity and cognition. Pharmacol Biochem Behav 2015; 135:46-52. [PMID: 25989044 DOI: 10.1016/j.pbb.2015.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 04/21/2015] [Accepted: 04/22/2015] [Indexed: 01/08/2023]
Abstract
In this study, we report the pharmacological effects of a novel PDE10A inhibitor, SEP-39. SEP-39 is a potent (1.0nM) inhibitor of human PDE10A in vitro, with good selectivity (>16000-fold) against other PDEs. In an in vivo occupancy study, the RO50 value was determined to be 0.7mg/kg (p.o.), corresponding to plasma and brain exposures of 28ng/mL and 43ng/g, respectively. Using microdialysis, we show that 3mg/kg (p.o.) SEP-39 significantly increased rat striatal cGMP concentrations. Furthermore, SEP-39 inhibits PCP-induced hyperlocomotion at doses of 1 and 3mg/kg (p.o.) corresponding to 59-86% occupancy. At similar doses in a catalepsy study, the time on the bar was increased but the maximal effect was less than that seen with haloperidol. In an EEG study, 3 and 10mg/kg (p.o.) SEP-39 suppressed REM intensity and increased the latency to REM sleep. We also demonstrate the procognitive effects of SEP-39 in the rat novel object recognition assay. These effects appear to require less PDE10A inhibition than the reversal of PCP-induced hyperlocomotion or EEG effects, as improvements in recognition index were seen at doses of 0.3mg/kg and above. Our data demonstrate that SEP-39 is a potent, orally active PDE10A inhibitor with therapeutic potential in a number of psychiatric indications.
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Affiliation(s)
- Philip G Jones
- Discovery and Preclinical Research, Sunovion Pharmaceuticals, 84 Waterford Drive, Marlborough, MA 01752, USA.
| | - Michael C Hewitt
- Constellation Pharmaceuticals, 215 First Street, Suite 200, Cambridge, MA 02142, USA
| | - John E Campbell
- Epizyme Inc., 400 Technology Square 4th Floor, Cambridge, MA 02139, USA
| | - Maria S Quinton
- Retrophin Inc., 301 Binney St. 3rd floor, Cambridge, MA 02142, USA
| | - Sharon Engel
- Discovery and Preclinical Research, Sunovion Pharmaceuticals, 84 Waterford Drive, Marlborough, MA 01752, USA
| | - Robert Lew
- Translational Medicine and Early Development, Sunovion Pharmaceuticals, 84 Waterford Drive, Marlborough, MA 01752, USA
| | - Una Campbell
- Translational Medicine and Early Development, Sunovion Pharmaceuticals, 84 Waterford Drive, Marlborough, MA 01752, USA
| | - Douglas F Burdi
- Discovery and Preclinical Research, Sunovion Pharmaceuticals, 84 Waterford Drive, Marlborough, MA 01752, USA
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Lew R, Jacob J. Polymorphous light eruption: a common skin disease uncommonly recognized in the Hispanic population. Oxf Med Case Reports 2014; 2014:145-7. [PMID: 25988060 PMCID: PMC4369994 DOI: 10.1093/omcr/omu055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 09/29/2014] [Accepted: 10/27/2014] [Indexed: 11/13/2022] Open
Abstract
Polymorphous light eruption (PMLE) is a common acquired disease entity belonging to the idiopathic photodermatoses that is uncommonly considered in the Hispanic population. The pathogenesis of the disease and the mechanism of adaptation in skin (hardening phenomenon) have yet to be elucidated. PMLE is characterized by recurrent abnormal delayed reactions to sunlight ranging from pruritic erythematous papules, papulovesicles and plaques to erythema multiforme. It commonly occurs in the spring or early summer with a predilection for females. A Pubmed review of the literature shows no case reports or literature regarding PMLE in Hispanics. To the best of our knowledge, we report the first case of a 41-year-old Hispanic female diagnosed with PMLE. A high index of suspicion must remain in this group. Additional studies reviewing epidemiology in this group and detailing similar cases may be suggested.
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Affiliation(s)
- Robert Lew
- University of Connecticut Medical Center, Farmington, CT, USA
| | - Jason Jacob
- Hartford Hospital, Hartford, CT, USA
- Correspondence address. 80 Seymour Street, Hartford, CT 06102, USA. Tel: +1-8609722876; Fax: +1-8609725057; E-mail:
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Rybin D, Doros G, Rosenheck R, Lew R. The impact of missing data on the results of a schizophrenia study. Pharm Stat 2014; 14:4-10. [PMID: 25327503 DOI: 10.1002/pst.1651] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 07/03/2014] [Accepted: 09/07/2014] [Indexed: 11/09/2022]
Abstract
Missing data pose a serious challenge to the integrity of randomized clinical trials, especially of treatments for prolonged illnesses such as schizophrenia, in which long-term impact assessment is of great importance, but the follow-up rates are often no more than 50%. Sensitivity analysis using Bayesian modeling for missing data offers a systematic approach to assessing the sensitivity of the inferences made on the basis of observed data. This paper uses data from an 18-month study of veterans with schizophrenia to demonstrate this approach. Data were obtained from a randomized clinical trial involving 369 patients diagnosed with schizophrenia that compared long-acting injectable risperidone with a psychiatrist's choice of oral treatment. Bayesian analysis utilizing a pattern-mixture modeling approach was used to validate the reported results by detecting bias due to non-random patterns of missing data. The analysis was applied to several outcomes including standard measures of schizophrenia symptoms, quality of life, alcohol use, and global mental status. The original study results for several measures were confirmed against a wide range of patterns of non-random missingness. Robustness of the conclusions was assessed using sensitivity parameters. The missing data in the trial did not likely threaten the validity of previously reported results.
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Affiliation(s)
- Denis Rybin
- Boston University, Biostatistics, Boston, MA, USA; Boston VA Research Institute, VA Boston Healthcare System, Boston, MA, USA
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Korgavkar K, Firoz EF, Xiong M, Lew R, Marcolivio K, Burnside N, Dyer R, Weinstock MA. Measuring the severity of topical 5-fluorouracil toxicity. J Cutan Med Surg 2014; 18:229-35. [PMID: 25008439 DOI: 10.2310/7750.2013.13143] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Topical 5% 5-fluorouracil (5-FU) is known to cause toxicity, such as erythema, pain, and crusting/erosions. OBJECTIVES We sought to develop a scale to measure this toxicity and test the scale for reliability. METHODS A scale was developed involving four parameters: erythema severity, percentage of face involved in erythema, crusting/erosions severity, and percentage of face involved in crusting/erosions. Thirteen raters graded 99 sets of photographs from the Veterans Affairs Keratinocyte Carcinoma Chemoprevention (VAKCC) Trial using these parameters. RESULTS Intraclass correlation overall for 13 raters was 0.82 (95% CI 0.77-0.86). There was no statistically significant trend in reliability by level of training in dermatology. CONCLUSIONS This scale is a reliable method of evaluating the severity of toxicity from topical 5-fluorouracil and can be used by dermatologists and nondermatologists alike.
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Affiliation(s)
- K.C. Lee
- Dermatoepidemiology Unit; VA Medical Center; Providence RI U.S.A
- Department of Dermatology; Brown University; Providence RI U.S.A
| | - R. Lew
- Department of Veterans Affairs; VA Medical Center; Boston MA U.S.A
| | - M.A. Weinstock
- Dermatoepidemiology Unit; VA Medical Center; Providence RI U.S.A
- Department of Dermatology; Brown University; Providence RI U.S.A
- Department of Epidemiology; Brown University; Providence RI U.S.A
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Thwin SS, Hermes E, Lew R, Barnett P, Liang M, Valley D, Rosenheck R. Assessment of the minimum clinically important difference in quality of life in schizophrenia measured by the Quality of Well-Being Scale and disease-specific measures. Psychiatry Res 2013; 209:291-6. [PMID: 23473656 DOI: 10.1016/j.psychres.2013.01.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 01/11/2013] [Accepted: 01/12/2013] [Indexed: 11/27/2022]
Abstract
This study examines the psychometric properties of the Quality of Well Being Scale (QWB), the Positive and Negative Syndrome Scale (PANSS), the Heinrich-Carpenter Quality of Life Scale (QOLS), and the Lenert PANSS-based utility measure in a cohort of patients with schizophrenia and identifies threshold values of clinically meaningful change using the Clinical Global Impressions scale (CGI), as the anchor. The correlation of these measures at baseline and change at 6 and 12 months post enrollment in a comparative effectiveness trial was evaluated in 350 veterans with schizophrenia or schizoaffective disorder. An equipercentile method was used to estimate the minimum clinically important difference (MCID) for each measure. Effect size of 0.30-0.50 for baseline quality of life associated with inpatient status supported concurrent validity. The QWB was moderately correlated with disease-specific measures. The MCID as detected by the CGI at 6 months was 0.17 for QWB, 0.15 for the Lenert utility score, 1.13 for the QOLS, and 20.2 for the PANSS. These differences were stable at 12 months. The QWB is significantly correlated with disease specific measures of health related quality of life in schizophrenia.
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Affiliation(s)
- Soe Soe Thwin
- VA-Boston Healthcare System, Boston, MA, USA; Boston University, Department of Biostatistics, Boston, MA, USA.
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Kilgarriff A, Charalabopoulou F, Gavrilidou M, Johannessen JB, Khalil S, Johansson Kokkinakis S, Lew R, Sharoff S, Vadlapudi R, Volodina E. Corpus-based vocabulary lists for language learners for nine languages. LANG RESOUR EVAL 2013. [DOI: 10.1007/s10579-013-9251-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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O’Dell JR, Mikuls TR, Taylor T, Ahluwalia V, Brophy M, Warren S, Lew R, Phibbs C, Anis AH, Cannella AC, Kunkel GA, Keystone E. THU0224 Randomized Double-Blind Comparative Effectiveness in RA Patients with Active Disease Despite Methotrexate (MTX): A Comparison of Conventional Disease-Modifying Anti-Rheumatic Drugs with a Biological. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Brooks M, Ajani A, Andrianopoulos N, Duffy S, Clark D, Black A, Lew R, New G, Brennan A, Reid C, Lancefield T, Carroll E, Lefkovits J. Prevalence and Trends in Obesity in a Large Australian PCI Cohort. Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.05.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Yudi M, Andrianopoulos N, Sharma R, Turaga V, Duffy S, Brennan A, Clark D, Yip T, Lew R, Reid C, Ajani A. Clinical Outcomes of Patients with ACS Treated with Prasugrel. Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.05.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fan VS, Gaziano JM, Lew R, Bourbeau J, Adams SG, Leatherman S, Thwin SS, Huang GD, Robbins R, Sriram PS, Sharafkhaneh A, Mador MJ, Sarosi G, Panos RJ, Rastogi P, Wagner TH, Mazzuca SA, Shannon C, Colling C, Liang MH, Stoller JK, Fiore L, Niewoehner DE. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Ann Intern Med 2012; 156:673-83. [PMID: 22586006 DOI: 10.7326/0003-4819-156-10-201205150-00003] [Citation(s) in RCA: 252] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Improving a patient's ability to self-monitor and manage changes in chronic obstructive pulmonary disease (COPD) symptoms may improve outcomes. OBJECTIVE To determine the efficacy of a comprehensive care management program (CCMP) in reducing the risk for COPD hospitalization. DESIGN A randomized, controlled trial comparing CCMP with guideline-based usual care. (ClinicalTrials.gov registration number: NCT00395083) SETTING: 20 Veterans Affairs hospital-based outpatient clinics. PARTICIPANTS Patients hospitalized for COPD in the past year. INTERVENTION The CCMP included COPD education during 4 individual sessions and 1 group session, an action plan for identification and treatment of exacerbations, and scheduled proactive telephone calls for case management. Patients in both the intervention and usual care groups received a COPD informational booklet; their primary care providers received a copy of COPD guidelines and were advised to manage their patients according to these guidelines. Patients were randomly assigned, stratifying by site based on random, permuted blocks of variable size. MEASUREMENTS The primary outcome was time to first COPD hospitalization. Staff blinded to study group performed telephone-based assessment of COPD exacerbations and hospitalizations, and all hospitalizations were blindly adjudicated. Secondary outcomes included non-COPD health care use, all-cause mortality, health-related quality of life, patient satisfaction, disease knowledge, and self-efficacy. RESULTS Of the eligible patients, 209 were randomly assigned to the intervention group and 217 to the usual care group. Citing serious safety concerns, the data monitoring committee terminated the intervention before the trial's planned completion after 426 (44%) of the planned total of 960 patients were enrolled. Mean follow-up was 250 days. When the study was stopped, the 1-year cumulative incidence of COPD-related hospitalization was 27% in the intervention group and 24% in the usual care group (hazard ratio, 1.13 [95% CI, 0.70 to 1.80]; P= 0.62). There were 28 deaths from all causes in the intervention group versus 10 in the usual care group (hazard ratio, 3.00 [CI, 1.46 to 6.17]; P= 0.003). Cause could be assigned in 27 (71%) deaths. Deaths due to COPD accounted for the largest difference: 10 in the intervention group versus 3 in the usual care group (hazard ratio, 3.60 [CI, 0.99 to 13.08]; P= 0.053). LIMITATIONS Available data could not fully explain the excess mortality in the intervention group. Ability to assess the quality of the educational sessions provided by the case managers was limited. CONCLUSION A CCMP in patients with severe COPD had not decreased COPD-related hospitalizations when the trial was stopped prematurely. The CCMP was associated with unanticipated excess mortality, results that differ markedly from similar previous trials. A data monitoring committee should be considered in the design of clinical trials involving behavioral interventions.
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Affiliation(s)
- Vincent S Fan
- Health Services Research and Development Center of Excellence, Veterans Affairs Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA.
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Stanton N, Lew R, Boyle N, Hope RJ, Dyre BP, Bustamante EA. An Implementation of a Graded Deceleration Display in Brake Light Warning Systems. ACTA ACUST UNITED AC 2011. [DOI: 10.1177/1071181311551328] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Rosenheck RA, Krystal JH, Lew R, Barnett PG, Fiore L, Valley D, Thwin SS, Vertrees JE, Liang MH. Long-acting risperidone and oral antipsychotics in unstable schizophrenia. N Engl J Med 2011; 364:842-51. [PMID: 21366475 DOI: 10.1056/nejmoa1005987] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Long-acting injectable risperidone, a second-generation antipsychotic agent, may improve adherence to treatment and outcomes in schizophrenia, but it has not been tested in a long-term randomized trial involving patients with unstable disease. METHODS We randomly assigned patients in the Veterans Affairs (VA) system who had schizophrenia or schizoaffective disorder and who had been hospitalized within the previous 2 years or were at imminent risk for hospitalization to 25 to 50 mg of long-acting injectable risperidone every two weeks or to a psychiatrist's choice of an oral antipsychotic. All patients were followed for up to 2 years. The primary end point was hospitalization in a VA or non-VA psychiatric hospital. Symptoms, quality of life, and functioning were assessed in blinded videoconference interviews. RESULTS Of 369 participants, 40% were hospitalized at randomization, 55% were hospitalized within the previous 2 years, and 5% were at risk for hospitalization. The rate of hospitalization after randomization was not significantly lower among patients who received long-acting injectable risperidone than among those who received oral antipsychotics (39% after 10.8 months vs. 45% after 11.3 months; hazard ratio, 0.87; 95% confidence interval, 0.63 to 1.20). Psychiatric symptoms, quality of life, scores on the Personal and Social Performance scale of global functioning, and neurologic side effects were not significantly improved with long-acting injectable risperidone as compared with control treatments. Patients who received long-acting injectable risperidone reported more adverse events at the injection site and more extrapyramidal symptoms. CONCLUSIONS Long-acting injectable risperidone was not superior to a psychiatrist's choice of oral treatment in patients with schizophrenia and schizoaffective disorder who were hospitalized or at high risk for hospitalization, and it was associated with more local injection-site and extrapyramidal adverse effects. (Supported by the VA Cooperative Studies Program and Ortho-McNeil Janssen Scientific Affairs; ClinicalTrials.gov number, NCT00132314.).
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Affiliation(s)
- Robert A Rosenheck
- Veterans Affairs (VA) New England Mental Illness, Research Education and Clinical Center, VA Connecticut Healthcare System, West Haven, CT 06516, USA.
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Rosenheck RA, Krystal JH, Lew R, Barnett PG, Thwin SS, Fiore L, Valley D, Huang GD, Neal C, Vertrees JE, Liang MH. Challenges in the design and conduct of controlled clinical effectiveness trials in schizophrenia. Clin Trials 2011; 8:196-204. [PMID: 21270143 DOI: 10.1177/1740774510392931] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The introduction of antipsychotic medication has been a major advance in the treatment of schizophrenia and allows millions of people to live outside of institutions. It is generally believed that long-acting intramuscular antipsychotic medication is the most effective approach to increasing medication adherence and thereby reduce relapse in high-risk patients with schizophrenia, but the data are scant. PURPOSE To report the design of a study to assess the effect of long-acting injectable risperidone in unstable patients and under more realistic conditions than previously studied and to evaluate the effect of this medication on psychiatric inpatient hospitalization, schizophrenia symptoms, quality of life, medication adherence, side effects, and health care costs. METHODS The trial was an open randomized clinical comparative effectiveness trial in patients with schizophrenia or schizo-affective disorders in which parenteral risperidone was compared to an oral antipsychotic regimen selected by each control patient's psychiatrist. Participants had unstable psychiatric disease defined by recent hospitalization or exhibition of unusual need for psychiatric services. The primary endpoint was hospitalization for psychiatric indications; the secondary endpoint was psychiatric symptoms. RESULTS Overall, 382 patients were randomized. Determination of a persons' competency to understand the elements of informed consent was addressed. The use of a closed-circuit TV interview for psychosocial measures provided an economical, high quality, reliable means of collecting data. A unique method for insuring that usual care was optimal was incorporated in the follow-up of all subjects. LIMITATIONS Patients with schizophrenia or schizo-affective disorders and with the common co-morbid illnesses seen in the VA are a challenging group of subjects to study in long-term trials. Some techniques unique in the VA and found useful may not be generalizable or applicable in other research or treatment settings. CONCLUSIONS The trial tested a new antipsychotic medication early in its adoption in the Veterans Health Administration. The VA has a unique electronic medical record and database which can be used to identify the endpoint, that is, first hospitalization due to a psychiatric problem, with complete ascertainment. Several methodologic solutions addressed competency to understand elements of consent, the costs and reliability of collecting interview data gathering, and insuring usual care.
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Affiliation(s)
- Robert A Rosenheck
- Veterans Affairs (VA) Connecticut Healthcare System, West Haven, CT, USA.
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Moy ML, Reilly JJ, Ries AL, Mosenifar Z, Kaplan RM, Lew R, Garshick E. Multivariate models of determinants of health-related quality of life in severe chronic obstructive pulmonary disease. ACTA ACUST UNITED AC 2010; 46:643-54. [PMID: 19882497 DOI: 10.1682/jrrd.2008.09.0127] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Persons with severe chronic obstructive pulmonary disease (COPD) and similar levels of forced expiratory volume in 1 second (FEV(1)), exercise capacity, and dyspnea have a wide range of health-related quality of life (HRQL). We identified the independent determinants of HRQL in persons with COPD. Comprehensive assessments of physiological, psychosocial, and clinical variables from the National Emphysema Treatment Trial were used. HRQL was assessed by the Medical Outcomes Study 36-Item Short Form Physical Component Summary (PCS) and Mental Component Summary (MCS) scores and the St. George's Respiratory Questionnaire total score (SGRQ-TS). In multivariate linear regression models, exercise capacity, dyspnea, age, single-breath diffusing capacity of the lung for carbon monoxide percent predicted, and self-report of being disabled were significant determinants of PCS score. Dyspnea, depression, antidepressant use, daytime sleepiness, and education were significant determinants of MCS score. Prior participation in pulmonary rehabilitation, supplemental oxygen use, and oral corticosteroid use were significant determinants of SGRQ-TS. Although FEV(1), 6-minute walk test distance, and dyspnea significantly correlated with HRQL, their effects on HRQL were reduced when other variables were considered. Greater exercise capacity, prior participation in pulmonary rehabilitation, and use of supplemental oxygen were significantly associated with better HRQL. Self-perception of being disabled, (Abstract continued) depression, dyspnea, oral corticosteroid use, and daytime sleepiness were associated with worse HRQL. To optimize HRQL, clinicians should pay attention to a number of clinical and physiological factors.
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Affiliation(s)
- Marilyn L Moy
- Department of Veteran Affairs (VA), Veterans Health Administration, Rehabilitation Research and Development Service, Boston, MA, USA.
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Burdi DF, Hunt R, Fan L, Hu T, Wang J, Guo Z, Huang Z, Wu C, Hardy L, Detheux M, Orsini MA, Quinton MS, Lew R, Spear K. Design, synthesis, and structure-activity relationships of novel bicyclic azole-amines as negative allosteric modulators of metabotropic glutamate receptor 5. J Med Chem 2010; 53:7107-18. [PMID: 20809633 DOI: 10.1021/jm100736h] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A novel series of diaryl bicyclic azole-amines that are potent selective negative modulators of metabotropic glutamate receptor 5 (mGluR5) were identified through rational design. An initial hit compound 5a of modest potency (IC(50) = 1.2 μM) was synthesized. Evaluation of structure-activity relationships (SAR) on the left-hand side of the molecule revealed a preference for a 2-substituted pyridine group linked directly to the central heterocycle. Variation of the central azolo-amine portion of the molecule revealed a preference for the [4,5-c]-oxazoloazepine scaffold, while right-hand side variants showed a preference for ortho- and meta-substituted benzene rings linked directly to the tertiary amine of the saturated heterocycle. These iterations led to the synthesis of 29b, a potent (IC(50) = 16 nM) and selective negative modulator that showed good brain penetrance, high receptor occupancy, and a duration of action greater than 1 h in rat when administered intraperitoneally. Formal PK studies in rat and Rhesus monkey revealed a short half-life that was attributable to high first-pass clearance.
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Affiliation(s)
- Douglas F Burdi
- Discovery & Early Clinical Research, Sepracor Inc., 84 Waterford Drive, Marlborough, Massachusetts 01752, USA.
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Dyre BP, Lew R. Environmental modulations of visually-induced steering errors resulting from non-rigid transparent optical flow. J Vis 2010. [DOI: 10.1167/8.6.1159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Yan B, Ajani A, Andrianopoulos N, Duffy S, Clark D, Brennan A, Loane P, Sebastian M, New G, Lew R, Reid C. Recent Trends in Percutaenous Coronary Intervention Practise in Victorian Public Hospitals: Insights from the Melbourne Interventional Group Registry. Heart Lung Circ 2010. [DOI: 10.1016/j.hlc.2010.06.746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Zivin JA, Albers GW, Bornstein N, Chippendale T, Dahlof B, Devlin T, Fisher M, Hacke W, Holt W, Ilic S, Kasner S, Lew R, Nash M, Perez J, Rymer M, Schellinger P, Schneider D, Schwab S, Veltkamp R, Walker M, Streeter J. Effectiveness and safety of transcranial laser therapy for acute ischemic stroke. Stroke 2009; 40:1359-64. [PMID: 19233936 DOI: 10.1161/strokeaha.109.547547] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE We hypothesized that transcranial laser therapy (TLT) can use near-infrared laser technology to treat acute ischemic stroke. The NeuroThera Effectiveness and Safety Trial-2 (NEST-2) tested the safety and efficacy of TLT in acute ischemic stroke. METHODS This double-blind, randomized study compared TLT treatment to sham control. Patients receiving tissue plasminogen activator and patients with evidence of hemorrhagic infarct were excluded. The primary efficacy end point was a favorable 90-day score of 0 to 2 assessed by the modified Rankin Scale. Other 90-day end points included the overall shift in modified Rankin Scale and assessments of change in the National Institutes of Health Stroke Scale score. RESULTS We randomized 660 patients: 331 received TLT and 327 received sham; 120 (36.3%) in the TLT group achieved favorable outcome versus 101 (30.9%), in the sham group (P=0.094), odds ratio 1.38 (95% CI, 0.95 to 2.00). Comparable results were seen for the other outcome measures. Although no prespecified test achieved significance, a post hoc analysis of patients with a baseline National Institutes of Health Stroke Scale score of <16 showed a favorable outcome at 90 days on the primary end point (P<0.044). Mortality rates and serious adverse events did not differ between groups with 17.5% and 17.4% mortality, 37.8% and 41.8% serious adverse events for TLT and sham, respectively. CONCLUSIONS TLT within 24 hours from stroke onset demonstrated safety but did not meet formal statistical significance for efficacy. However, all predefined analyses showed a favorable trend, consistent with the previous clinical trial (NEST-1). Both studies indicate that mortality and adverse event rates were not adversely affected by TLT. A definitive trial with refined baseline National Institutes of Health Stroke Scale exclusion criteria is planned.
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Affiliation(s)
- Justin A Zivin
- Department of Neurosciences, University of California San Diego, San Diego, CA 92161, USA.
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Abstract
The use of tissue plasminogen activator in ischemic stroke is controversial. Many practicing physicians believe that its usefulness is established, while others, including professional specialty societies, are less sanguine. A review of the literature appears to show that the use of tissue plasminogen activator is efficacious and can result in highly improved outcomes for a majority of eligible patients. These findings may implicate important potential legal issues. Informed consent concerns and, potentially, medical malpractice claims may result, particularly in the context of evidence-based practice, pay for performance, and the currently limited use of tissue plasminogen activator for eligible patients.
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Affiliation(s)
- Bryan A Liang
- Institute of Health Law Studies, California Western School of Law, San Diego, CA 92101, USA.
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Yan BP, Ajani AE, New G, Duffy SJ, Farouque O, Shaw J, Sebastian M, Lew R, Brennan A, Andrianopoulos N, Reid C, Clark DJ. Are drug-eluting stents indicated in large coronary arteries? Insights from a multi-centre percutaneous coronary intervention registry. Int J Cardiol 2008; 130:374-9. [DOI: 10.1016/j.ijcard.2008.06.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 06/11/2008] [Accepted: 06/28/2008] [Indexed: 11/16/2022]
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Ajani AE, Reid CM, Duffy SJ, Andrianopoulos N, Lefkovits J, Black A, New G, Lew R, Shaw JA, Yan BP, Gurvitch R, Al‐Fiadh A, Brennan AL, Clark DJ. Outcomes after percutaneous coronary intervention in contemporary Australian practice: insights from a large multicentre registry. Med J Aust 2008; 189:423-8. [DOI: 10.5694/j.1326-5377.2008.tb02113.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Accepted: 05/08/2008] [Indexed: 11/17/2022]
Affiliation(s)
- Andrew E Ajani
- Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC
| | - Christopher M Reid
- Centre for Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC
| | | | - Nick Andrianopoulos
- Centre for Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC
| | - Jeffrey Lefkovits
- Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC
| | | | | | | | | | - Bryan P Yan
- Massachusetts General Hospital and Harvard Medical School, Boston, Mass, USA
| | - Ronen Gurvitch
- Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC
| | | | - Angela L Brennan
- Centre for Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC
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Yan BP, Duffy SJ, Clark DJ, Lefkovits J, Warren R, Gurvitch R, Lew R, Sebastian M, Brennan A, Andrianopoulos N, Reid CM, Ajani AE. Rates of stent thrombosis in bare-metal versus drug-eluting stents (from a large Australian multicenter registry). Am J Cardiol 2008; 101:1716-22. [PMID: 18549846 DOI: 10.1016/j.amjcard.2008.02.058] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 02/13/2008] [Accepted: 02/13/2008] [Indexed: 11/27/2022]
Abstract
Recent reports suggest that drug-eluting stents (DESs) may increase the risk of stent thrombosis (ST) relative to bare-metal stents (BMSs). Therefore, the aim of this study was to compare DES and BMS outcomes with a specific focus on ST. We analyzed 30-day and 1-year outcomes of 2,919 patients who underwent percutaneous coronary intervention with stent implantation from the Melbourne Interventional Group registry. Academic Research Consortium definitions of ST were used: (1) definite ST (confirmed using angiography in patients with an acute coronary syndrome), (2) probable ST (unexplained death <30 days or target-vessel myocardial infarction without angiographic confirmation), and (3) possible ST (unexplained death >30 days). Multivariate analysis was performed to identify predictors of ST. The incidence of ST (early or late) was similar between BMSs and DESs (1.6% vs 1.4%; p=0.66), and DES use was not predictive of ST. Independent predictors of ST included the absence of clopidogrel therapy at 30 days (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.29 to 5.29, p<0.01), renal failure (OR 3.30, 95% CI 1.43 to 7.59, p<0.01), index procedure presentation with an acute coronary syndrome (OR 2.59, 95% CI 1.14 to 5.87, p=0.02), diabetes mellitus (OR 2.25, 95% CI 1.19 to 4.23, p=0.01), and total stent length >or=20 mm (OR 1.85, 95% CI 1.00 to 3.42, p=0.04). In conclusion, DESs were not associated with increased risk of ST compared with BMSs at 12 months in this large Australian registry that selectively used DESs for patients at high risk of restenosis.
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Lew R. Drug development for sleep therapeutics - A Marcus Evans conference. IDrugs 2008; 11:245-249. [PMID: 18379954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Robert Lew
- Sepracor Inc, 84 Waterford Drive, Marlborough, Massachusetts 01752-7010, USA.
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Aithal J, Rahman M, Andrianopoulos N, Duplessis T, Dyson J, New G, Eccleston D, Lew R, Al-Daher S, Yip T, Black A, Sebastian M. First Australian Experience of an Endothelial Progenitor Cell (EPC) Capture Stent: Insights from a Multicentre Registry. Heart Lung Circ 2008. [DOI: 10.1016/j.hlc.2008.05.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Savitz SI, Lew R, Bluhmki E, Hacke W, Fisher M. Shift analysis versus dichotomization of the modified Rankin scale outcome scores in the NINDS and ECASS-II trials. Stroke 2007; 38:3205-12. [PMID: 17975102 DOI: 10.1161/strokeaha.107.489351] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The SAINT I trial that showed a significant benefit of the neuroprotectant NXY-059 used a novel outcome for acute ischemic stroke trials: a shift toward good functional outcome on the 7-category modified Rankin scale (mRS). METHODS We used the Cochran-Mantel-Haenszel shift test to analyze the distribution of the 90-day mRS outcomes in the NINDS and ECASS-II databases and compared the results with a dichotomized mRS outcome by logistic regression (0 to 2 vs 3 to 6, or 0 to 1 vs 2 to 6). We also stratified each dataset based on National Institutes of Health Stroke Scale baseline severity. RESULTS Each dataset showed a statistically significant shift in the 90-day mRS distributions favoring tissue plasminogen activator (odds ratio, 1.6 for NINDS, 1.3 for ECASS-II). For ECASS-II, larger shift effects appeared in National Institutes of Health Stroke Scale 0 to 6 and 16 to 40 strata. Similarly, the mRS 0 to 2 analysis but not mRS 0 to 1 found similar treatment effects in both datasets (odds ratio, 1.6 for NINDS, 1.5 for ECASS-II) and similar variations in the low and high strata in the ECASS-II trial. NINDS found no significant treatment effects across the strata. After removing the strata at the fringes, the shift test lost significance in both datasets. CONCLUSIONS Tissue plasminogen activator causes a beneficial shift toward wellness on the mRS in both the NINDS and ECASS-II trials, and ECASS-II would have been a positive trial according to the shift approach. However, the shift effect is not global for all treated patients and does not outperform the dichotomized 0 to 2 outcome. Patients with mild and severe deficits also shifted favorably on the mRS in the ECASS-II trial.
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Affiliation(s)
- Sean I Savitz
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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