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Munroe ES, Spicer A, Castellvi-Font A, Zalucky A, Dianti J, Graham Linck E, Talisa V, Urner M, Angus DC, Baedorf-Kassis E, Blette B, Bos LD, Buell KG, Casey JD, Calfee CS, Del Sorbo L, Estenssoro E, Ferguson ND, Giblon R, Granholm A, Harhay MO, Heath A, Hodgson C, Houle T, Jiang C, Kramer L, Lawler PR, Leligdowicz A, Li F, Liu K, Maiga A, Maslove D, McArthur C, McAuley DF, Serpa Neto A, Oosthuysen C, Perner A, Prescott HC, Rochwerg B, Sahetya S, Samoilenko M, Schnitzer ME, Seitz KP, Shah F, Shankar-Hari M, Sinha P, Slutsky AS, Qian ET, Webb SA, Young PJ, Zampieri FG, Zarychanski R, Fan E, Semler MW, Churpek M, Goligher EC, Platform of Randomized Adaptive Clinical Trials in Critical Illness (PRACTICAL) investigators, Evidence-based Individualized Treatment Effects (EvITE) Group. Evidence-based personalised medicine in critical care: a framework for quantifying and applying individualised treatment effects in patients who are critically ill. THE LANCET. RESPIRATORY MEDICINE 2025; 13:556-568. [PMID: 40250459 DOI: 10.1016/s2213-2600(25)00054-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Revised: 01/22/2025] [Accepted: 02/11/2025] [Indexed: 04/20/2025]
Abstract
Clinicians aim to provide treatments that will result in the best outcome for each patient. Ideally, treatment decisions are based on evidence from randomised clinical trials. Randomised trials conventionally report an aggregated difference in outcomes between patients in each group, known as an average treatment effect. However, the actual effect of treatment on outcomes (treatment response) can vary considerably between individuals, and can differ substantially from the average treatment effect. This variation in response to treatment between patients-heterogeneity of treatment effect-is particularly important in critical care because common critical care syndromes (eg, sepsis and acute respiratory distress syndrome) are clinically and biologically heterogeneous. Statistical approaches have been developed to analyse heterogeneity of treatment effect and predict individualised treatment effects for each patient. In this Review, we outline a framework for deriving and validating individualised treatment effects and identify challenges to applying individualised treatment effect estimates to inform treatment decisions in clinical care.
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Affiliation(s)
- Elizabeth S Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Alexandra Spicer
- Division of Pulmonary and Critical Care, Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Andrea Castellvi-Font
- Department of Critical Care, Hospital del Mar, and Critical Illness Research Group (GREPAC), Hospital del Mar Research Institute (IMIM), Barcelona, Spain; Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Ann Zalucky
- Department of Critical Care Medicine, Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary and Alberta Health Services, Foothills Medical Center, Calgary, AB, Canada; Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jose Dianti
- Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Emma Graham Linck
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Victor Talisa
- Center for Reasearch, Investigation, and Systems Modeling of Acute Illness, Department of Critical Care Medicine, University of Pittsburgh, PA, USA
| | - Martin Urner
- Toronto General Hospital Research Institute, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Derek C Angus
- Center for Reasearch, Investigation, and Systems Modeling of Acute Illness, Department of Critical Care Medicine, University of Pittsburgh, PA, USA
| | | | - Bryan Blette
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lieuwe D Bos
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, Netherlands
| | - Kevin G Buell
- Division of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Lorenzo Del Sorbo
- Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Elisa Estenssoro
- Hospital Interzonal San Martin de La Plata, Buenos Aires, Argentina
| | - Niall D Ferguson
- Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Rachel Giblon
- Division of Biostatistics, University of Toronto, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna Heath
- Division of Biostatistics, University of Toronto, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Timothy Houle
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cong Jiang
- Faculté of Pharmacie, Université de Montréal, Montreal, QC, Canada
| | - Lina Kramer
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, Netherlands
| | - Patrick R Lawler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Division of Cardiology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Aleksandra Leligdowicz
- Division of Critial Care Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Kuan Liu
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Amelia Maiga
- Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Colin McArthur
- Department of Critical Care Medicine, Te Toka Tumai Auckland City Hospital, Auckland, New Zealand
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paolo, Brazil; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Charissa Oosthuysen
- Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Hallie C Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sarina Sahetya
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Mireille E Schnitzer
- Faculté of Pharmacie, Université de Montréal, Montreal, QC, Canada; Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, QC, Canada
| | - Kevin P Seitz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Faraaz Shah
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manu Shankar-Hari
- Centre for Inflammation Research, Institute for Regeneration and Repair, The University of Edinburgh, Edinburgh, UK
| | - Pratik Sinha
- Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Edward T Qian
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Steve A Webb
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Paul J Young
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Wellington Hospital, Wellington, New Zealand; Medical Research Institute of New Zealand, Wellington, New Zealand; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Fernando G Zampieri
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Eddy Fan
- Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Churpek
- Division of Pulmonary and Critical Care, Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA; School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Ewan C Goligher
- Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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Curley MAQ, Kalvas LB, Perry-Eaddy MA, Asaro LA, Wypij D. A Decision-Making Grid for Coenrollment in Multiple Clinical Trials. Nurs Res 2025; 74:241-245. [PMID: 39679895 DOI: 10.1097/nnr.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2024]
Abstract
BACKGROUND Although subject coenrollment into multiple trials is desirable, thoughtful consideration is required to avoid compromising each trial's scientific integrity. OBJECTIVE We developed a Decision-Making Grid (GRID) to help investigators determine whether a clinical trial is compatible with a second clinical trial, thus allowing coenrollment, or if it should be considered competing, prohibiting coenrollment. METHODS The GRID evaluates 21 elements across four domains: scientific integrity, data interpretation, feasibility/burden, and additional considerations. Optimally, each principal investigator shares their protocol, completes the GRID independently, and then meets to compare their perspectives, seeking a mutually acceptable agreement. RESULTS The GRID has facilitated coenrollment decision-making for the RESTORE and PROSpect pediatric critical care clinical trials. In RESTORE , five trials were reviewed; one was approved for coenrollment, and four were deemed competing. In PROSpect , 26 trials have been reviewed; 20 are approved for coenrollment, and six were deemed competing. In both RESTORE and PROSpect , the principal investigators of multiple trials arranged a mutually acceptable sharing agreement. DISCUSSION The GRID provides a systematic process to help investigators evaluate the effect of coenrollment in multiple clinical trials.
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Germain N, Audet M, Graves L, Murthy S, McLeod SL, Khangura J, Golchi S, McRae AD, Hohl CM, Cheng I, Olivier Chevrier G, Marshall JC, Archambault PM. CAEP 2024 Academic Symposium: adaptive platform trials in emergency medicine in Canada. CAN J EMERG MED 2025; 27:329-341. [PMID: 40295353 DOI: 10.1007/s43678-025-00874-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2025] [Accepted: 01/24/2025] [Indexed: 04/30/2025]
Abstract
OBJECTIVE The Canadian Association of Emergency Physicians 2024 Academic Symposium Panel on adaptive platform trials explored whether adaptive platform trials could be implemented in Canadian emergency departments (EDs). This panel aimed to propose and refine recommendations formulated by the results of a rapid review and responses from a panel of experts about conducting adaptive platform trials in EDs. METHODS From November 2023 to May 2024, a rapid review was conducted on the existing logistical and ethical barriers and facilitators to structuring adaptive platform trials in emergency medicine. The emerging themes and ideas were collected and used to conduct individual semi-structured interviews with key stakeholders, including leaders in emergency medicine research, methodologists and biostatisticians specializing in these designs, patient partners, research personnel, and investigators involved in platform trials across Canada and abroad. RESULTS From 23 articles and 17 expert interviews, we identified facilitators and barriers to adaptive platform trials in Canadian emergency medicine spread across five domains: evidence strength and quality, relative advantage, adaptability, complexity, and implementation climate and readiness. The most salient needs according to investigators were purposeful and clinically relevant trial design, methodological expertise, and harmonious collaboration with ethics authorities. We provide 14 recommendations across 4 levels: policy, trialist, site, and patient to address barriers to adaptive platform trials in emergency medicine. For each recommendation, we provided corresponding implementation strategies from the Expert Recommendations for Implementing Change (ERIC). CONCLUSIONS Adaptive trial designs are well suited for emergency settings provided the interventions are both easy for clinicians to administer and relevant enough to ameliorate the practice of emergency medicine. These designs are particularly tailored to tackle confirmatory trials, emerging diseases, and trauma care, but barriers like a chaotic ED, complex statistical and methodological requirements, and regulatory considerations persist and require thoughtful implementation strategies.
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Affiliation(s)
- Nathalie Germain
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Département de médecine sociale et préventive, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Martyne Audet
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | | | - Srinivas Murthy
- Department of Pediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jaspreet Khangura
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Shirin Golchi
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Corinne M Hohl
- Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Ivy Cheng
- Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Gabrielle Olivier Chevrier
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - John C Marshall
- Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Patrick M Archambault
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada.
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.
- VITAM-Centre de recherche en santé durable, Québec, QC, Canada.
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Zampieri FG, Ezekowitz JA. The "Small" Clinical Trial: Methods, Analysis, and Interpretation in Acute Care Cardiology. Can J Cardiol 2025; 41:656-668. [PMID: 39536916 DOI: 10.1016/j.cjca.2024.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Revised: 11/02/2024] [Accepted: 11/06/2024] [Indexed: 11/16/2024] Open
Abstract
Clinical trials in acute care settings, particularly those involving small populations or high mortality contexts, present unique challenges in design and analysis. In this review we explore novel statistical approaches and methodological considerations for such trials, with a focus on cardiovascular therapies. We discuss the concept of "small" sample sizes and their limitations and cover various analytical frameworks, including frequentist and Bayesian approaches, and emphasize their implications for result interpretation and reproducibility. We examine end points such as "days alive and free specific to disease state," which combines mortality and morbidity measures, the win ratio for hierarchical end points, and ordinal scales that capture detailed patient outcomes. These methods potentially increase statistical power and provide more clinically relevant measures compared with traditional binary outcomes; an extensive use of simulations is used to clarify this point. The use of longitudinal ordinal models is presented as a promising method to capture complex patient trajectories over time, offering insights into treatment effects at various disease stages. We also address the potential of adaptive platform trials for rare conditions, allowing for more efficient use of limited patient populations. In this overview we aim to guide researchers and clinicians in selecting optimal trial designs and analytical strategies, to ultimately improve the quality, efficiency, and interpretability of evidence in acute care cardiology.
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Affiliation(s)
- Fernando G Zampieri
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Justin A Ezekowitz
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Pepke-Żaba J, Chorostowska-Wynimko J, Ryan S, Randerath W, Meiners S, Saglani S, Heuvelin E, Genton C, Gappa M, Powell P, Polverino E, Roche N, Siddiqui S. ERS Clinical Research Collaboration programme: more than research networking - enriching respiratory science and impacting clinical practice in Europe and beyond. Eur Respir J 2025; 65:2402520. [PMID: 40147855 DOI: 10.1183/13993003.02520-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2024] [Accepted: 01/16/2025] [Indexed: 03/29/2025]
Affiliation(s)
- Joanna Pepke-Żaba
- Royal Papworth Hospital, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Joanna Chorostowska-Wynimko
- Department of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - Silke Ryan
- Pulmonary and Sleep Disorders Unit, St. Vincent's University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Winfried Randerath
- Clinic of Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Bethanien Hospital, Solingen, Germany
- Institute for Pneumology at the University of Cologne, Solingen, Germany
| | - Silke Meiners
- Research Center Borstel, Leibniz Lung Center, Airway Research Center North (ARCN), Member of the German Center for Lung Research (DZL), Borstel, Germany
- Institute of Experimental Medicine, Christian-Albrechts University Kiel, Kiel, Germany
| | - Sejal Saglani
- Imperial Biomedical Research Centre, National Heart and Lung Institute, Imperial College London, London, UK
| | - Elise Heuvelin
- Scientific Activities Department, European Respiratory Society, Lausanne, Switzerland
| | - Céline Genton
- Scientific Activities Department, European Respiratory Society, Lausanne, Switzerland
| | - Monika Gappa
- Dept of Paediatric and Adolescent Medicine, Evangelisches Krankenhaus Duesseldorf, Duesseldorf, Germany
| | | | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBERES, Barcelona, Spain
| | - Nicolas Roche
- Respiratory Medicine, Université Paris Cité, APHP Centre, Cochin Hospital and Institute (UMR1016), Paris, France
| | - Salman Siddiqui
- Imperial Biomedical Research Centre, National Heart and Lung Institute, Imperial College London, London, UK
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Rose L, Camporota L, Contreras A, Couper K, Hadfield D, Alleyne S, Barabas J, Boex SM, Connolly BA, Dark P, Davies C, Dawson A, De Soyza A, Felton TW, Guck J, Hale D, Hill MC, Hopkins PA, Hossain A, Ji C, Jin H, Kandiyali R, Khan KA, Kitchen GB, Krovi DN, Lall R, Law E, Lea K, Madan JJ, McGrath BA, Michael A, Mills GH, Mildner R, Noufaily A, Parekh D, Parvin C, Patel V, Perkins G, Rafferty GF, Shankar-Hari M, Shyamsunder M, Steiner M, Tassie E, Thirlwall J, Thompson M, Watkins B, Williams RL, Yeung J, Zanganeh M, Starr K, McAuley D. The COnfederation of REspiratory Critical Care Trials (CoReCCT): a UK research confederation. Br J Anaesth 2025; 134:566-568. [PMID: 39694754 DOI: 10.1016/j.bja.2024.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2024] [Revised: 10/24/2024] [Accepted: 10/24/2024] [Indexed: 12/20/2024] Open
Affiliation(s)
- Louise Rose
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK; Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, UK.
| | - Luigi Camporota
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK; Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | | | - Keith Couper
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Dan Hadfield
- Department of Critical Care, King's College Hospital, London, UK
| | | | - Judit Barabas
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | | | - Bronwen A Connolly
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Paul Dark
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Angela Dawson
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Anthony De Soyza
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Tim W Felton
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jonathan Guck
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Danielle Hale
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | | | - Philip A Hopkins
- Department of Critical Care, King's College Hospital, London, UK
| | - Anower Hossain
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Chen Ji
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Huajie Jin
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | | | - Kamran A Khan
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Gareth B Kitchen
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Deepthi N Krovi
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Erin Law
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Kirsty Lea
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Jason J Madan
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Brendan A McGrath
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alexia Michael
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Gary H Mills
- Departments of Anaesthesia and Intensive Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Reinout Mildner
- Department of Paeditaric Intensive Care, Birmingham Children's Hospital, Birmingham, UK
| | - Angela Noufaily
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Dhruv Parekh
- Department of Inflammation and Aging, University of Birmingham, Birmingham, UK
| | | | - Vivan Patel
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Gavin Perkins
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Gerrard F Rafferty
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Manu Shankar-Hari
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | | | - Michael Steiner
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Emma Tassie
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Jenny Thirlwall
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | | | - Ben Watkins
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | | | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | | | - Kath Starr
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - Danny McAuley
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
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Janani L, Phillips R, Van Vogt E, Liu X, Waddington C, Cro S. Past, present, and future of Phase 3 vaccine trial design: rethinking statistics for the 21st century. Clin Exp Immunol 2025; 219:uxae104. [PMID: 39570146 PMCID: PMC11754867 DOI: 10.1093/cei/uxae104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 10/23/2024] [Accepted: 11/19/2024] [Indexed: 11/22/2024] Open
Abstract
Vaccines are crucial for protecting health globally; however, their widespread use relies on rigorous clinical development programmes. This includes Phase 3 randomized controlled trials (RCTs) to confirm their safety, immunogenicity, and efficacy. Traditionally, such trials used fixed designs with predetermined assumptions, lacking the flexibility to change during the trial or stop early due to overwhelming evidence of either efficacy or futility. Modern vaccine trials benefit from innovative approaches like adaptive designs, allowing for planned trial adaptations based on accumulating data. Here, we provide an overview of the evolution of Phase 3 vaccine trial design and statistical analysis methods from traditional to more innovative contemporary methods. This includes adaptive trial designs, which offer ethical advantages and enable early termination if indicated; Bayesian methods, which combine prior knowledge and observed trial data to increase efficiency and enhance result interpretation; modern statistical analysis methods, which enable more accurate and precise inferences; the estimand framework, which ensures the primary question of interest is addressed in a trial; novel approaches using machine learning methods to assess heterogeneity of treatment effects; and statistical advances in safety analysis to evaluate reactogenicity and clinical adverse events. We conclude with insights into the future direction of vaccine trials, aiming to inform clinicians and researchers about conventional and novel RCT design and analysis approaches to facilitate the conduct of efficient, timely trials.
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Affiliation(s)
- Leila Janani
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Rachel Phillips
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Ellie Van Vogt
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Claire Waddington
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary’s Hospital, London, UK
| | - Suzie Cro
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
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Abu-Sultaneh S, Iyer NP, Fernández A, Tume LN, Kneyber MCJ, López-Fernández YM, Emeriaud G, Ramnarayan P, Khemani RG. Framework for Research Gaps in Pediatric Ventilator Liberation. Chest 2024; 166:1056-1070. [PMID: 38852880 PMCID: PMC11562655 DOI: 10.1016/j.chest.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 05/03/2024] [Accepted: 05/11/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND The 2023 International Pediatric Ventilator Liberation Clinical Practice Guidelines provided evidence-based recommendations to guide pediatric critical care providers on how to perform daily aspects of ventilator liberation. However, because of the lack of high-quality pediatric studies, most recommendations were conditional based on very low to low certainty of evidence. RESEARCH QUESTION What are the research gaps related to pediatric ventilator liberation that can be studied to strengthen the evidence for future updates of the guidelines? STUDY DESIGN AND METHODS We conducted systematic reviews of the literature in eight predefined Population, Intervention, Comparator, Outcome (PICO) areas related to pediatric ventilator liberation to generate recommendations. Subgroups responsible for each PICO question subsequently identified major research gaps by synthesizing the literature. These gaps were presented at an international symposium at the Pediatric Acute Lung Injury and Sepsis Investigators meeting in spring 2022 for open discussion. Feedback was incorporated, and final evaluation of research gaps are summarized herein. Although randomized controlled trials (RCTs) represent the highest level of evidence, the panel sought to highlight areas where alternative study designs also may be appropriate, given challenges with conducting large multicenter RCTs in children. RESULTS Significant research gaps were identified in six broad areas related to pediatric ventilator liberation. Several of these areas necessitate multicenter RCTs to provide definitive results, whereas other gaps can be addressed with multicenter observational studies or quality improvement initiatives. Furthermore, a need for some physiologic studies in several areas remains, particularly regarding newer diagnostic methods to improve identification of patients at high risk of extubation failure. INTERPRETATION Although pediatric ventilator liberation guidelines have been created, the certainty of evidence remains low and multiple research gaps exist that should be bridged through high-quality RCTs, multicenter observational studies, and quality improvement initiatives.
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Affiliation(s)
- Samer Abu-Sultaneh
- Division of Pediatric Critical Care, Department of Pediatrics Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine Indianapolis, IN.
| | - Narayan Prabhu Iyer
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Analía Fernández
- Division of Critical Care Medicine, Hospital General de Agudos "C. Durand," Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Lyvonne N Tume
- Edge Hill University Health Research Institute, Ormskirk, England
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Yolanda M López-Fernández
- Pediatric Critical Care Division, Department of Pediatrics, Cruces University Hospital, BioBizkaia Health Research Institute, Bizkaia, Spain
| | - Guillaume Emeriaud
- Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, QC, Canada
| | - Padmanabhan Ramnarayan
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, England
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
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Abstract
The understanding of acute respiratory distress syndrome (ARDS) has evolved greatly since it was first described in a 1967 case series, with several subsequent updates to the definition of the syndrome. Basic science advances and clinical trials have provided insight into the mechanisms of lung injury in ARDS and led to reduced mortality through comprehensive critical care interventions. This review summarizes the current understanding of the epidemiology, pathophysiology, and management of ARDS. Key highlights include a recommended new global definition of ARDS and updated guidelines for managing ARDS on a backbone of established interventions such as low tidal volume ventilation, prone positioning, and a conservative fluid strategy. Future priorities for investigation of ARDS are also highlighted.
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Affiliation(s)
- Katherine D Wick
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA, USA
- Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
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