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Hull MA, Ow PL, Ruddock S, Brend T, Smith AF, Marshall H, Song M, Chan AT, Garrett WS, Yilmaz O, Drew DA, Collinson F, Cockbain AJ, Jones R, Loadman PM, Hall PS, Moriarty C, Cairns DA, Toogood GJ. Randomised, placebo-controlled, phase 3 trial of the effect of the omega-3 polyunsaturated fatty acid eicosapentaenoic acid (EPA) on colorectal cancer recurrence and survival after surgery for resectable liver metastases: EPA for Metastasis Trial 2 (EMT2) study protocol. BMJ Open 2023; 13:e077427. [PMID: 38030258 PMCID: PMC10689403 DOI: 10.1136/bmjopen-2023-077427] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION There remains an unmet need for safe and cost-effective adjunctive treatment of advanced colorectal cancer (CRC). The omega-3 polyunsaturated fatty acid eicosapentaenoic acid (EPA) is safe, well-tolerated and has anti-inflammatory as well as antineoplastic properties. A phase 2 randomised trial of preoperative EPA free fatty acid 2 g daily in patients undergoing surgery for CRC liver metastasis showed no difference in the primary endpoint (histological tumour proliferation index) compared with placebo. However, the trial demonstrated possible benefit for the prespecified exploratory endpoint of postoperative disease-free survival. Therefore, we tested the hypothesis that EPA treatment, started before liver resection surgery (and continued postoperatively), improves CRC outcomes in patients with CRC liver metastasis. METHODS AND ANALYSIS The EPA for Metastasis Trial 2 trial is a randomised, double-blind, placebo-controlled, phase 3 trial of 4 g EPA ethyl ester (icosapent ethyl (IPE; Vascepa)) daily in patients undergoing liver resection surgery for CRC liver metastasis with curative intent. Trial treatment continues for a minimum of 2 years and maximum of 4 years, with 6 monthly assessments, including quality of life outcomes, as well as annual clinical record review after the trial intervention. The primary endpoint is CRC progression-free survival. Key secondary endpoints are overall survival, as well as the safety and tolerability of IPE. A minimum 388 participants are estimated to provide 247 CRC progression events during minimum 2-year follow-up, allowing detection of an HR of 0.7 in favour of IPE, with a power of 80% at the 5% (two sided) level of significance, assuming drop-out of 15%. ETHICS AND DISSEMINATION Ethical and health research authority approval was obtained in January 2018. All data will be collected by 2025. Full trial results will be published in 2026. Secondary analyses of health economic data, biomarker studies and other translational work will be published subsequently. TRIAL REGISTRATION NUMBER NCT03428477.
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Affiliation(s)
- Mark A Hull
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Pei Loo Ow
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sharon Ruddock
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Tim Brend
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Alexandra F Smith
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Helen Marshall
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Mingyang Song
- Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wendy S Garrett
- Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Omer Yilmaz
- Koch Institute for Integrative Cancer Research at Massachusetts Institute of Technology, Boston, Massachusetts, USA
| | - David A Drew
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fiona Collinson
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Robert Jones
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Paul M Loadman
- Institute of Cancer Therapeutics, University of Bradford, Bradford, UK
| | - Peter S Hall
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | | | - David A Cairns
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Giles J Toogood
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Hall PS, Swinson D, Cairns DA, Waters JS, Petty R, Allmark C, Ruddock S, Falk S, Wadsley J, Roy R, Tillett T, Nicoll J, Cummins S, Mano J, Grumett S, Stokes Z, Kamposioras KV, Chatterjee A, Garcia A, Waddell T, Guptal K, Maisey N, Khan M, Dent J, Lord S, Crossley A, Katona E, Marshall H, Grabsch HI, Velikova G, Ow PL, Handforth C, Howard H, Seymour MT. Efficacy of Reduced-Intensity Chemotherapy With Oxaliplatin and Capecitabine on Quality of Life and Cancer Control Among Older and Frail Patients With Advanced Gastroesophageal Cancer: The GO2 Phase 3 Randomized Clinical Trial. JAMA Oncol 2021; 7:869-877. [PMID: 33983395 PMCID: PMC8120440 DOI: 10.1001/jamaoncol.2021.0848] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/04/2021] [Indexed: 01/10/2023]
Abstract
Importance Older and/or frail patients are underrepresented in landmark cancer trials. Tailored research is needed to address this evidence gap. Objective The GO2 randomized clinical trial sought to optimize chemotherapy dosing in older and/or frail patients with advanced gastroesophageal cancer, and explored baseline geriatric assessment (GA) as a tool for treatment decision-making. Design, Setting, and Participants This multicenter, noninferiority, open-label randomized trial took place at oncology clinics in the United Kingdom with nurse-led geriatric health assessment. Patients were recruited for whom full-dose combination chemotherapy was considered unsuitable because of advanced age and/or frailty. Interventions There were 2 randomizations that were performed: CHEMO-INTENSITY compared oxaliplatin/capecitabine at Level A (oxaliplatin 130 mg/m2 on day 1, capecitabine 625 mg/m2 twice daily on days 1-21, on a 21-day cycle), Level B (doses 0.8 times A), or Level C (doses 0.6 times A). Alternatively, if the patient and clinician agreed the indication for chemotherapy was uncertain, the patient could instead enter CHEMO-BSC, comparing Level C vs best supportive care. Main Outcomes and Measures First, broad noninferiority of the lower doses vs reference (Level A) was assessed using a permissive boundary of 34 days reduction in progression-free survival (PFS) (hazard ratio, HR = 1.34), selected as acceptable by a forum of patients and clinicians. Then, the patient experience was compared using Overall Treatment Utility (OTU), which combines efficacy, toxic effects, quality of life, and patient value/acceptability. For CHEMO-BSC, the main outcome measure was overall survival. Results A total of 514 patients entered CHEMO-INTENSITY, of whom 385 (75%) were men and 299 (58%) were severely frail, with median age 76 years. Noninferior PFS was confirmed for Levels B vs A (HR = 1.09 [95% CI, 0.89-1.32]) and C vs A (HR = 1.10 [95% CI, 0.90-1.33]). Level C produced less toxic effects and better OTU than A or B. No subgroup benefited from higher doses: Level C produced better OTU even in younger or less frail patients. A total of 45 patients entered the CHEMO-BSC randomization: overall survival was nonsignificantly longer with chemotherapy: median 6.1 vs 3.0 months (HR = 0.69 [95% CI, 0.32-1.48], P = .34). In multivariate analysis in 522 patients with all variables available, baseline frailty, quality of life, and neutrophil to lymphocyte ratio were independently associated with OTU, and can be combined in a model to estimate the probability of different outcomes. Conclusions and Relevance This phase 3 randomized clinical trial found that reduced-intensity chemotherapy provided a better patient experience without significantly compromising cancer control and should be considered for older and/or frail patients. Baseline geriatric assessment can help predict the utility of chemotherapy but did not identify a group benefiting from higher-dose treatment. Trial Registration isrctn.org Identifier: ISRCTN44687907.
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Affiliation(s)
- Peter S. Hall
- University of Leeds, Leeds, United Kingdom
- University of Edinburgh, Edinburgh, United Kingdom
| | - Daniel Swinson
- Leeds Teaching Hospitals National Health Service Trust, United Kingdom
| | | | - Justin S. Waters
- Maidstone and Tunbridge Wells National Health Service Trust, Maidstone, United Kingdom
| | | | | | | | - Stephen Falk
- Bristol Oncology Centre, Bristol, United Kingdom
| | | | - Rajarshi Roy
- Hull University Hospitals National Health Service Trust, Hull, United Kingdom
| | | | - Jonathan Nicoll
- North Cumbria University Hospitals National Health Service Trust, Carlisle, United Kingdom
| | - Sebastian Cummins
- Royal Surrey County Hospital National Health Service Foundation Trust, Guildford, United Kingdom
| | - Joseph Mano
- The Royal Wolverhampton National Health Service Trust, Wolverhampton, United Kingdom
| | - Simon Grumett
- The Dudley Group National Health Service Foundation Trust, Dudley, United Kingdom
| | - Zuzana Stokes
- United Lincolnshire Hospitals National Health Service Trust, Lincoln, United Kingdom
| | | | - Anirban Chatterjee
- The Shrewsbury and Telford Hospital National Health Service Trust, Shrewsbury, United Kingdom
| | - Angel Garcia
- Betsi Cadwaladr University Local Health Board, Bangor, United Kingdom
| | - Tom Waddell
- The Christie National Health Service Foundation Trust, Manchester, United Kingdom
| | - Kamalnayan Guptal
- Worcestershire Acute Hospitals National Health Service Trust, Worcester, United Kingdom
| | - Nick Maisey
- Guys and St Thomas’s National Health Service Foundation Trust, London, United Kingdom
| | - Mohammed Khan
- York Teaching Hospital National Health Service Foundation Trust, Scarborough, United Kingdom
| | - Jo Dent
- Calderdale and Huddersfield National Health Service Foundation Trust, Huddersfield, United Kingdom
| | - Simon Lord
- University of Oxford, Oxford, United Kingdom
| | - Ann Crossley
- Leeds Teaching Hospitals National Health Service Trust, United Kingdom
| | | | | | - Heike I. Grabsch
- University of Leeds, Leeds, United Kingdom
- Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Pei Loo Ow
- University of Leeds, Leeds, United Kingdom
| | | | | | - Matthew T. Seymour
- University of Leeds, Leeds, United Kingdom
- Leeds Teaching Hospitals National Health Service Trust, United Kingdom
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Ford GA, Bhakta BB, Cozens A, Hartley S, Holloway I, Meads D, Pearn J, Ruddock S, Sackley CM, Saloniki EC, Santorelli G, Walker MF, Farrin AJ. Safety and efficacy of co-careldopa as an add-on therapy to occupational and physical therapy in patients after stroke (DARS): a randomised, double-blind, placebo-controlled trial. Lancet Neurol 2020; 18:530-538. [PMID: 31122493 PMCID: PMC6527868 DOI: 10.1016/s1474-4422(19)30147-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/20/2018] [Accepted: 03/21/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Dopamine is a key modulator of striatal function and learning and might improve motor recovery after stroke. Previous small trials of dopamine agonists after stroke provide equivocal evidence of effectiveness on improving motor recovery. We aimed to assess the safety and efficacy of co-careldopa plus routine occupational and physical therapy during early rehabilitation after stroke. METHODS This double-blind, multicentre, randomised controlled trial of co-careldopa versus placebo in addition to routine NHS occupational and physical therapy was done at 51 UK NHS acute inpatient stroke rehabilitation services. We recruited patients with new or recurrent clinically diagnosed ischaemic or haemorrhagic (excluding subarachnoid haemorrhage) stroke 5-42 days before randomisation, who were unable to walk 10 m or more, had a score of less than 7 points on the Rivermead Mobility Index, were expected to need rehabilitation, and were able to access rehabilitation after discharge from hospital. Participants were assigned (1:1) using stratified random blocks to receive 6 weeks of oral co-careldopa or matched placebo in addition to routine NHS physiotherapy and occupational therapy. The initial two doses of co-careldopa were 62·5 mg (50 mg of levodopa and 12·5 mg of carbidopa) and the remaining doses were 125 mg (100 mg of levodopa and 25 mg of carbidopa). Participants were required to take a single oral tablet 45-60 min before physiotherapy or occupational therapy session. The primary outcome was ability to walk independently, defined as a Rivermead Mobility Index score of 7 or more, at 8 weeks. Primary and safety analyses were done in the intention-to-treat population. The trial is registered on the ISRCTN registry, number ISRCTN99643613. FINDINGS Between May 30, 2011, and March 28, 2014, of 1574 patients found eligible, 593 (mean age 68·5 years) were randomly assigned to either the co-careldopa group (n=308) or to the placebo group (n=285), on an average 18 days after stroke onset. Primary outcome data were available for all 593 patients. We found no evidence that the ability to walk independently improved with co-careldopa (125 [41%] of 308 patients) compared with placebo (127 [45%] of 285 patients; odds ratio 0·78 [95% CI 0·53-1·15]) at 8 weeks. Mortality at 12 months did not differ between the two groups (22 [7%] vs 17 [6%]). Serious adverse events were largely similar between groups. Vomiting during therapy sessions, after taking the study drug, was the most frequent adverse event and was more frequent in the co-careldopa group than the placebo group (19 [6·2%] vs 9 [3·2%]). INTERPRETATION Co-careldopa in addition to routine occupational and physical therapy does not seem to improve walking after stroke. Further research might identify subgroups of patients with stroke who could benefit from dopaminergic therapy at different doses or times after stroke with more intensive motor therapy. FUNDING Medical Research Council.
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Affiliation(s)
- Gary A Ford
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK.
| | - Bipin B Bhakta
- The Academic Department of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | | | - Suzanne Hartley
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ivana Holloway
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - John Pearn
- The Academic Department of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Sharon Ruddock
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Catherine M Sackley
- School of Population and Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Eirini-Christina Saloniki
- Centre for Health Services Studies and Personal Social Services Research Unit, University of Kent, Canterbury, UK
| | - Gillian Santorelli
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Marion F Walker
- Rehabilitation and Ageing, Queens Medical Centre, University of Nottingham, Nottingham, UK
| | - Amanda J Farrin
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Davidson B, Gurusamy K, Corrigan N, Croft J, Ruddock S, Pullan A, Brown J, Twiddy M, Birtwistle J, Morris S, Woodward N, Bandula S, Hochhauser D, Prasad R, Olde Damink S, Coolson M, Laarhoven KV, de Wilt JH. Liver resection surgery compared with thermal ablation in high surgical risk patients with colorectal liver metastases: the LAVA international RCT. Health Technol Assess 2020; 24:1-38. [PMID: 32370822 DOI: 10.3310/hta24210] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 02/06/2023] Open
Abstract
BACKGROUND Although surgical resection has been considered the only curative option for colorectal liver metastases, thermal ablation has recently been suggested as an alternative curative treatment. There have been no adequately powered trials comparing surgery with thermal ablation. OBJECTIVES Main objective - to compare the clinical effectiveness and cost-effectiveness of thermal ablation versus liver resection surgery in high surgical risk patients who would be eligible for liver resection. Pilot study objectives - to assess the feasibility of recruitment (through qualitative study), to assess the quality of ablations and liver resection surgery to determine acceptable standards for the main trial and to centrally review the reporting of computed tomography scan findings relating to ablation and outcomes and recurrence rate in both arms. DESIGN A prospective, international (UK and the Netherlands), multicentre, open, pragmatic, parallel-group, randomised controlled non-inferiority trial with a 1-year internal pilot study. SETTING Tertiary liver, pancreatic and gallbladder (hepatopancreatobiliary) centres in the UK and the Netherlands. PARTICIPANTS Adults with a specialist multidisciplinary team diagnosis of colorectal liver metastases who are at high surgical risk because of their age, comorbidities or tumour burden and who would be suitable for liver resection or thermal ablation. INTERVENTIONS Thermal ablation conducted as per local policy (but centres were encouraged to recruit within Cardiovascular and Interventional Radiological Society of Europe guidelines) versus surgical liver resection performed as per centre protocol. MAIN OUTCOME MEASURES Pilot study - patients' and clinicians' acceptability of the trial to assist in optimisation of recruitment. Primary outcome - disease-free survival at 2 years post randomisation. Secondary outcomes - overall survival, timing and site of recurrence, additional therapy after treatment failure, quality of life, complications, length of hospital stay, costs, trial acceptability, and disease-free survival measured from end of intervention. It was planned that 5-year survival data would be documented through record linkage. Randomisation was performed by minimisation incorporating a random element, and this was a non-blinded study. RESULTS In the pilot study over 1 year, a total of 366 patients with colorectal liver metastases were screened and 59 were considered eligible. Only nine participants were randomised. The trial was stopped early and none of the planned statistical analyses was performed. The key issues inhibiting recruitment included fewer than anticipated patients eligible for both treatments, misconceptions about the eligibility criteria for the trial, surgeons' preference for one of the treatments ('lack of clinical equipoise' among some of the surgeons in the centre) with unconscious bias towards surgery, patients' preference for one of the treatments, and lack of dedicated research nurses for the trial. CONCLUSIONS Recruitment feasibility was not demonstrated during the pilot stage of the trial; therefore, the trial closed early. In future, comparisons involving two very different treatments may benefit from an initial feasibility study or a longer period of internal pilot study to resolve these difficulties. Sufficient time should be allowed to set up arrangements through National Institute for Health Research (NIHR) Research Networks. TRIAL REGISTRATION Current Controlled Trials ISRCTN52040363. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 21. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Brian Davidson
- Royal Free Campus, Division of Surgery and Interventional Science, University College London, London, UK
| | - Kurinchi Gurusamy
- Royal Free Campus, Division of Surgery and Interventional Science, University College London, London, UK
| | - Neil Corrigan
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Julie Croft
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sharon Ruddock
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Alison Pullan
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Julia Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Maureen Twiddy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,Institute of Clinical and Applied Health Research, Faculty of Health Science, University of Hull, Hull, UK
| | | | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | | | | | | | - Raj Prasad
- Surgery and Transplantation, Leeds Teaching Hospital, Leeds, UK
| | | | - Marielle Coolson
- General Surgery, Maastricht University, Maastricht, the Netherlands
| | - K van Laarhoven
- Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
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Swinson D, Hall P, Lord S, Marshall H, Ruddock S, Allmark C, Cairns D, Waters J, Wadsley J, Falk S, Roy R, Joseph M, Nicoll J, Kamposioras K, Tillett T, Cummins S, Grumett S, Stokes Z, Waddell T, Chatterjee A, Garcia A, Khan M, Petty R, Seymour M. OPTIMIZING CHEMOTHERAPY FOR FRAIL AND/OR ELDERLY PATIENTS WITH ADVANCED GASTROESOPHAGEAL CANCER (AGOAC): THE GO2 PHASE III TRIAL. J Geriatr Oncol 2019. [DOI: 10.1016/s1879-4068(19)31133-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ruddock-hudson M, Ruddock S, Rahimi S. Blowing the whistle on mental health and wellbeing: The experiences of Australian Football League Umpires. J Sci Med Sport 2019. [DOI: 10.1016/j.jsams.2019.08.140] [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: 10/25/2022]
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Harrison C, Ruddock-Hudson M, Ruddock S, Mayes S, O’Halloran P, Cook J. Wellness monitoring in Professional Ballet Dancers: A pilot study. J Sci Med Sport 2019. [DOI: 10.1016/j.jsams.2019.08.097] [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: 10/25/2022]
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Ruddock S, Rahimi-Golkhanden S, Ruddock-Hudson M, Wollersheim D. Tracking the mental health outcomes of occupational burnout with Australian Rules Football coaches: A 2-year longitudinal study. J Sci Med Sport 2019. [DOI: 10.1016/j.jsams.2019.08.241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Nowotny BM, Basnayake S, Lorenz K, Hall J, Ruddock S, Fennessy G, Cox E, Hodges R, Loh E, Wallace EM. Using medico-legal claims for quality improvement in maternity care: application and revision of an NHSLA coding taxonomy. BJOG 2019; 126:1437-1444. [PMID: 31131503 DOI: 10.1111/1471-0528.15823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To validate the NHSLA maternity claims taxonomy at the level of a single maternity service and assess its ability to direct quality improvement. DESIGN Qualitative descriptive study. SETTING Medico-legal claims between 1 January 2000 and 31 December 2016 from a maternity service in metropolitan Melbourne, Australia. POPULATION All obstetric claims and incident notifications occurring within the date range were included for analysis. METHODS De-identified claims and notifications data were derived from the files of the insurer of Victorian public health services. Data included claim date, incident date and summary, and claim cost. All reported issues were coded using the NHSLA taxonomy and the lead issue identified. MAIN OUTCOME MEASURES Rate of claims and notifications, relative frequency of issues, a revised taxonomy. RESULTS A combined total of 265 claims and incidents were reported during the 6 years. Of these 59 were excluded, leaving 198 medico-legal events for analysis (1.66 events/1000 births). The costs for all claims was $46.7 million. The most common claim issues were related to management of labour (n = 63, $17.7 million), cardiotocographic interpretation (n = 43, $24.4 million), and stillbirth (n = 35, $656,750). The original NHSLA classification was not sufficiently detailed to inform care improvement programmes. A revised taxonomy and coding flowchart is presented. CONCLUSIONS Systematic analysis of obstetric medico-legal claims data can potentially be used to inform quality and safety improvement. TWEETABLE ABSTRACT New taxonomy to target health improvement from maternity claims based on NHSLA Ten Years of Maternity Claims.
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Affiliation(s)
- B M Nowotny
- Department of Obstetrics and Gynaecology, School of Clinical Sciences, The Ritchie Centre, Monash University, Clayton, Vic., Australia.,Safer Care Victoria, Victorian Department of Health and Human Services, Melbourne, Vic., Australia
| | | | - K Lorenz
- Victorian Bar, Melbourne, Vic., Australia
| | - J Hall
- Maryborough District Health Service, Maryborough, Vic., Australia
| | - S Ruddock
- Monash Health, Clayton, Vic., Australia
| | - G Fennessy
- Victorian Managed Insurance Authority, Melbourne, Vic., Australia
| | - E Cox
- Victorian Managed Insurance Authority, Melbourne, Vic., Australia
| | - R Hodges
- Department of Obstetrics and Gynaecology, School of Clinical Sciences, The Ritchie Centre, Monash University, Clayton, Vic., Australia.,Monash Health, Clayton, Vic., Australia
| | - E Loh
- St Vincent's Health Australia, East Melbourne, Vic., Australia
| | - E M Wallace
- Department of Obstetrics and Gynaecology, School of Clinical Sciences, The Ritchie Centre, Monash University, Clayton, Vic., Australia.,Safer Care Victoria, Victorian Department of Health and Human Services, Melbourne, Vic., Australia
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Swinson D, Hingorani M, Stokes Z, Dent J, Guptal K, Chatterjee A, Kamposioras K, Grumett SA, Khan M, Marshall H, Ruddock S, Allmark C, Katona E, Howard HC, Velikova G, Lord S, Hall PS, Seymour MT. Best supportive care (BSC) with or without low-dose chemotherapy (chemo) in frail elderly patients with advanced gastroesophageal cancer (aGOAC): The uncertain randomization of the GO2 phase III trial. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.4051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4051 Background: Before 2000, trials comparing BSC +/- chemo for aGOAC showed overall survival (OS) benefit, but in predominantly fit patients (pts). We have revisited this question in a modern context, using low-dose chemo in a frail population, with comprehensive baseline health and frailty assessment. Methods: In the GO2 trial, elderly and/or frail aGOAC pts with a “certain” indication for chemo were randomised between 3 chemo doses. In this GO2 substudy, pts with an “uncertain” indication for chemo were instead randomised to BSC ± the lowest dose chemo. Pts were eligible if clinician and pt agreed the indication for chemo was uncertain. There was no PS threshold, but eGFR ≥30 and bili < 2xULN were required. Baseline assessment included global QL, symptom & functional scales, frailty and comorbidity. Randomisation was 1:1 to BSC alone, or with oxaliplatin 78 mg/m2 d1, capecitabine 375 mg/m2 bd d1-21 (modified if eGFR 30-50 ml/min or bili 1.5-2.0 xULN), q21d. QL was reassessed after 9 and 18 wks. The primary endpoint analysis was OS, adjusted for baseline factors. The sample size for this exploratory sub-study was not pre-set, but around 60 pts were anticipated. Results: 558 pts entered GO2 at 61 centres 2014-17, of whom only 45 pts (8%) at 21 centres entered this uncertain randomisation. This would provide 80% power at p = 0.05 (2-tailed) to detect an OS HR of 0.3. OS was shorter in pts with worse baseline PS (p<0.01) or distant mets (p<0.05). OS was not significantly improved with chemo; however we cannot exclude HR >0.32. QL deteriorated less with BSC+chemo than with BSC alone. Conclusions: In this frail, poor PS population, we observed a small survival benefit with chemo but this did not reach statistical significance. Clinicians should carefully consider BSC alone as a valid treatment option for aGOAC pts with poor PS and/or frailty. Clinical trial information: 44687907. [Table: see text]
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Affiliation(s)
| | | | - Zuzana Stokes
- United Lincolnshire Hospitals, Lincoln, United Kingdom
| | - Jo Dent
- Calderdale and Huddersfield Royal Infirmary, Huddersfield, United Kingdom
| | | | | | | | | | - Mohammad Khan
- York Teaching Hospital NHS Foundation Trust, York, United Kingdom
| | | | | | | | | | - Helen C Howard
- Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
| | - Galina Velikova
- Leeds Institute of Cancer and Pathology/St James's Institute of Oncology, Leeds, United Kingdom
| | - Simon Lord
- University of Oxford, Oxford, United Kingdom
| | - Peter S Hall
- St James University Hospital, Leeds, United Kingdom
| | - Matthew T. Seymour
- National Institute for Health Research Clinical Research Network, Leeds, United Kingdom
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Hall PS, Swinson D, Waters JS, Wadsley J, Falk S, Roy R, Tillett T, Nicoll J, Cummings S, Grumett SA, Kamposioras K, Garcia A, Allmark C, Marshall H, Ruddock S, Katona E, Velikova G, Petty RD, Grabsch HI, Seymour MT. Optimizing chemotherapy for frail and elderly patients (pts) with advanced gastroesophageal cancer (aGOAC): The GO2 phase III trial. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.4006] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
4006 Background: Many pts with aGOAC are elderly and/or frail. We previously compared epirubin/ oxaliplatin/ capecitabine (EOCap) vs OCap vs Cap in a pick-the-winner study and found OCap best. GO2 was designed to find the optimum dose of OCap and to explore the use of an objective baseline geriatric assessment to individualize doses for maximum Overall Treatment Utility (OTU), a composite of clinical benefit, tolerability, QL and patient value. Methods: Pts with aGOAC were eligible if unsuitable for full-dose EOCap due to age or frailty, but fit for OCap; GFR ≥ 30, bili <2x ULN. Baseline assessment included global QL; symptoms; functional scales; comorbidity; frailty. Randomization was 1:1:1 to dose Level A (Ox 130 mg/m2d1, Cap 625 mg/m2bd d1-21, q21d), B (80% Level A doses) or C (60% Level A doses). Pts with GFR 30-50 ml/min or bili 1.5-2.0 xULN received 75% of the allocated dose of Cap. At 9 wks, pts were scored for OTU. Continuation thereafter was based on clinical judgement. Non-inferiority (vs A) was assessed using PFS censored at 12 months, with boundary HR 1.34 (based on discussion with pts and clinicians), needing 284 PFS events per 2-way comparison. Baseline fitness was assessed as predictive of OTU, overall and by interaction with dose level. Results: 514 pts were randomised, 2014-17, at 61 UK centres. Clinical trial information: 44687907. Non-inferiority of PFS is confirmed for Level B vs A (HR 1.09, CI 0.89-1.32) and for Level C vs A (HR 1.10, CI 0.90-1.33). Level C pts had less toxicity and better OTU outcomes than A or B. When analysed by baseline age, frailty and PS, Level C produced the best OTU even in younger, less frail and better PS patients; no group was identified who benefit more from the higher dose levels. Conclusions: This is the largest RCT to date specifically investigating frail and/or elderly aGOAC pts, and should guide future treatment. The lowest dose tested was non-inferior in terms of PFS and produced less toxicity and better overall treatment utility.[Table: see text]
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Affiliation(s)
- Peter S Hall
- University of Edinburgh, Edinburgh, United Kingdom
| | | | | | | | - Stephen Falk
- Bristol Haematology and Oncology Centre, Bristol, United Kingdom
| | | | | | - Jonathan Nicoll
- North Cumbria University Hospitals, Carlisle, United Kingdom
| | | | | | | | | | | | | | | | | | | | | | - Heike I. Grabsch
- Leeds Institute of Cancer Studies and Pathology, University of Leeds, Leeds, United Kingdom
| | - Matthew T. Seymour
- National Institute for Health Research Clinical Research Network, Leeds, United Kingdom
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Ruddock S, Ruddock-Hudson M, Rahimi-Golkhandan S. The impact of job-burnout on Australian Football League coaches: Mental health and well-being. J Sci Med Sport 2017. [DOI: 10.1016/j.jsams.2017.09.341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ruddock S, Bhakta B, Lilley-Kelly A, Hartley S, Barnard L. Rapid set up of research centres in a trial in an evolving research governance world. Trials 2013. [PMCID: PMC3980248 DOI: 10.1186/1745-6215-14-s1-p132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Hartley S, Ruddock S, Bhakta B, Pearn J, Barnard L, Fergusson A, Langan D, Farrin A. Maximising adherence to study protocol within pharmaco-rehabilitation clinical trials. Trials 2011. [PMCID: PMC3287708 DOI: 10.1186/1745-6215-12-s1-a133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Thompson JE, Vaughan TJ, Williams AJ, Wilton J, Johnson KS, Bacon L, Green JA, Field R, Ruddock S, Martins M, Pope AR, Tempest PR, Jackson RH. A fully human antibody neutralising biologically active human TGFbeta2 for use in therapy. J Immunol Methods 1999; 227:17-29. [PMID: 10485251 DOI: 10.1016/s0022-1759(99)00060-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [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: 12/15/2022]
Abstract
Phage display provides a methodology for obtaining fully human antibodies directed against human transforming growth factor-beta (TGFbeta) suitable for the treatment of fibrotic disorders. The strategy employed was to isolate a human single chain Fv (scFv) fragment that neutralises human TGFbeta2 from a phage display repertoire, convert it into a human IgG4 and then determine its TGFbeta binding and neutralisation properties and its physical characteristics. Several scFv fragments binding to TGFbeta2 were isolated by panning of an antibody phage display repertoire, and subsequent chain shuffling of the selected V(H) domains with a library of V(L) domains. The three most potent neutralising antibodies were chosen for conversion to IgG4 format. The IgG4 antibodies were ranked for their ability to neutralise TGFbeta2 and the most potent, 6B1 IgG4, was chosen for further characterisation. 6B1 IgG4 has a high affinity for TGFbeta2 with a dissociation constant of 0.89 nM as determined using the BIAcore biosensor and only 9% cross-reactivity with TGFbeta3 (dissociation constant, 10 nM). There was no detectable binding to TGFbeta1. 6B1 IgG4 strongly neutralises (IC50 = 2 nM) the anti-proliferative effect of TGFbeta2 in bioassays using TF1 human erythroleukaemia cells. Similarly, there was strong inhibition of binding of TGFbeta2 to cell surface receptors in a radioreceptor assay using A549 cells. 6B1 IgG4 shows no detectable cross-reactivity with related or unrelated antigens by immunocytochemistry or ELISA. The 6B1 V(L) domain has entirely germline framework regions and the V(H) domain has only three non-germline framework amino acids. This, together with its fully human nature, should minimise any potential immunogenicity of 6B1 IgG4 when used in therapy of fibrotic diseases mediated by TGFbeta2.
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Affiliation(s)
- J E Thompson
- Cambridge Antibody Technology, The Science Park, Melbourn, Royston, Cambridgeshire, UK
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Berg JD, Ruddock S, Allen-Narker RA, Bradby GV, Davis M, Buckley BM. Drugs as probes of organ function: evaluation of the hepatobiliary axis using oral rifampicin and novel high performance liquid chromatography. Ann Clin Biochem 1987; 24 ( Pt 1):36-40. [PMID: 3827182 DOI: 10.1177/000456328702400105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Investigation of the uptake and metabolism of drugs by organs such as the liver may allow assessment of specific aspects of organ function. Rifampicin, when orally administered, is transported into the hepatocyte from portal blood and thence passes, with its deacetylated metabolite, into the systemic circulation and into bile. This paper reports an investigation of the pharmacokinetics of a sub-therapeutic oral dose of rifampicin in healthy subjects, in patients with cirrhosis and in subjects with Gilbert's syndrome. The areas under the plasma concentration curves (AUC) in patients with cirrhosis were significantly greater than in healthy subjects. Subjects with Gilbert's syndrome had decreased AUCs compared with healthy subjects and were clearly distinguished from patients with cirrhosis. Rifampicin concentration in serum was measured by HPLC using a novel direct injection technique.
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Gannon MX, Goldman MD, Simms MH, Ruddock S, Ashton F, Slaney G. Perioperative complications of in-situ vein bypass. Ann R Coll Surg Engl 1986; 68:134-6. [PMID: 3729260 PMCID: PMC2498128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Experience with 146 in-situ vein bypass procedures for obliterative arterial disease are reviewed to determine the specific complication of the technique. Vein wall injury with the Hall valvulotome occurred in 6 patients (4%) and vein patching of a stenosed femoral vein was required in 2 patients. Residual arteriovenous fistulae occurred in 24 patients (16.5%) of whom 9 had an associated graft thrombosis distal to the fistula of which 6 were corrected by thrombectomy and fistula ligation. Perioperative thrombosis occurred in 29 grafts (20%) and was more common in the femoropopliteal group (23/80) than in the femorocrural group (6/66) (P less than 0.01, X2 = 7.55). Fourteen of the femoropopliteal and two of the femorocrural thromboses were corrected resulting in an immediate patency of 89% and 94% respectively with the cumulative patency at one year being 77.5% and 79%. Complications of the in-situ bypass technique remain despite having largely overcome the problems of valve disruption. However, until a standard method emerges careful note must be made of technique and complications when considering reports of in-situ bypass patency.
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