To whom do the results of the multicenter, randomized, controlled INSECT trial (ISRCTN 24023541) apply?--assessment of external validity

Adverse events in MS patients fulfilling or not inclusion criteria of the respective clinical trial - The problem of generalizability

BACKGROUND

The aim of this study was to evaluate how many MS patients treated with an approved DMD in routine care would have fulfilled the inclusion and exclusion criteria of phase III clinical trial and would therefore be eligible for the respective drug trial. Further, adverse events and disease progression for these patients were compared.

METHODS

A comparison of patients fulfilling phase III clinical trial inclusion and exclusion criteria and those who do not with regard to sociodemographic and clinical characteristics, adverse events and disease progression. Database was the REGIMS register, a national, prospective, observational, clinical multicentre registry. 1248 MS Patients were included.

RESULTS

27.2% patients would have been eligible for inclusion into a phase III clinical trial of their indication. Patients who did not meet the criterion age are more likely to have a serious adverse event (SAE), whereas patients who did not fulfil the criterion relapse had a significant lower occurrence of an adverse event (AE). Non-fulfilment of other inclusion criteria (EDSS Score; medication history and MS type) did not show any significant differences in drug safety variables, AE and SAE.

CONCLUSION

Our results suggest that a low transferability of phase III clinical trial criteria, to patients in routine care with the exception of age, does not imply a higher risk with regard to adverse and serious adverse events.

Patienten* nach unauffälliger elektiver laparoskopischer Cholezystektomie können ohne Laborwertkontrollen entlassen werden – Ergebnisse einer prospektiven Studie

Hintergrund

Die Bedeutung postoperativer Laborkontrollen nach elektiver laparoskopischer Cholezystektomie (lap. CHE) ist umstritten. Das Ziel dieser prospektiven Studie war es, herauszufinden, ob Patienten* bei unauffälligem perioperativem Verlauf nach lap. CHE ohne Laborwertkontrollen sicher entlassen werden können.

Methodik

Vom 09/20 bis 03/22 wurden alle Patienten* mit einer lap. CHE gescreent und nach Erhalt des Einverständnisses in die Studie eingeschlossen. Der Verlauf wurde mit einem Scoring- (Punktewert 3–15 Punkte) und Befragungsbogen strukturiert verfolgt. Ein Scoringwert von ≤ 9 Punkten beschrieb einen unauffälligen perioperativen Verlauf. Die Ethikkommission Heidelberg hat dieser Studie zugestimmt (S-026/2020).

Ergebnisse

Es wurden 275 Patienten* mit Gallenblasenoperation erfasst. Davon unterzogen sich 80 % einer elektiven lap. CHE. 56 Patienten* (25 %) wurden in die Studie eingeschlossen, 51 Patienten* wurden bei einem Scoringwert ≤ 9 Punkten ohne Blutentnahme entlassen. Das Durchschnittsalter der 51 Patienten* war 50,8 Jahre, der durchschnittliche Krankenhausaufenthalt betrug 2,6 Tage. 40 von 51 Patienten* (78,4 %) konnten postoperativ befragt werden. Bei keinem der Patienten* kam es nach Entlassung zu relevanten Komplikationen. 27 der 40 Patienten* (67,5 %) sind postoperativ noch einmal zum Hausarzt gegangen. Aufgrund anderer Operationen und einer endoskopischen Intervention sind 4 Patienten* erneut stationär behandelt worden. Alle Patienten* waren mit dem chirurgischen Verlauf zufrieden.

Diskussion

Patienten* mit unauffälligem perioperativem Verlauf nach elektiver lap. CHE (Scoringwert ≤ 9 Punkten) können ohne postoperative Laborwertkontrolle entlassen werden.

Clinical Trial Generalizability Assessment in the Big Data Era: A Review

Clinical studies, especially randomized, controlled trials, are essential for generating evidence for clinical practice. However, generalizability is a long‐standing concern when applying trial results to real‐world patients. Generalizability assessment is thus important, nevertheless, not consistently practiced. We performed a systematic review to understand the practice of generalizability assessment. We identified 187 relevant articles and systematically organized these studies in a taxonomy with three dimensions: (i) data availability (i.e., before or after trial (a priori vs. a posteriori generalizability)); (ii) result outputs (i.e., score vs. nonscore); and (iii) populations of interest. We further reported disease areas, underrepresented subgroups, and types of data used to profile target populations. We observed an increasing trend of generalizability assessments, but < 30% of studies reported positive generalizability results. As a priori generalizability can be assessed using only study design information (primarily eligibility criteria), it gives investigators a golden opportunity to adjust the study design before the trial starts. Nevertheless, < 40% of the studies in our review assessed a priori generalizability. With the wide adoption of electronic health records systems, rich real‐world patient databases are increasingly available for generalizability assessment; however, informatics tools are lacking to support the adoption of generalizability assessment practice.

Risk factors for incisional surgical site infection after elective laparoscopic colorectal surgery

BACKGROUND

Surgical site infection (SSI) is a common morbidity in patients undergoing colorectal surgery, and the focus of previous studies has primarily been on incisional SSI. Most reports thus far have focused on open surgery rather than on laparoscopic colorectal surgery (Lap CR). Therefore, the aim of the present study was to identify the risk factors for incisional SSI in patients undergoing elective Lap CR.

METHODS

This retrospective study was conducted to evaluate the occurrence and risk factors of incisional SSI for elective Lap CR. From January 2008 to June 2018, 1825 consecutive patients with a preoperative diagnosis of colorectal cancer who underwent Lap CR were analyzed at a single institution.

RESULTS

Incidence of incisional SSI was 3.3%. Postoperative hospital stay (days) was significantly longer in the incisional SSI group than in the non-incisional SSI group (8 [6-12] vs 10 [8-19], P < 0.001). Incisional SSI were significantly associated with five operative factors: blood loss (g) (P < 0.014), midline wound length (mm) (P = 0.038), suture materials (P = 0.014), suture technique (interrupted vs continuous mass closure, P = 0.003), and organ/space SSI (P = 0.041). Multivariate analysis showed that continuous mass closure (odds ratio 0.290; 95% confidence interval 0.101-0.831, P = 0.021) was the only factor independently associated with the incidence of incisional SSI.

CONCLUSIONS

Incidence of incisional SSI was comparable to that in previous reports. Continuous mass closure decreased the risk of incisional SSI in elective Lap CR.

External validity of a randomised controlled trial on the treatment of severe infections caused by MRSA

OBJECTIVES

To assess the external validity of a pragmatic, investigator-initiated RCT on treatment of severe infections caused by methicillin-resistant Staphylococcus aureus (MRSA), we compared patient characteristics and treatment effect estimates for patients included in the RCT versus those excluded.

PARTICIPANTS AND OUTCOMES

The RCT included hospitalised patients with documented or highly-probable invasive MRSA infections who were randomised to vancomycin versus trimethoprim-sulfamethoxazole (TMP-SMX) treatment, between 2007 and 2014. A concomitant observational study prospectively included all consecutive patients, between 2008 and 2011, who were excluded from the RCT due to no consent, meningitis, left-sided endocarditis, severe neutropaenia, chronic renal dialysis or treatment with study medications for longer than 48 h. The primary outcomes were clinical failure at day 7 and 30-day mortality for both studies. We compared baseline and infection characteristics, outcome rates and treatment effect estimates for included versus excluded patients.

RESULTS

The RCT included 252 patients who were compared with 220 excluded patients who were observed. Inability to provide informed consent was the main reason for patient exclusion. Excluded patients' functional and cognitive performance was significantly poorer than that of included patients. Sepsis was more severe among excluded patients (higher rates of mechanical ventilation, indwelling catheters, septic shock and organ failure). Clinical failure occurred in 83/252 (32.9%) versus 175/220 (79.5%) and deaths in 32 (12.7%) versus 64 (29.1%) for included versus excluded patients, p<0.001 for both comparisons. Comparing vancomycin to TMP-SMX, in the RCT mortality, was non-significantly lower with vancomycin (OR 0.76, 95% CIs 0.36 to 1.62), while in the observational analysis of excluded patients, mortality was significantly higher with vancomycin (OR 2.63, 1.04 to 6.65), p=0.04 for the difference.

CONCLUSIONS

Patient characteristics, outcome event rates and treatment effects differed significantly in the setting of a RCT, despite its pragmatic design, compared to patients treated outside the trial settings.

BariSurg trial: Sleeve gastrectomy versus Roux-en-Y gastric bypass in obese patients with BMI 35-60 kg/m(2) - a multi-centre randomized patient and observer blind non-inferiority trial

Background

Roux-en-Ygastric bypass (RYGB) and sleeve gastrectomy (SG) rank among the most frequently applied bariatric procedures worldwide due to their positive risk/benefit correlation. A systematic review revealed a similar excess weight loss (EWL) 2 years postoperatively between SG and RYGB. However, there is a lack of randomized controlled multi-centre trials comparing SG and RYGB, not only concerning EWL, but also in terms of remission of obesity-related co-morbidities, gastroesophageal reflux disease (GERD) and quality of life (QoL) in the mid- and long-term.

Methods

The BariSurg trial was designed as a multi-centre, randomized controlled patient and observer blind trial. The trial protocol was approved by the corresponding ethics committees of the centres. To demonstrate EWL non-inferiority of SG compared to RYGB, power calculation was performed according to a non-inferiority study design. Morbidity, mortality, remission of obesity-related co-morbidities, GERD course and QoL are major secondary endpoints. 248 patients between 18 and 70 years, with a body mass index (BMI) between 35–60 kg/m² and indication for bariatric surgery according to the most recent German S3-guidelines will be randomized. The primary and secondary endpoints will be assessed prior to surgery and afterwards at discharge and at the time points 3–6, 12, 24, 36, 48 and 60 months postoperatively.

Discussion

With its five year follow-up, the BariSurg-trial will provide further evidence based data concerning the impact of SG and RYGB on EWL, remission of obesity-related co-morbidities, the course of GERD and QoL.

Trial registration

The trial protocol has been registered in the German Clinical Trials Register DRKS00004766.

Surgical-site infection after abdominal wall closure with triclosan-impregnated polydioxanone sutures: results of a randomized clinical pathway facilitated trial (NCT00998907)

BACKGROUND

Wound infections after abdominal surgery are still frequent types of nosocomial infections. Suture materials might serve as a vehicle for mechanical transport of bacteria into the surgical wound. To prevent the contamination of suture material in surgical wounds, triclosan-coated suture materials with antibacterial activity was developed. We here report a prospective randomized pathway controlled trial investigating the effect of triclosan impregnation of polydioxanone sutures used for abdominal wall closure on the rate of surgical-site infections.

PATIENTS AND METHODS

A total of 856 patients included in this trial underwent a standardized clinical pathway documented abdominal wall closure after abdominal surgery. Patients were randomized to have the fascia closed with either a 2-0 polydioxanone loop or a triclosan impregnated 2-0 polydioxanone loop. The primary outcome was the number of wound infections. Risk factors for poor wound healing were collected prospectively to compare the two groups.

RESULTS

When a PDS loop suture for abdominal wall closure was used, 42 (11.3%) patients with wound infections were detected. The number of patients with wound infections decreased significantly to 31 when the PDS plus for abdominal wall closure was used (6.4%, P < .05). Other risk factors for the development of side infections were comparably in the two groups.

CONCLUSION

This clinical pathway facilitated trial shows that triclosan impregnation of a 2-0 polydioxanone closing suture can decrease wound infections in patients having a laparotomy for general and abdominal vascular procedures.