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Marcus HJ, Ramirez PT, Khan DZ, Layard Horsfall H, Hanrahan JG, Williams SC, Beard DJ, Bhat R, Catchpole K, Cook A, Hutchison K, Martin J, Melvin T, Stoyanov D, Rovers M, Raison N, Dasgupta P, Noonan D, Stocken D, Sturt G, Vanhoestenberghe A, Vasey B, McCulloch P. Author Correction: The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring. Nat Med 2024; 30:1213. [PMID: 38297095 DOI: 10.1038/s41591-024-02836-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Affiliation(s)
- Hani J Marcus
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK.
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK.
| | - Pedro T Ramirez
- Department of Obstetrics and Gynaecology, Houston Methodist Hospital Neal Cancer Center, Houston, TX, USA
| | - Danyal Z Khan
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - Hugo Layard Horsfall
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - John G Hanrahan
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - Simon C Williams
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - David J Beard
- RCS Surgical Interventional Trials Unit (SITU) & Robotic and Digital Surgery Initiative (RADAR), Nuffield Dept Orthopaedics, Rheumatology and Musculo-skeletal Sciences, University of Oxford, Oxford, UK
| | - Rani Bhat
- Department of Gynaecological Oncology, Apollo Hospital, Bengaluru, India
| | - Ken Catchpole
- Department of Anaesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Andrew Cook
- NIHR Coordinating Centre and Clinical Trials Unit, University of Southampton, Southampton, UK
| | | | - Janet Martin
- Department of Anesthesia & Perioperative Medicine, University of Western Ontario, Ontario, Canada
| | - Tom Melvin
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Republic of Ireland
| | - Danail Stoyanov
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - Maroeska Rovers
- Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands
| | - Nicholas Raison
- Department of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Prokar Dasgupta
- King's Health Partners Academic Surgery, King's College London, London, UK
| | | | - Deborah Stocken
- RCSEng Surgical Trials Centre, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Anne Vanhoestenberghe
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Baptiste Vasey
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Peter McCulloch
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK.
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Harji DP, Griffiths B, Stocken D, Pearse R, Blazeby J, Brown JM. Protocolized care pathways in emergency general surgery: a systematic review and meta-analysis. Br J Surg 2024; 111:znae057. [PMID: 38513265 PMCID: PMC10957158 DOI: 10.1093/bjs/znae057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/18/2023] [Accepted: 10/22/2023] [Indexed: 03/23/2024]
Abstract
BACKGROUND Emergency abdominal surgery is associated with significant postoperative morbidity and mortality. The delivery of standardized pathways in this setting may have the potential to transform clinical care and improve patient outcomes. METHODS The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and October 2022. All randomized and non-randomized cohort studies comparing protocolized care streams with standard care protocols in adult patients (>18 years old) undergoing major emergency abdominal surgery with 30-day follow-up data were included. Studies were excluded if they reported on standardized care protocols in the trauma or elective setting. Outcomes assessed included length of stay, 30-day postoperative morbidity, 30-day postoperative mortality and 30-day readmission and reoperations rates. Risk of bias was assessed using ROBINS-I for non-randomized studies and RoB-2 for randomized controlled trials. Meta-analysis was performed using random effects modelling. RESULTS Seventeen studies including 20 927 patients were identified, with 12 359 patients undergoing protocolized care pathways and 8568 patients undergoing standard care pathways. Thirteen unique protocolized pathways were identified, with a median of eight components (range 6-15), with compliance of 24-100%. Protocolized care pathways were associated with a shorter hospital stay compared to standard care pathways (mean difference -2.47, 95% c.i. -4.01 to -0.93, P = 0.002). Protocolized care pathways had no impact on postoperative mortality (OR 0.87, 95% c.i. 0.41 to 1.87, P = 0.72). A reduction in specific postoperative complications was observed, including postoperative pneumonia (OR 0.42 95% c.i. 0.24 to 0.73, P = 0.002) and surgical site infection (OR 0.34, 95% c.i. 0.21 to 0.55, P < 0.001). DISCUSSION Protocolized care pathways in the emergency setting currently lack standardization, with variable components and low compliance; however, despite this they are associated with short-term clinical benefits.
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Affiliation(s)
- Deena P Harji
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ben Griffiths
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Rupert Pearse
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jane Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical research Centre, Bristol, UK
| | - Julia M Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Thomson S, Ainsworth G, Selvanathan S, Brown S, Croft J, Kelly R, Mujica-Mota R, Rousseau N, Higham R, Stocken D. Clinical and cost-effectiveness of PCF versus ACD in the treatment of cervical brachialgia (FORVAD trial). Br J Neurosurg 2024; 38:141-148. [PMID: 37807634 DOI: 10.1080/02688697.2023.2267119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 10/01/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Cervical radiculopathy occurs when a nerve root is compressed in the spine, if symptoms fail to resolve after 6 weeks surgery may be indicated. Anterior Cervical Discectomy (ACD) is the commonest procedure, Posterior Cervical Foraminotomy (PCF) is an alternative that avoids the risk of damage to anterior neck structures. This prospective, Phase III, UK multicentre, open, individually randomised controlled trial was performed to determine whether PCF is superior to ACD in terms of improving clinical outcome as measured by the Neck Disability Index (NDI) 52 weeks post-surgery. METHOD Following consent to participate and collection of baseline data, subjects with cervical brachialgia were randomised to ACD or PCF in a 1:1 ratio on the day of surgery. Clinical outcomes were assessed on day 1 and patient reported outcomes on day 1 and weeks 6, 12, 26, 39 and 52 post-operation. A total of 252 participants were planned to be randomised. Statistical analysis was limited to descriptive statistics. Health economic outcomes were also described. RESULTS The trial was closed early (n = 23). Compared to baseline, the median (interquartile range (IQR)) NDI score at 52 weeks reduced from 44.0 (36.0, 62.0) to 25.3 (20.0, 42.0) in the PCF group and increased from 35.6 (34.0, 44.0) to 45.0 (20.0, 57.0) in the ACD group. ACD may be associated with more swallowing, voice and other complications and was more expensive; neck and arm pain scores were similar. CONCLUSIONS The trial was closed early, therefore no definitive conclusions on clinical or cost-effectiveness could be made.
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Affiliation(s)
- Simon Thomson
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Senthil Selvanathan
- Academic Unit of Health Economics, Institute of Health Sciences, University of Leeds, UK
| | - Sarah Brown
- Clinical Trials Research Unit, University of Leeds, UK
| | - Julie Croft
- Clinical Trials Research Unit, University of Leeds, UK
| | - Rachel Kelly
- Clinical Trials Research Unit, University of Leeds, UK
| | | | | | - Ruchi Higham
- Clinical Trials Research Unit, University of Leeds, UK
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Gamble C, Lewis S, Stocken D, Juszczak E, Bradburn M, Doré C, Kean S. Determining a risk-proportionate approach to the validation of statistical programming for clinical trials. Clin Trials 2024; 21:85-94. [PMID: 37957825 PMCID: PMC10865752 DOI: 10.1177/17407745231204036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND The contribution of the statistician to the design and analysis of a clinical trial is acknowledged as essential. Ability to reconstruct the statistical contribution to a trial requires rigorous and transparent documentation as evidenced by the reproducibility of results. The process of validating statistical programmes is a key requirement. While guidance relating to software development and life cycle methodologies details steps for validation by information systems developers, there is no guidance applicable to programmes written by statisticians. We aimed to develop a risk-based approach to the validation of statistical programming that would support scientific integrity and efficient resource use within clinical trials units. METHODS The project was embedded within the Information Systems Operational Group and the Statistics Operational Group of the UK Clinical Research Collaboration Registered Clinical Trials Unit network. Members were asked to share materials relevant to validation of statistical programming. A review of the published literature, regulatory guidance and knowledge of relevant working groups was undertaken. Surveys targeting the Information Systems Operational Group and Statistics Operational Group were developed to determine current practices across the Registered Clinical Trials Unit network. A risk-based approach was drafted and used as a basis for a workshop with representation from statisticians, information systems developers and quality assurance managers (n = 15). The approach was subsequently modified and presented at a second, larger scale workshop (n = 47) to gain a wider perspective, with discussion of content and implications for delivery. The approach was revised based on the discussions and suggestions made. The workshop was attended by a member of the Medicines for Healthcare products Regulatory Agency Inspectorate who also provided comments on the revised draft. RESULTS Types of statistical programming were identified and categorised into six areas: generation of randomisation lists; programmes to explore/understand the data; data cleaning, including complex checks; derivations including data transformations; data monitoring; or interim and final analysis. The risk-based approach considers each category of statistical programme against the impact of an error and its likelihood, whether the programming can be fully prespecified, the need for repeated use and the need for reproducibility. Approaches to the validation of programming within each category are proposed. CONCLUSION We have developed a risk-based approach to the validation of statistical programming. It endeavours to facilitate the implementation of targeted quality assurance measures while making efficient use of limited resources.
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Affiliation(s)
- Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Steff Lewis
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Edmund Juszczak
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Mike Bradburn
- Clinical Trials Research Unit, ScHARR, University of Sheffield, Sheffield, UK
| | - Caroline Doré
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Sharon Kean
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
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Marcus HJ, Ramirez PT, Khan DZ, Layard Horsfall H, Hanrahan JG, Williams SC, Beard DJ, Bhat R, Catchpole K, Cook A, Hutchison K, Martin J, Melvin T, Stoyanov D, Rovers M, Raison N, Dasgupta P, Noonan D, Stocken D, Sturt G, Vanhoestenberghe A, Vasey B, McCulloch P. The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring. Nat Med 2024; 30:61-75. [PMID: 38242979 DOI: 10.1038/s41591-023-02732-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/20/2023] [Indexed: 01/21/2024]
Abstract
The next generation of surgical robotics is poised to disrupt healthcare systems worldwide, requiring new frameworks for evaluation. However, evaluation during a surgical robot's development is challenging due to their complex evolving nature, potential for wider system disruption and integration with complementary technologies like artificial intelligence. Comparative clinical studies require attention to intervention context, learning curves and standardized outcomes. Long-term monitoring needs to transition toward collaborative, transparent and inclusive consortiums for real-world data collection. Here, the Idea, Development, Exploration, Assessment and Long-term monitoring (IDEAL) Robotics Colloquium proposes recommendations for evaluation during development, comparative study and clinical monitoring of surgical robots-providing practical recommendations for developers, clinicians, patients and healthcare systems. Multiple perspectives are considered, including economics, surgical training, human factors, ethics, patient perspectives and sustainability. Further work is needed on standardized metrics, health economic assessment models and global applicability of recommendations.
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Affiliation(s)
- Hani J Marcus
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK.
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK.
| | - Pedro T Ramirez
- Department of Obstetrics and Gynaecology, Houston Methodist Hospital Neal Cancer Center, Houston, TX, USA
| | - Danyal Z Khan
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - Hugo Layard Horsfall
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - John G Hanrahan
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - Simon C Williams
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - David J Beard
- RCS Surgical Interventional Trials Unit (SITU) & Robotic and Digital Surgery Initiative (RADAR), Nuffield Dept Orthopaedics, Rheumatology and Musculo-skeletal Sciences, University of Oxford, Oxford, UK
| | - Rani Bhat
- Department of Gynaecological Oncology, Apollo Hospital, Bengaluru, India
| | - Ken Catchpole
- Department of Anaesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Andrew Cook
- NIHR Coordinating Centre and Clinical Trials Unit, University of Southampton, Southampton, UK
| | | | - Janet Martin
- Department of Anesthesia & Perioperative Medicine, University of Western Ontario, Ontario, Canada
| | - Tom Melvin
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Republic of Ireland
| | - Danail Stoyanov
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - Maroeska Rovers
- Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands
| | - Nicholas Raison
- Department of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Prokar Dasgupta
- King's Health Partners Academic Surgery, King's College London, London, UK
| | | | - Deborah Stocken
- RCSEng Surgical Trials Centre, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Anne Vanhoestenberghe
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Baptiste Vasey
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Peter McCulloch
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK.
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Meacock J, Smedley A, Sinha P, Igra M, Macmullen-Price J, Jayne D, Stocken D, Currie S, Thomson S. Consistency of Radiological Grading of Cervical Foraminal Stenosis. Curr Med Imaging 2023; 20:CMIR-EPUB-135999. [PMID: 37957876 DOI: 10.2174/0115734056266400231106054026] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/05/2023] [Accepted: 09/25/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND The degree of cervical foraminal stenosis on MRI scans may be measured and categorised using the Kim or modified Kim methods. These grading scales have not previously been validated in a cohort of patients awaiting surgery. OBJECTIVES To establish the normal foraminal and root diameters as well as the consistency of inter and intra-rater grading using the Kim and modified Kim grading systems in pre-operative surgical patients. METHODS Asymptomatic cervical nerve roots and foramina demonstrated on the pre-operative MRI scans of adult surgical patients with cervical radiculopathy were measured and categorised by six raters using the Kim and modified Kim grading methods. Repeat "second pass" measurements were made by the same assessors on the same images a minimum of one month later. RESULTS Foraminal diameters (mm) in asymptomatic foramina were C2/C3 (mean±SD): 4.18±1.44, C3/C4 2.96±1.23, C4/C5 3.02±1.19, C5/C6 3.15±1.33, C6/C7 3.53±1.36, C7/T1 3.93±1.34. Nerve root diameters were C3 3.11±0.87, C4 2.95±0.77, C5 2.56±0.73, C6 2.26±0.76, C7 2.56±0.82, C8 3.83±0.86. Inter-rater consistency was kappa [95% CI]: Kim 0.01 [0.00, 0.03], modified Kim 0.08 [0.05, 0.10]. Intra-rater consistency was kappa [95% CI]: Kim 0.81 [0.77, 0.86], modified Kim 0.69 [0.62, 0.76]. CONCLUSION There was poor inter-rater consistency but good intra-rater consistency when assessing the severity of foraminal stenosis on axial T2 MRI scans. Foraminal diameter was narrowest at C3/C4 and C4/C5, whereas the smallest root diameter was C5/C6. Volumetric or oblique MR may improve consistency.
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Affiliation(s)
- James Meacock
- Department of Neurosurgery, Floor G, Jubilee Wing, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom
| | - Alexander Smedley
- Department of Neurosurgery, Floor G, Jubilee Wing, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom
| | - Priyank Sinha
- Department of Neurosurgery, Floor G, Jubilee Wing, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom
| | - Mark Igra
- Department of Neuroradiology, Floor B, Clarendon Wing, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom
| | - Jeremy Macmullen-Price
- Department of Neuroradiology, Floor B, Clarendon Wing, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom
| | - David Jayne
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, United Kingdom
| | - Deborah Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9NL, United Kingdom
| | - Stuart Currie
- Department of Neuroradiology, Floor B, Clarendon Wing, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom
| | - Simon Thomson
- Leeds Teaching Hospitals NHS Trust Neurosurgery Leeds United Kingdom
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Thomson S, Ainsworth G, Selvanathan S, Kelly R, Collier H, Mujica-Mota R, Talbot R, Brown ST, Croft J, Rousseau N, Higham R, Al-Tamimi Y, Buxton N, Carleton-Bland N, Gledhill M, Halstead V, Hutchinson P, Meacock J, Mukerji N, Pal D, Vargas-Palacios A, Prasad A, Wilby M, Stocken D. Posterior cervical foraminotomy versus anterior cervical discectomy for Cervical Brachialgia: the FORVAD RCT. Health Technol Assess 2023; 27:1-228. [PMID: 37929307 PMCID: PMC10641711 DOI: 10.3310/otoh7720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/07/2023] Open
Abstract
Background Posterior cervical foraminotomy and anterior cervical discectomy are routinely used operations to treat cervical brachialgia, although definitive evidence supporting superiority of either is lacking. Objective The primary objective was to investigate whether or not posterior cervical foraminotomy is superior to anterior cervical discectomy in improving clinical outcome. Design This was a Phase III, unblinded, prospective, United Kingdom multicentre, parallel-group, individually randomised controlled superiority trial comparing posterior cervical foraminotomy with anterior cervical discectomy. A rapid qualitative study was conducted during the close-down phase, involving remote semistructured interviews with trial participants and health-care professionals. Setting National Health Service trusts. Participants Patients with symptomatic unilateral cervical brachialgia for at least 6 weeks. Interventions Participants were randomised to receive posterior cervical foraminotomy or anterior cervical discectomy. Allocation was not blinded to participants, medical staff or trial staff. Health-care use from providing the initial surgical intervention to hospital discharge was measured and valued using national cost data. Main outcome measures The primary outcome measure was clinical outcome, as measured by patient-reported Neck Disability Index score 52 weeks post operation. Secondary outcome measures included complications, reoperations and restricted American Spinal Injury Association score over 6 weeks post operation, and patient-reported Eating Assessment Tool-10 items, Glasgow-Edinburgh Throat Scale, Voice Handicap Index-10 items, PainDETECT and Numerical Rating Scales for neck and upper-limb pain over 52 weeks post operation. Results The target recruitment was 252 participants. Owing to slow accrual, the trial closed after randomising 23 participants from 11 hospitals. The qualitative substudy found that there was support and enthusiasm for the posterior cervical FORaminotomy Versus Anterior cervical Discectomy in the treatment of cervical brachialgia trial and randomised clinical trials in this area. However, clinical equipoise appears to have been an issue for sites and individual surgeons. Randomisation on the day of surgery and processes for screening and approaching participants were also crucial factors in some centres. The median Neck Disability Index scores at baseline (pre surgery) and at 52 weeks was 44.0 (interquartile range 36.0-62.0 weeks) and 25.3 weeks (interquartile range 20.0-42.0 weeks), respectively, in the posterior cervical foraminotomy group (n = 14), and 35.6 weeks (interquartile range 34.0-44.0 weeks) and 45.0 weeks (interquartile range 20.0-57.0 weeks), respectively, in the anterior cervical discectomy group (n = 9). Scores appeared to reduce (i.e. improve) in the posterior cervical foraminotomy group, but not in the anterior cervical discectomy group. The median Eating Assessment Tool-10 items score for swallowing was higher (worse) after anterior cervical discectomy (13.5) than after posterior cervical foraminotomy (0) on day 1, but not at other time points, whereas the median Glasgow-Edinburgh Throat Scale score for globus was higher (worse) after anterior cervical discectomy (15, 7, 6, 6, 2, 2.5) than after posterior cervical foraminotomy (3, 0, 0, 0.5, 0, 0) at all postoperative time points. Five postoperative complications occurred within 6 weeks of surgery, all after anterior cervical discectomy. Neck pain was more severe on day 1 following posterior cervical foraminotomy (Numerical Rating Scale - Neck Pain score 8.5) than at the same time point after anterior cervical discectomy (Numerical Rating Scale - Neck Pain score 7.0). The median health-care costs of providing initial surgical intervention were £2610 for posterior cervical foraminotomy and £4411 for anterior cervical discectomy. Conclusions The data suggest that posterior cervical foraminotomy is associated with better outcomes, fewer complications and lower costs, but the trial recruited slowly and closed early. Consequently, the trial is underpowered and definitive conclusions cannot be drawn. Recruitment was impaired by lack of individual equipoise and by concern about randomising on the day of surgery. A large prospective multicentre trial comparing anterior cervical discectomy and posterior cervical foraminotomy in the treatment of cervical brachialgia is still required. Trial registration This trial is registered as ISRCTN10133661. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 21. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon Thomson
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gemma Ainsworth
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rachel Kelly
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Howard Collier
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rebecca Talbot
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sarah Tess Brown
- 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
| | - Nikki Rousseau
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ruchi Higham
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Yahia Al-Tamimi
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Buxton
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Martin Gledhill
- Department of Speech and Language Therapy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Peter Hutchinson
- Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James Meacock
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nitin Mukerji
- Department of Neurosurgery, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Debasish Pal
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Anantharaju Prasad
- Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Martin Wilby
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Everett CC, Berry C, McCann GP, Fernandez C, Reynolds C, Bucciarelli-Ducci C, Dall'Armellina E, Prasad A, Foley JR, Mangion K, Bijsterveld P, Brown J, Stocken D, Walker S, Sculpher M, Plein S, Greenwood JP. Randomised trial of stable chest pain investigation: 3-year clinical and quality of life results from CE-MARC 2. Open Heart 2023; 10:openhrt-2022-002221. [PMID: 37130657 PMCID: PMC10163591 DOI: 10.1136/openhrt-2022-002221] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 04/11/2023] [Indexed: 05/04/2023] Open
Abstract
AIMS Guidelines for suspected cardiac chest pain have used historical risk stratification tools, advocating invasive coronary angiography (ICA) first-line in those at highest risk. We aimed to determine whether different strategies to manage suspected stable angina affected medium-term cardiovascular event rates and patient-reported quality of life (QoL) measures. METHODS CE-MARC 2, a three-arm parallel group trial, randomised patients with suspected stable cardiac chest pain and a Duke Clinical pretest likelihood of coronary artery disease between 10% and 90%. Patients were randomised to either first-line cardiovascular magnetic resonance (CMR), single-photon emission computed tomography (SPECT) or the UK National Institute for Health and Care Excellence (NICE) CG95 (2010) guidelines-directed care. For the three arms, 1-year and 3-year first major adverse cardiovascular event (MACE) rates and QoL assessed by the Seattle Angina Questionnaire, Short Form 12 (V.12) Questionnaire and EuroQol-5 Dimension Questionnaire were recorded. RESULTS 1202 patients were randomised to CMR (n=481), SPECT (n=481) and NICE (n=240). Forty-two patients (18 CMR, 18 SPECT, 6 NICE) experienced one or more MACEs. The percentage rates (95% CIs) of MACE in the CMR, SPECT and NICE groups at 3 years were 3.7% (2.4%, 5.8%), 3.7% (2.4%, 5.8%) and 2.1% (0.9%, 4.8%), respectively. QoL scores did not significantly differ across domains. CONCLUSION Despite a fourfold increase in referrals for ICA, the NICE CG95 (2010) guidelines risk-stratified care strategy did not significantly reduce 3-year MACE or improve QoL, as compared with functional imaging with CMR or SPECT. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT01664858).
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Affiliation(s)
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | | | | | - Erica Dall'Armellina
- School of Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Abhiram Prasad
- Cardiovascular Diseases, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - James R Foley
- School of Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kenneth Mangion
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | | | - Julia Brown
- School of Medicine, University of Leeds, Leeds, UK
| | | | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
| | - Sven Plein
- School of Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - John P Greenwood
- School of Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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9
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Twiddy M, Birtwistle J, Edmondson A, Croft J, Gordon K, Meads D, Burke D, Griffiths B, Rose A, Sagar P, Stocken D, Brown JMB, Harji D. Recruiting to surgical trials in the emergency setting: using a mixed methods study to understand clinician and patient perspectives. BJS Open 2022; 6:zrac137. [PMID: 36417312 PMCID: PMC9683391 DOI: 10.1093/bjsopen/zrac137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/23/2022] [Revised: 09/20/2022] [Accepted: 09/29/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Undertaking randomized clinical trials (RCTs) in emergency surgical settings is associated with methodological and practical challenges. This study explored patients' and clinicians' perspectives associated with the conduct of an RCT comparing laparoscopic and open colorectal surgery in the acute setting. METHODS All eligible patients screened and enrolled for the 'Laparoscopic versus open colorectal surgery in the acute setting (LaCeS)' multicentre, randomized clinical feasibility trial in five UK NHS Trusts were invited to respond to a survey. Patients and healthcare professionals were also invited to take part in semi-structured interviews. Survey and interviews explored the acceptability of the feasibility trial. Interviews were audio recorded, transcribed verbatim, and analysed using thematic analysis. Survey data were analysed descriptively to assess patient views of the trial and intervention. RESULTS Out of 72 patients enrolled for the LaCeS RCT, survey data were collected from 28 patients (38.9 per cent), and interviews were conducted with 16 patients and 14 healthcare professionals. Thirteen out of 28 patients (46 per cent) had treatment preferences but these were not strong enough to deter participation. Twelve of the patients interviewed believed that their surgeon preferred laparoscopic surgery, but this did not deter them from participating in the trial. Half of the surgeons interviewed expressed the view that laparoscopic surgery was of benefit in this setting, but recognized that the need for research evidence outweighed their personal treatment preferences. Eight of the 14 recruiters reported that the emergency setting affected recruitment, especially in centres with fewer recruiting surgeons. Interviewees reported that recruitment was helped significantly by using surgical trainees to consent patients. CONCLUSION This study identified specific challenges for the LaCeS trial design to address and adds significant insights to our understanding of recruiting to emergency surgical trials more broadly.
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Affiliation(s)
- Maureen Twiddy
- Hull York Medical School, Institute of Clinical and Applied Health Research, Faculty of Health Sciences, University of Hull, Hull, UK
| | - Jacqueline Birtwistle
- Department of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Amanda Edmondson
- Department of Psychology, Nottingham Trent University,Nottingham, UK
| | - Julie Croft
- Leeds Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Kathryn Gordon
- Leeds Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - David Meads
- Department of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Dermot Burke
- Department of Colorectal Surgery, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ben Griffiths
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Azmina Rose
- Patient and Public Involvement Representative for the LaCeS Trial
| | - Peter Sagar
- Department of Colorectal Surgery, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Deborah Stocken
- Leeds Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Julia M B Brown
- Leeds Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Deena Harji
- Leeds Clinical Trials Research Unit, University of Leeds, Leeds, UK
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
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10
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Bridgewater J, Fletcher P, Palmer DH, Malik HZ, Prasad R, Mirza D, Anthony A, Corrie P, Falk S, Finch-Jones M, Wasan H, Ross P, Wall L, Wadsley J, Evans TR, Stocken D, Stubbs C, Praseedom R, Ma YT, Davidson B, Neoptolemos J, Iveson T, Cunningham D, Garden OJ, Valle JW, Primrose J. Long-Term Outcomes and Exploratory Analyses of the Randomized Phase III BILCAP Study. J Clin Oncol 2022; 40:2048-2057. [PMID: 35316080 DOI: 10.1200/jco.21.02568] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/16/2021] [Accepted: 02/09/2022] [Indexed: 01/03/2023] Open
Abstract
PURPOSE The BILCAP study described a modest benefit for capecitabine as adjuvant therapy for curatively resected biliary tract cancer (BTC), and capecitabine has become the standard of care. We present the long-term data and novel exploratory subgroup analyses. METHODS This randomized, controlled, multicenter, phase III study recruited patients age 18 years or older with histologically confirmed cholangiocarcinoma or muscle-invasive gallbladder cancer after resection with curative intent and an Eastern Cooperative Oncology Group performance status of < 2. Patients were randomly assigned 1:1 to receive oral capecitabine (1,250 mg/m2 twice daily on days 1-14 of a 21-day cycle, for eight cycles) or observation. The primary outcome was overall survival (OS). This study is registered with EudraCT 2005-003318-13. RESULTS Between March 15, 2006, and December 4, 2014, 447 patients were enrolled; 223 patients with BTC resected with curative intent were randomly assigned to the capecitabine group and 224 to the observation group. At the data cutoff of January 21, 2021, the median follow-up for all patients was 106 months (95% CI, 98 to 108). In the intention-to-treat analysis, the median OS was 49.6 months (95% CI, 35.1 to 59.1) in the capecitabine group compared with 36.1 months (95% CI, 29.7 to 44.2) in the observation group (adjusted hazard ratio 0.84; 95% CI, 0.67 to 1.06). In a protocol-specified sensitivity analysis, adjusting for minimization factors, nodal status, grade, and sex, the OS hazard ratio was 0.74 (95% CI, 0.59 to 0.94). We further describe the prognostic impact of R status, grade, nodal status, and sex. CONCLUSION This long-term analysis supports the previous analysis, suggesting that capecitabine can improve OS in patients with resected BTC when used as adjuvant chemotherapy after surgery and should be considered as the standard of care.
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Affiliation(s)
| | | | - Daniel H Palmer
- Molecular and Clinical Cancer Medicine, Liverpool, United Kingdom
| | | | - Raj Prasad
- Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom
| | - Darius Mirza
- Birmingham Woman's and Children's NHS Trust, Birmingham, United Kingdom
| | - Alan Anthony
- Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom
| | - Pippa Corrie
- Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - Stephen Falk
- University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Meg Finch-Jones
- University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Harpreet Wasan
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Paul Ross
- Guys and St Thomas's NHS Trust, London, United Kingdom
| | - Lucy Wall
- Western General Hospital, Edinburgh, United Kingdom
| | | | | | - Deborah Stocken
- Leeds Institute of Clinical Trials Research, Leeds, United Kingdom
| | - Clive Stubbs
- Cancer Clinical Trials Unit, Birmingham, United Kingdom
| | - Raaj Praseedom
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Yuk Ting Ma
- Institute of Immunology and Immunotherapy, Birmingham, United Kingdom
| | | | | | - Tim Iveson
- University Hospital Southampton NHS Trust, Southampton, United Kingdom
| | | | | | - Juan W Valle
- University of Manchester, Manchester, United Kingdom
| | - John Primrose
- University of Southampton, Southampton, United Kingdom
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11
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Homer V, Yap C, Bond S, Holmes J, Stocken D, Walker K, Robinson EJ, Wheeler G, Brown S, Hinsley S, Schipper M, Weir CJ, Rantell K, Prior T, Yu LM, Kirkpatrick J, Bedding A, Gamble C, Gaunt P. Early phase clinical trials extension to guidelines for the content of statistical analysis plans. BMJ 2022; 376:e068177. [PMID: 35131744 PMCID: PMC8819597 DOI: 10.1136/bmj-2021-068177] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Victoria Homer
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Christina Yap
- Clinical Trials and Statistics Unit, Institute for Cancer Research, London, UK
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge, UK
| | - Jane Holmes
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Katrina Walker
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Emily J Robinson
- Royal Marsden Clinical Trials Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Graham Wheeler
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Sarah Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Samantha Hinsley
- Cancer Research UK Glasgow Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Matthew Schipper
- Departments of Radiation Oncology and Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Khadija Rantell
- Medicines and Healthcare products Regulatory Agency, London, UK
| | - Thomas Prior
- Early Development Oncology Statistics Department, Janssen Research and Development, Spring House, PA, USA
| | - Ly-Mee Yu
- Primary Care Clinical Trials Unit, University of Oxford, Oxford, UK
| | | | | | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Piers Gaunt
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK
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12
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Rayner F, Anderson AE, Baker KF, Buckley CD, Dyke B, Fenton S, Filer A, Goodyear CS, Hilkens CMU, Hiu S, Kerrigan S, Kurowska-Stolarska M, Matthews F, McInnes I, Ng WF, Pratt AG, Prichard J, Raza K, Siebert S, Stocken D, Teare MD, Young S, Isaacs JD. BIOlogical Factors that Limit sustAined Remission in rhEumatoid arthritis (the BIO-FLARE study): protocol for a non-randomised longitudinal cohort study. BMC Rheumatol 2021; 5:22. [PMID: 34275488 PMCID: PMC8286860 DOI: 10.1186/s41927-021-00194-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/09/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Our knowledge of immune-mediated inflammatory disease (IMID) aetiology and pathogenesis has improved greatly over recent years, however, very little is known of the factors that trigger disease relapses (flares), converting diseases from inactive to active states. Focussing on rheumatoid arthritis (RA), the challenge that we will address is why IMIDs remit and relapse. Extrapolating from pathogenetic factors involved in disease initiation, new episodes of inflammation could be triggered by recurrent systemic immune dysregulation or locally by factors within the joint, either of which could be endorsed by overarching epigenetic factors or changes in systemic or localised metabolism. METHODS The BIO-FLARE study is a non-randomised longitudinal cohort study that aims to enrol 150 patients with RA in remission on a stable dose of non-biologic disease-modifying anti-rheumatic drugs (DMARDs), who consent to discontinue treatment. Participants stop their DMARDs at time 0 and are offered an optional ultrasound-guided synovial biopsy. They are studied intensively, with blood sampling and clinical evaluation at weeks 0, 2, 5, 8, 12 and 24. It is anticipated that 50% of participants will have a disease flare, whilst 50% remain in drug-free remission for the study duration (24 weeks). Flaring participants undergo an ultrasound-guided synovial biopsy before reinstatement of previous treatment. Blood samples will be used to investigate immune cell subsets, their activation status and their cytokine profile, autoantibody profiles and epigenetic profiles. Synovial biopsies will be examined to profile cell lineages and subtypes present at flare. Blood, urine and synovium will be examined to determine metabolic profiles. Taking into account all generated data, multivariate statistical techniques will be employed to develop a model to predict impending flare in RA, highlighting therapeutic pathways and informative biomarkers. Despite initial recruitment to time and target, the SARS-CoV-2 pandemic has impacted significantly, and a decision was taken to close recruitment at 118 participants with complete data. DISCUSSION This study aims to investigate the pathogenesis of flare in rheumatoid arthritis, which is a significant knowledge gap in our understanding, addressing a major unmet patient need. TRIAL REGISTRATION The study was retrospectively registered on 27/06/2019 in the ISRCTN registry 16371380 .
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Affiliation(s)
- Fiona Rayner
- Translational and Clinical Research Institute, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK.
- Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
| | - Amy E Anderson
- Translational and Clinical Research Institute, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Kenneth F Baker
- Translational and Clinical Research Institute, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Christopher D Buckley
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and Institute for Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Bernard Dyke
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and Institute for Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Sally Fenton
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and Institute for Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Andrew Filer
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and Institute for Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Carl S Goodyear
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Catharien M U Hilkens
- Translational and Clinical Research Institute, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Shaun Hiu
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sean Kerrigan
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | | | - Fiona Matthews
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Iain McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Wan-Fai Ng
- Translational and Clinical Research Institute, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Arthur G Pratt
- Translational and Clinical Research Institute, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jonathan Prichard
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Karim Raza
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and Institute for Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Stefan Siebert
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Deborah Stocken
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - M Dawn Teare
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen Young
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and Institute for Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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13
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Ewies A, Ahmed I, Al-Azzawi F, Pitkin J, Gupta P, Persic M, Sahu B, Elgobashy A, Barraclough L, Woodman J, Babrah J, Bowden S, Stocken D, Billingham L, Sundar S, Rea D. Folic acid supplementation in postmenopausal women with hot flushes: phase III randomised double-blind placebo-controlled trial. BJOG 2021; 128:2024-2033. [PMID: 33982872 DOI: 10.1111/1471-0528.16739] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/30/2020] [Accepted: 02/09/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess whether folic acid supplementation ameliorates hot flushes. DESIGN Double-blind, placebo-controlled randomised trial. SETTING Nine hospitals in England. POPULATION Postmenopausal women experiencing ≥50 hot flushes weekly. METHODS Women (n = 164) were randomly assigned in a 1:1 ratio to receive folic acid 5 mg tablet or placebo daily for 12 weeks. Participants recorded frequency and severity of hot flushes in a Sloan Diary daily and completed Greene Climacteric and Utian Quality of Life (UQoL) Scales at 4-week intervals. MAIN OUTCOME MEASURES The change in daily Hot Flush Score at week 12 from randomisation based on Sloan Diary Composite Score B calculation. RESULTS Data of 143 (87%) women were available for the primary outcome. The mean change (SD) in Hot Flush Score at week 12 was -6.98 (10.30) and -4.57 (9.46) for folic acid and placebo group, respectively. The difference between groups in the mean change was -2.41 (95% CI -5.68 to 0.87) (P = 0.149) and in the adjusted mean change -2.61 (95% CI -5.72 to 0.49) (P = 0.098). Analysis of secondary outcomes indicated an increased benefit in the folic acid group regarding changes in total and emotional UQoL scores at week 8 when compared with placebo. The difference in the mean change from baseline was 5.22 (95% CI 1.16-9.28) and 1.88 (95% CI 0.23-3.52) for total and emotional score, respectively. CONCLUSIONS The study was not able to demonstrate that folic acid had a statistically significant greater benefit in reducing Hot Flush Score over 12 weeks in postmenopausal women when compared with placebo. TWEETABLE ABSTRACT Folic acid may ameliorate hot flushes in postmenopausal women but confirmation is required from a larger study.
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Affiliation(s)
- Aaa Ewies
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - I Ahmed
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - F Al-Azzawi
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - J Pitkin
- London Northwest University Healthcare NHS Trust, Harrow, UK.,Imperial College London, London, UK
| | - P Gupta
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M Persic
- University Hospital of Derby and Burton NHS Foundation Trust, Derby, UK
| | - B Sahu
- Princess Royal Hospital, Shrewsbury and Telford NHS Trust, Shrewsbury, UK
| | - A Elgobashy
- The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | | | - J Woodman
- University Hospital Coventry and Warwickshire, Coventry, UK
| | - J Babrah
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - S Bowden
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - L Billingham
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - S Sundar
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - D Rea
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK.,University Hospitals of Birmingham, Birmingham, UK
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14
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De Siqueira J, Jones A, Waduud M, Troxler M, Stocken D, Scott DJA. Systematic review of interventions to increase the use of arteriovenous fistulae and grafts in incident haemodialysis patients. J Vasc Access 2021; 23:832-838. [PMID: 33845658 PMCID: PMC9465552 DOI: 10.1177/11297298211006994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Patients who commence haemodialysis (HD) through arteriovenous fistulae and
grafts (AVF/G) have improved survival compared to those who do so by venous
lines. Objectives: This systematic review aims to assimilate the evidence for any strategy which
increases the proportion of HD patients starting dialysis through AVF/G. Data sources: Medline, Embase, Cochrane Central and Scopus. Study eligibility, participants and interventions: English language studies comparing any educational, clinical or service
organisation intervention for adult patients with end stage renal failure
and reporting incident AVF/G use. Study appraisal and synthesis: Two reviewers assessed studies for eligibility independently. Outcome data
was extracted and reported as relative risk. Reporting was performed with
reference to the PRISMA statement. Results: Of 1272 studies, 6 were eligible for inclusion. Studies varied in design and
intervention. Formal meta-analysis was not appropriate. One randomised
controlled trial and two cohort studies assessed the role of a renal access
coordinator. Two cohort studies assessed the implementation of qualitive
initiative programmes and one cohort study assessed a national, structured
education programme. Results between studies were contradictory with some
reporting improvements in incident AVF/G use and some no significant
difference. Quality was generally low. Conclusions: It is not possible to reach firm conclusions nor make strategic
recommendations. A comprehensive package of care which educates and
identifies patients approaching dialysis in a timely manner may improve
incident AVF/G use. An unbiased, robust comparison of different strategies
for timing AVF/G referral is required.
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Affiliation(s)
- Jonathan De Siqueira
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alexander Jones
- Department of Vascular Surgery, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Mohammed Waduud
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Max Troxler
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Deborah Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David Julian A Scott
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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15
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Geifman N, Azadbakht N, Zeng J, Wilkinson T, Dand N, Buchan I, Stocken D, Di Meglio P, Warren RB, Barker JN, Reynolds NJ, Barnes MR, Smith CH, Griffiths CEM, Peek N. Defining trajectories of response in patients with psoriasis treated with biologic therapies. Br J Dermatol 2021; 185:825-835. [PMID: 33829489 DOI: 10.1111/bjd.20140] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The effectiveness and cost-effectiveness of biologic therapies for psoriasis are significantly compromised by variable treatment responses. Thus, more precise management of psoriasis is needed. OBJECTIVES To identify subgroups of patients with psoriasis treated with biologic therapies, based on changes in their disease activity over time, that may better inform patient management. METHODS We applied latent class mixed modelling to identify trajectory-based patient subgroups from longitudinal, routine clinical data on disease severity, as measured by the Psoriasis Area and Severity Index (PASI), from 3546 patients in the British Association of Dermatologists Biologics and Immunomodulators Register, as well as in an independent cohort of 2889 patients pooled across four clinical trials. RESULTS We discovered four discrete classes of global response trajectories, each characterized in terms of time to response, size of effect and relapse. Each class was associated with differing clinical characteristics, e.g. body mass index, baseline PASI and prevalence of different manifestations. The results were verified in a second cohort of clinical trial participants, where similar trajectories following the initiation of biologic therapy were identified. Further, we found differential associations of the genetic marker HLA-C*06:02 between our registry-identified trajectories. CONCLUSIONS These subgroups, defined by change in disease over time, may be indicative of distinct endotypes driven by different biological mechanisms and may help inform the management of patients with psoriasis. Future work will aim to further delineate these mechanisms by extensively characterizing the subgroups with additional molecular and pharmacological data.
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Affiliation(s)
- N Geifman
- The Manchester Molecular Pathology Innovation Centre, University of Manchester, Manchester, UK.,Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - N Azadbakht
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - J Zeng
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - T Wilkinson
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - N Dand
- School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Health Data Research UK, London, UK
| | - I Buchan
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - D Stocken
- Clinical Trials Research Unit, University of Leeds, UK
| | - P Di Meglio
- St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - R B Warren
- Dermatology Centre, Salford Royal NHS Foundation Trust, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, UK
| | - J N Barker
- St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - N J Reynolds
- Institute of Translational and Clinical Medicine, Medical School, Newcastle University, Newcastle upon Tyne, UK.,Department of Dermatology, Royal Victoria Infirmary, and NIHR Newcastle Biomedical Research Centre, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - M R Barnes
- Centre for Translational Bioinformatics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - C H Smith
- St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - C E M Griffiths
- Dermatology Centre, Salford Royal NHS Foundation Trust, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, UK
| | - N Peek
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, UK
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16
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Loeff FC, Tsakok T, Dijk L, Hart MH, Duckworth M, Baudry D, Russell A, Dand N, van Leeuwen A, Griffiths CE, Reynolds NJ, Barker J, Burden AD, Warren RB, de Vries A, Bloem K, Wolbink GJ, Smith CH, Rispens T, Barker J, Benham M, Burden D, Evans I, Griffiths C, Hussain S, Kirby B, Lawson L, Mason K, McElhone K, Murphy R, Ormerod A, Owen C, Reynolds N, Smith C, Warren R, Barker JN, Barnes MR, Burden AD, DiMeglio P, Emsley R, Evans A, Griffiths CE, Payne K, Reynolds NJ, Smith CH, Stocken D, Warren RB. Clinical Impact of Antibodies against Ustekinumab in Psoriasis: An Observational, Cross-Sectional, Multicenter Study. J Invest Dermatol 2020; 140:2129-2137. [DOI: 10.1016/j.jid.2020.03.957] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/20/2020] [Accepted: 03/09/2020] [Indexed: 01/07/2023]
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Walker S, Cox E, Rothwell B, Berry C, McCann GP, Bucciarelli-Ducci C, Dall'Armellina E, Prasad A, Foley JRJ, Mangion K, Bijsterveld P, Everett C, Stocken D, Plein S, Greenwood JP, Sculpher M. Cost-effectiveness of cardiovascular imaging for stable coronary heart disease. Heart 2020; 107:381-388. [PMID: 32817271 PMCID: PMC7892375 DOI: 10.1136/heartjnl-2020-316990] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/23/2020] [Accepted: 06/28/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the cost-effectiveness of management strategies for patients presenting with chest pain and suspected coronary heart disease (CHD): (1) cardiovascular magnetic resonance (CMR); (2) myocardial perfusion scintigraphy (MPS); and (3) UK National Institute for Health and Care Excellence (NICE) guideline-guided care. METHODS Using UK data for 1202 patients from the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease 2 trial, we conducted an economic evaluation to assess the cost-effectiveness of CMR, MPS and NICE guidelines. Health outcomes were expressed as quality-adjusted life-years (QALYs), and costs reflected UK pound sterling in 2016-2017. Cost-effectiveness results were presented as incremental cost-effectiveness ratios and incremental net health benefits overall and for low, medium and high pretest likelihood of CHD subgroups. RESULTS CMR had the highest estimated QALY gain overall (2.21 (95% credible interval 2.15, 2.26) compared with 2.07 (1.92, 2.20) for NICE and 2.11 (2.01, 2.22) for MPS) and incurred comparable costs (overall £1625 (£1431, £1824) compared with £1753 (£1473, £2032) for NICE and £1768 (£1572, £1989) for MPS). Overall, CMR was the cost-effective strategy, being the dominant strategy (more effective, less costly) with incremental net health benefits per patient of 0.146 QALYs (-0.18, 0.406) compared with NICE guidelines at a cost-effectiveness threshold of £15 000 per QALY (93% probability of cost-effectiveness). Results were similar in the pretest likelihood subgroups. CONCLUSIONS CMR-guided care is cost-effective overall and across all pretest likelihood subgroups, compared with MPS and NICE guidelines.
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Affiliation(s)
- Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Edward Cox
- Centre for Health Economics, University of York, York, UK
| | | | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute, NIHR Bristol Cardiovascular Biomedical Research Centre and Clinical Research and Imaging Centre (CRIC), University of Bristol and University Hospitals Bristol NHD Trust, Bristol, UK
| | - Erica Dall'Armellina
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular & Metabolic Medicine, University of Leeds, Leeds, UK.,Oxford Centre of Cardiovascular Magnetic Resonance, Oxford University, Oxford, UK
| | - Abhiram Prasad
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.,Cardiovascular Sciences Research Centre, St George's, University of London, London, UK
| | - James Robert John Foley
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular & Metabolic Medicine, University of Leeds, Leeds, UK
| | - Kenneth Mangion
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Petra Bijsterveld
- CTRU - Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Colin Everett
- CTRU - Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Deborah Stocken
- CTRU - Clinical Trials Research Unit, Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sven Plein
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular & Metabolic Medicine, University of Leeds, Leeds, UK
| | - John P Greenwood
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular & Metabolic Medicine, University of Leeds, Leeds, UK
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
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18
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Harji DP, Marshall H, Gordon K, Twiddy M, Pullan A, Meads D, Croft J, Burke D, Griffiths B, Verjee A, Sagar P, Stocken D, Brown J. Laparoscopic versus open colorectal surgery in the acute setting (LaCeS trial): a multicentre randomized feasibility trial. Br J Surg 2020; 107:1595-1604. [PMID: 32573782 DOI: 10.1002/bjs.11703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/11/2020] [Accepted: 04/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately 30 000 people undergo major emergency abdominal gastrointestinal surgery annually, and 36 per cent of these procedures (around 10 800) are carried out for emergency colorectal pathology. Some 14 per cent of all patients requiring emergency surgery have a laparoscopic procedure. The aims of the LaCeS (laparoscopic versus open colorectal surgery in the acute setting) feasibility trial were to assess the feasibility, safety and acceptability of performing a large-scale definitive phase III RCT, with a comparison of emergency laparoscopic versus open surgery for acute colorectal pathology. METHODS LaCeS was designed as a prospective, multicentre, single-blind, parallel-group, pragmatic feasibility RCT with an integrated qualitative study. Randomization was undertaken centrally, with patients randomized on a 1 : 1 basis between laparoscopic or open surgery. RESULTS A total of 64 patients were recruited across five centres. The overall mean steady-state recruitment rate was 1·2 patients per month per site. Baseline compliance for clinical and health-related quality-of-life data was 99·8 and 93·8 per cent respectively. The conversion rate from laparoscopic to open surgery was 39 (95 per cent c.i. 23 to 58) per cent. The 30-day postoperative complication rate was 27 (13 to 46) per cent in the laparoscopic arm and 42 (25 to 61) per cent in the open arm. CONCLUSION Laparoscopic emergency colorectal surgery may have an acceptable safety profile. Registration number: ISRCTN15681041 ( http://www.controlled-trials.com).
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Affiliation(s)
- D P Harji
- Department of Colorectal Surgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - H Marshall
- Clinical Trials Research Unit, Leeds, UK
| | - K Gordon
- Clinical Trials Research Unit, Leeds, UK
| | - M Twiddy
- Institute of Clinical and Applied Health Research, University of Hull, Hull, UK
| | - A Pullan
- Clinical Trials Research Unit, Leeds, UK
| | - D Meads
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - J Croft
- Clinical Trials Research Unit, Leeds, UK
| | - D Burke
- Department of Colorectal Surgery, St James's University Hospital, Leeds, UK
| | - B Griffiths
- Department of Colorectal Surgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - A Verjee
- Patient and Public Involvement Representative for LaCeS Trial, UK
| | - P Sagar
- Department of Colorectal Surgery, St James's University Hospital, Leeds, UK
| | - D Stocken
- Clinical Trials Research Unit, Leeds, UK
| | - J Brown
- Clinical Trials Research Unit, Leeds, UK
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Pratt A, Siebert S, Cole M, Stocken D, Kelly S, Shaikh M, Cranston A, Morton M, Walker J, Frame S, Ng WF, Buckley C, Mcinnes I, Filer A, Isaacs JD. AB0356 TARGETING THE RHEUMATOID ARTHRITIS SYNOVIAL FIBROBLAST VIA CYCLIN DEPENDENT KINASE INHIBITION (TRAFIC): A PHASE 1B STUDY TO DETERMINE THE MAXIMUM TOLERATED DOSE OF SELICICLIB FOR REPURPOSING IN RHEUMATOID ARTHRITIS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.2443] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Current rheumatoid arthritis (RA) therapeutics target immune inflammation and are subject to ceiling effects, with non-response observed in a third of recipients together with low remission rates. Synovial fibroblasts (SFs) are stromal cells not yet targeted in RA, whose hyperplastic and proliferative properties drive inflammation and tissue destruction. Seliciclib (R-roscovitine) is an orally available cyclin-dependent kinase (CDK) inhibitor that suppresses SF proliferation and ameliorates inflammatory arthritis in rodents.Objectives:To determine the maximum tolerated dose (MTD) of seliciclib in patients with active RA despite anti-TNF, with or without background conventional disease modifying anti-rheumatic drugs (cDMARDs). Safety and pharmacokinetics (PK) were also evaluated.Methods:A restricted, one-stage Bayesian continual reassessment method (CRM) determined MTD based on a target dose-limiting toxicity (DLT) probability of 35%. RA patients (DAS28 ≥3.2) were recruited sequentially to cohorts of 3 subjects each. Cohort 1 received 400mg seliciclib daily for 4 consecutive days each week for 4 weeks, added to existing therapy. Each subsequent cohort received a dose determined by the toxicity-based CRM algorithm, calculated upon conclusion of the previous cohort. Safety was assessed through adverse event (AE) monitoring. Associations with relevant PK parameters were sought.Results:15 anti-TNF recipients were enrolled, 10 of whom were also taking cDMARDs (median DAS28 4.9). Application of the CRM algorithm prompted one dose increment during the study (to 600mg for cohort 2), but reversion to 400mg for subsequent cohorts (Figure 1A). After treatment of 5 cohorts, 400mg was determined the MTD, with a DLT probability of 0.35 (CI 0.18-0.52; Figure 1B). 6 patients experienced DLTs, of which two were classified as serious AEs (SAEs) in keeping with the safety profile of seliciclib; these are summarised in Table 1. Of 43/65 total AEs reported at any dose that didnotcontribute to a DLT, 26 were possibly, probably or definitely related to seliciclib; 19 of these 26 were mild, 7 moderate and none severe. The most frequent AE was mild nausea. No relationship of safety and/or tolerability with concomitant cDMARD use or PK was seen.Table 1.Characteristics of patients who developed HZ at initiation of baricitinibDLTSeliciclib dose (mg)Doses receivedContributing AEsContributing SAEsDescriptionOutcomeA1400830Constipation, N+V, liver injury; fatigue.Resolved2600430Constipation, N+V.Resolved3600101BFever, N+V, renal injury.Resolved4400831BConstipation, N+V, jaundice, liver injury.Resolved5400840Fever, dizziness, liver injury.Resolved6400890Dizziness, N+V, liver injury, bilirubin rise.Persistent AST riseConclusion:The MTD of seliciclib has been defined for RA. No unexpected safety concerns were identified to preclude ongoing evaluation in patients, which focuses on clinical, radiological and biological indicators of efficacy.Disclosure of Interests:Arthur Pratt Grant/research support from: Pfizer, GlaxoSmithKlein, Stefan Siebert Grant/research support from: BMS, Boehringer Ingelheim, Celgene, GlaxoSmithKline, Janssen, Novartis, Pfizer, UCB, Consultant of: AbbVie, Boehringer Ingelheim, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Celgene, Janssen, Novartis, Michael Cole: None declared, Deborah Stocken: None declared, Stephen Kelly: None declared, Muddassir Shaikh: None declared, Amy Cranston: None declared, Miranda Morton: None declared, Jennifer Walker: None declared, Sheelagh Frame Employee of: Cyclacel Ltd., Wan-fai Ng: None declared, Chris Buckley Consultant of: Janssen, Pfizer, GSK, Galapagos, Gillead, Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB, Andrew Filer: None declared, John D Isaacs Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Gilead, Janssen, Merck, Pfizer, Roche
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Rennie KJ, O'Hara J, Rousseau N, Stocken D, Howel D, Ternent L, Drinnan M, Bray A, Rooshenas L, Hamilton DW, Steel A, Fouweather T, Hynes AM, Holstein EM, Oluboyede Y, Abouhajar A, Wilson JA, Carrie S. Nasal Airway Obstruction Study (NAIROS): a phase III, open-label, mixed-methods, multicentre randomised controlled trial of septoplasty versus medical management of a septal deviation with nasal obstruction. Trials 2020; 21:179. [PMID: 32054508 PMCID: PMC7020359 DOI: 10.1186/s13063-020-4081-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/16/2020] [Indexed: 11/23/2022] Open
Abstract
Background Septoplasty (surgery to straighten a deviation in the nasal septum) is a frequently performed operation worldwide, with approximately 250,000 performed annually in the US and 22,000 in the UK. Most septoplasties aim to improve diurnal and nocturnal nasal obstruction. The evidence base for septoplasty clinical effectiveness is hitherto very limited. Aims To establish, and inform guidance for, the best management strategy for individuals with nasal obstruction associated with a deviated septum. Methods/design A multicentre, mixed-methods, open label, randomised controlled trial of septoplasty versus medical management for adults with a deviated septum and a reduced nasal airway. Eligible patients will have septal deflection visible at nasendoscopy and a nasal symptom score ≥ 30 on the NOSE questionnaire. Surgical treatment comprises septoplasty with or without reduction of the inferior nasal turbinate on the anatomically wider side of the nose. Medical management comprises a nasal saline spray followed by a fluorinated steroid spray daily for six months. The recruitment target is 378 patients, recruited from up to 17 sites across Scotland, England and Wales. Randomisation will be on a 1:1 basis, stratified by gender and severity (NOSE score). Participants will be followed up for 12 months post randomisation. The primary outcome measure is the total SNOT-22 score at 6 months. Clinical and economic outcomes will be modelled against baseline severity (NOSE scale) to inform clinical decision-making. The study includes a recruitment enhancement process, and an economic evaluation. Discussion The NAIROS trial will evaluate the clinical effectiveness and cost-effectiveness of septoplasty versus medical management for adults with a deviated septum and symptoms of nasal blockage. Identifying those individuals most likely to benefit from surgery should enable more efficient and effective clinical decision-making, and avoid unnecessary operations where there is low likelihood of patient benefit. Trial registration EudraCT: 2017–000893-12, ISRCTN: 16168569. Registered on 24 March 2017.
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Affiliation(s)
- Katherine J Rennie
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - James O'Hara
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK.,Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Freeman Road, Newcastle upon Tyne, NE7 7DN, UK
| | - Nikki Rousseau
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
| | - Deborah Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Denise Howel
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
| | - Laura Ternent
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
| | - Mike Drinnan
- Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Freeman Road, Newcastle upon Tyne, NE7 7DN, UK.,Northern Medical Physics and Clinical Engineering, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Alison Bray
- Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Freeman Road, Newcastle upon Tyne, NE7 7DN, UK.,Northern Medical Physics and Clinical Engineering, Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.,NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Leila Rooshenas
- Bristol Population Health Science Institute, University of Bristol, Bristol, BS8 2PS, UK
| | - David W Hamilton
- Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Freeman Road, Newcastle upon Tyne, NE7 7DN, UK
| | - Alison Steel
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - Tony Fouweather
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
| | - Ann-Marie Hynes
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - Eva-Maria Holstein
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - Yemi Oluboyede
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
| | - Alaa Abouhajar
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - Janet A Wilson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK.,Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Freeman Road, Newcastle upon Tyne, NE7 7DN, UK
| | - Sean Carrie
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK. .,Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Freeman Road, Newcastle upon Tyne, NE7 7DN, UK.
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Tsakok T, Wilson N, Dand N, Loeff FC, Bloem K, Baudry D, Duckworth M, Pan S, Pushpa-Rajah A, Standing JF, de Vries A, Alsharqi A, Becher G, Murphy R, Wahie S, Wright A, Griffiths CEM, Reynolds NJ, Barker J, Warren RB, Burden AD, Rispens T, Stocken D, Smith C. Association of Serum Ustekinumab Levels With Clinical Response in Psoriasis. JAMA Dermatol 2019; 155:1235-1243. [PMID: 31532460 PMCID: PMC6751771 DOI: 10.1001/jamadermatol.2019.1783] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Question Can therapeutic drug monitoring for the interleukin-12 and interleukin-23 inhibitor ustekinumab optimize treatment pathways and outcomes in patients with psoriasis? Findings This cohort study of 491 patients with psoriasis found that early serum ustekinumab levels were associated with a subsequent 75% reduction from baseline in Psoriasis Area and Severity Index score, although this association did not hold across other Psoriasis Area and Severity Index outcomes. Drug immunogenicity appeared to be low, with antidrug antibodies detected in only 17 of 490 patients (3.5%). Meaning This study provides evidence that measurement of early ustekinumab levels could be useful to direct treatment strategy in patients with psoriasis; adequate drug exposure early in the treatment cycle may be particularly important in determining clinical outcome. Importance High-cost biologic therapies have transformed the management of immune-mediated inflammatory diseases. To optimize outcomes and reduce costs, dose adjustment informed by measurement of circulating drug levels has been shown to be effective in various settings. However, limited evidence exists for this approach with the interleukin 12 and interleukin 23 inhibitor ustekinumab. Objective To evaluate clinical utility of therapeutic drug monitoring for ustekinumab in patients with psoriasis. Design, Setting, and Participants A prospective observational cohort of 491 adults with psoriasis was recruited to the multicenter Biomarkers of Systemic Treatment Outcomes in Psoriasis study within the British Association of Dermatologists Biologic and Immunomodulators Register from June 2009 to December 2017; samples from some patients were taken between 2009 and 2011 as part of a pilot study with the same inclusion criteria. Exposure Serum ustekinumab level measured at any point during the dosing cycle using an enzyme-linked immunosorbent assay. Main Outcomes and Measures Disease activity measured using the Psoriasis Area and Severity Index (PASI) score. Treatment response outcomes were PASI75 (75% reduction in PASI score from baseline [primary outcome]), PASI90 (90% reduction of PASI score from baseline), and absolute PASI score of 1.5 or less. Results A total of 491 patients (171 women and 320 men; mean [SD] age, 45.7 [12.8] years) had 1 or more serum samples (total, 853 samples obtained 0-56 weeks from start of treatment) and 1 or more PASI scores within the first year of treatment. Antidrug antibodies were detected in only 17 of 490 patients (3.5%). Early measured drug levels (1-12 weeks after starting treatment) were associated with PASI75 response 6 months after starting treatment (odds ratio, 1.38; 95% CI, 1.11-1.71) when adjusted for baseline PASI score, age, and ustekinumab dose. However, this finding was not consistent across the other PASI outcomes (PASI90 and PASI score of ≤1.5). Conclusions and Relevance This real-world study provides evidence that measurement of early serum ustekinumab levels could be useful to direct the treatment strategy for psoriasis. Adequate drug exposure early in the treatment cycle may be particularly important in determining clinical outcome.
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Affiliation(s)
- Teresa Tsakok
- St John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom.,St John's Institute of Dermatology, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Nina Wilson
- Institute of Health and Society, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Nick Dand
- Department of Medical and Molecular Genetics, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Floris C Loeff
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam, the Netherlands
| | - Karien Bloem
- Biologics Lab, Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | - David Baudry
- St John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Michael Duckworth
- St John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Shan Pan
- Infection, Immunity, Inflammation Section, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Angela Pushpa-Rajah
- St John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Joseph F Standing
- Infection, Immunity, Inflammation Section, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Annick de Vries
- Biologics Lab, Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | - Ali Alsharqi
- Department of Dermatology, Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | | | - Ruth Murphy
- Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, United Kingdom
| | - Shyamal Wahie
- Department of Dermatology, University Hospital of North Durham, Durham, United Kingdom
| | - Andrew Wright
- Centre for Skin Sciences, University of Bradford, Bradford, United Kingdom
| | - Christopher E M Griffiths
- Dermatology Centre, Salford Royal National Health Service Foundation Trust, Manchester, United Kingdom.,The University of Manchester, Manchester Academic Health Science Centre, National Institute for Health Research Manchester Biomedical Research Centre, Manchester, United Kingdom
| | - Nick J Reynolds
- Dermatology Sciences, Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom.,Department of Dermatology, Royal Victoria Infirmary, Newcastle Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Jonathan Barker
- St John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom.,St John's Institute of Dermatology, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Richard B Warren
- Dermatology Centre, Salford Royal National Health Service Foundation Trust, Manchester, United Kingdom
| | - A David Burden
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Theo Rispens
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam, the Netherlands
| | - Deborah Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Catherine Smith
- St John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom.,St John's Institute of Dermatology, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
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Kunadian V, Wilson N, Stocken D, Ali H, McColl E, Burns G, Howe N, Fisher A, De Soyza A. P666Anti-platelet therapy in the primary prevention of cardiovascular disease in patients with chronic obstructive pulmonary disease: randomised controlled proof of concept trial (APPLE COPD-ICON 2). Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
The APPLE COPD-ICON2 trial is a prospective 2x2 factorial, double blinded proof of concept randomised controlled trial targeting patients with chronic obstructive pulmonary disease (COPD) at high risk of cardiovascular disease. The primary goal was to investigate if antiplatelet therapy (APT) will produce the predefined cut-off of platelet inhibition measured using the Multiplate test. We also assessed inflammatory biomarkers in serum.
Patients were randomised to Aspirin plus placebo, ticagrelor plus placebo, Aspirin plus ticagrelor or placebo only for 6 months. The primary outcome is inhibition of arachidonic acid (ASPI-test, cut-off <40) and adenosine diphosphate (ADP-test, cut-off <46) induced platelet aggregation at 6 months based on intention to treat (ITT) and sensitivity per protocol (PP) analyses. Safety outcomes included rates of major/minor bleeding.
Of 543 patients screened, 120 were recruited (mean age of 67.5 years). The ITT response rate to Aspirin was 48.3% (95% confidence interval [CI] 35.8–61.0%) according to ASPI-test and the response rate to ticagrelor was 41.4% (95% CI 29.3–54.6%) according to ADP-test. The PP ASPI-test response rate to Aspirin was 68.3% (95% CI 52.3–80.9%) and the PP ADP-test response rate to ticagrelor was 68.8% (95% CI 50.4–82.6%). There were no differences between the groups in the changes in Quality of Life using questionnaires (EQ5D 5L, St. George's COPD-C), inflammatory markers, carotid intima media thickness and vascular stiffness from baseline to 6-months. There were 5 type 1 bleeds according to the BARC criteria recorded in this study; 2 in the placebo arm, 2 in the Aspirin arm, and 1 in the ticagrelor arm. The MRC Dyspnoea score, FEV1 and FVC was similar across the groups.
Primary outcome measures Aspirin No Aspirin Ticagrelor No Ticagrelor ITT analysis set* n 60 60 58 62 Baseline No. of responders 1 6 4 1 % (95% CI) 1.7 (0.2, 11.3) 10 (4.5, 20.8) 6.9 (2.6, 17.3) 1.6 (0.2, 10.9) 6 months No. of responders 29 7 24 2 % (95% CI) 48.3 (35.8, 61) 11.7 (5.6, 22.8) 41.4 (29.3, 54.6) 3.2 (0.8, 12.3) PP analysis set** n 41 45 32 54 6 months No. of responders 28 7 22 2 % (95% CI) 68.3 (52.3, 80.9) 15.6 (7.5, 29.6) 68.8 (50.4, 82.6) 3.7 (0.9, 14.0) *Descriptive statistics for the primary outcome of response for the comparative groups at baseline and 6 months for the ITT analysis set and **PP analysis set. Note that response is ASPI response in the Aspirin and No Aspirin columns and ADP response in the ticagrelor and No ticagrelor columns.
Primary outcome measure
Nearly one third of COPD patients did not have a platelet response to antiplatelet therapy with Aspirin and ticagrelor. These findings support the high pro-thrombotic milieu and the need for further research in COPD patients.
Acknowledgement/Funding
Astra Zeneca (Funder reference number ISSBRIL0303)
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Affiliation(s)
- V Kunadian
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - N Wilson
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - D Stocken
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - H Ali
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - E McColl
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - G Burns
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - N Howe
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - A Fisher
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - A De Soyza
- Newcastle University, Newcastle upon Tyne, United Kingdom
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23
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Tarn JR, Howard-Tripp N, Lendrem DW, Mariette X, Saraux A, Devauchelle-Pensec V, Seror R, Skelton AJ, James K, McMeekin P, Al-Ali S, Hackett KL, Lendrem BC, Hargreaves B, Casement J, Mitchell S, Bowman SJ, Price E, Pease CT, Emery P, Lanyon P, Hunter J, Gupta M, Bombardieri M, Sutcliffe N, Pitzalis C, McLaren J, Cooper A, Regan M, Giles I, Isenberg D, Saravanan V, Coady D, Dasgupta B, McHugh N, Young-Min S, Moots R, Gendi N, Akil M, Griffiths B, Johnsen SJA, Norheim KB, Omdal R, Stocken D, Everett C, Fernandez C, Isaacs JD, Gottenberg JE, Ng WF. Symptom-based stratification of patients with primary Sjögren's syndrome: multi-dimensional characterisation of international observational cohorts and reanalyses of randomised clinical trials. Lancet Rheumatol 2019; 1:e85-e94. [PMID: 38229348 PMCID: PMC7134527 DOI: 10.1016/s2665-9913(19)30042-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/20/2019] [Accepted: 08/20/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Heterogeneity is a major obstacle to developing effective treatments for patients with primary Sjögren's syndrome. We aimed to develop a robust method for stratification, exploiting heterogeneity in patient-reported symptoms, and to relate these differences to pathobiology and therapeutic response. METHODS We did hierarchical cluster analysis using five common symptoms associated with primary Sjögren's syndrome (pain, fatigue, dryness, anxiety, and depression), followed by multinomial logistic regression to identify subgroups in the UK Primary Sjögren's Syndrome Registry (UKPSSR). We assessed clinical and biological differences between these subgroups, including transcriptional differences in peripheral blood. Patients from two independent validation cohorts in Norway and France were used to confirm patient stratification. Data from two phase 3 clinical trials were similarly stratified to assess the differences between subgroups in treatment response to hydroxychloroquine and rituximab. FINDINGS In the UKPSSR cohort (n=608), we identified four subgroups: Low symptom burden (LSB), high symptom burden (HSB), dryness dominant with fatigue (DDF), and pain dominant with fatigue (PDF). Significant differences in peripheral blood lymphocyte counts, anti-SSA and anti-SSB antibody positivity, as well as serum IgG, κ-free light chain, β2-microglobulin, and CXCL13 concentrations were observed between these subgroups, along with differentially expressed transcriptomic modules in peripheral blood. Similar findings were observed in the independent validation cohorts (n=396). Reanalysis of trial data stratifying patients into these subgroups suggested a treatment effect with hydroxychloroquine in the HSB subgroup and with rituximab in the DDF subgroup compared with placebo. INTERPRETATION Stratification on the basis of patient-reported symptoms of patients with primary Sjögren's syndrome revealed distinct pathobiological endotypes with distinct responses to immunomodulatory treatments. Our data have important implications for clinical management, trial design, and therapeutic development. Similar stratification approaches might be useful for patients with other chronic immune-mediated diseases. FUNDING UK Medical Research Council, British Sjogren's Syndrome Association, French Ministry of Health, Arthritis Research UK, Foundation for Research in Rheumatology. VIDEO ABSTRACT.
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Affiliation(s)
- Jessica R Tarn
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Nadia Howard-Tripp
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dennis W Lendrem
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Xavier Mariette
- Université Paris-Sud, AP-HP Université Paris-Saclay, Hôpital Bicêtre, Department of Rheumatology, INSERM UMR1184, Le Kremlin-Bicêtre, France
| | - Alain Saraux
- Lymphocytes B et auto-immunité, Inserm U1227, University of Brest, Brest, France; Centre Hospitalier Régional Universitaire de Brest, Brest, France
| | - Valerie Devauchelle-Pensec
- Lymphocytes B et auto-immunité, Inserm U1227, University of Brest, Brest, France; Centre Hospitalier Régional Universitaire de Brest, Brest, France
| | - Raphaele Seror
- Université Paris-Sud, AP-HP Université Paris-Saclay, Hôpital Bicêtre, Department of Rheumatology, INSERM UMR1184, Le Kremlin-Bicêtre, France
| | - Andrew J Skelton
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Katherine James
- Interdisciplinary Computing & Complex BioSystems Research Group, School of Computing, Newcastle University, Newcastle upon Tyne, UK
| | - Peter McMeekin
- Faculty of Health and Life Science, Northumbria University, Newcastle upon Tyne, UK
| | - Shereen Al-Ali
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Department of Pathological Analyses, College of Science, University of Basrah, Basrah, Iraq
| | - Katie L Hackett
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Faculty of Health and Life Science, Northumbria University, Newcastle upon Tyne, UK
| | - B Clare Lendrem
- National Institute for Health Research Newcastle In Vitro Diagnostics Co-operative, NewcastleUniversity, Newcastle upon Tyne, UK
| | - Ben Hargreaves
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John Casement
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Sheryl Mitchell
- Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - Colin T Pease
- Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust Leeds, Leeds, UK
| | - Paul Emery
- Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust Leeds, Leeds, UK
| | - Peter Lanyon
- Nottingham University Hospitals NHS Trust, Rheumatology, Derby Road, Nottingham, UK
| | | | | | - Michele Bombardieri
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | | | - Costantino Pitzalis
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | | | | | - Marian Regan
- University Hospitals of Derby and Burton, Derby, UK
| | - Ian Giles
- Centre for Rheumatology, University College London, London, UK
| | - David Isenberg
- Centre for Rheumatology, University College London, London, UK
| | | | - David Coady
- City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Bhaskar Dasgupta
- Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK
| | - Neil McHugh
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | | | - Robert Moots
- University Hospital Aintree, University of Liverpool, Liverpool, UK
| | - Nagui Gendi
- Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, UK
| | - Mohammed Akil
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Bridget Griffiths
- Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | | | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Colin Everett
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Catherine Fernandez
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - John D Isaacs
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
| | - Jacques-Eric Gottenberg
- Department of Rheumatology, Centre de Référence National Pour les Maladies Auto-Immunes Systémiques Rares, CNRS, Strasbourg, France; Institut de Biologie Moléculaire et Cellulaire, Immunopathologie et Chimie Thérapeutique, Université de Strasbourg, Strasbourg, France
| | - Wan-Fai Ng
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
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Mahil SK, Wilson N, Dand N, Reynolds NJ, Griffiths CEM, Emsley R, Marsden A, Evans I, Warren RB, Stocken D, Barker JN, Burden AD, Smith CH. Psoriasis treat to target: defining outcomes in psoriasis using data from a real-world, population-based cohort study (the British Association of Dermatologists Biologics and Immunomodulators Register, BADBIR). Br J Dermatol 2019; 182:1158-1166. [PMID: 31286471 PMCID: PMC7317460 DOI: 10.1111/bjd.18333] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2019] [Indexed: 12/16/2022]
Abstract
Background The ‘treat to target’ paradigm improves outcomes and reduces costs in chronic disease management but is not yet established in psoriasis. Objectives To identify treatment targets in psoriasis using two common measures of disease activity: Psoriasis Area and Severity Index (PASI) and Physician's Global Assessment (PGA). Methods Data from a multicentre longitudinal U.K. cohort of patients with psoriasis receiving systemic or biologic therapies (British Association of Dermatologists Biologics and Immunomodulators Register, BADBIR) were used to identify absolute PASI thresholds for 90% (PASI 90) and 75% (PASI 75) improvements in baseline disease activity, using receiver operating characteristic curves. The relationship between PGA (clear, almost clear, mild, moderate, moderate–severe, severe) and PASI (range 0–72) was described, and the concordance between absolute and relative definitions of response was determined. The same approach was used to establish treatment response and eligibility definitions based on PGA. Results Data from 13 422 patients were available (58% male, 91% white ethnicity, mean age 44·9 years), including over 23 000 longitudinal PASI and PGA scores. An absolute PASI ≤ 2 was concordant with PASI 90 and an absolute PASI ≤ 4 was concordant with PASI 75 in 90% and 88% of cases, respectively. These findings were robust to subgroups of timing of assessment, baseline disease severity and treatment modality. PASI and PGA were strongly correlated (Spearman's rank correlation coefficient 0·92). The median PASI increased from 0 (interquartile range 0–0, range 0–23) to 19 (interquartile range 15–25, range 0–64) for PGA clear to severe, respectively. PGA clear/almost clear was concordant with PASI ≤ 2 in 90% of cases, and PGA moderate–severe severe was concordant with the National Institute for Health and Care Excellence PASI eligibility criteria for biologics in 81% of cases. Conclusions An absolute PASI ≤ 2 and PGA clear/almost clear represent relevant disease end points to inform treat‐to‐target management strategies in psoriasis. What's already known about this topic? The most commonly used relative disease activity measure in psoriasis is ≥ 90% improvement in Psoriasis Area and Severity Index (PASI 90); however, it has several limitations including dependency on a baseline severity assessment. Defining an absolute target disease activity end point in psoriasis has the potential to improve patient outcomes and reduce costs, as demonstrated by treat‐to‐target approaches in other chronic diseases such as hypertension and diabetes. The Physician's Global Assessment (PGA) is a popular alternative measure of psoriasis severity in daily practice; however, its utility has not been formally assessed with respect to PASI.
What does this study add? An absolute PASI ≤ 2 corresponds with PASI 90 response and is a relevant disease end point for treat‐to‐target approaches in psoriasis. There is a strong correlation between PASI and PGA. PGA moderate–severe/severe may serve as an alternative eligibility criterion for biologics to PASI‐based definitions, and PGA clear/almost clear is an appropriate alternative absolute treatment end point.
What are the clinical implications of this work? Absolute PASI ≤ 2 and PGA clear/almost clear represent relevant disease end points to inform treat‐to‐target management strategies in psoriasis.
Linked Editorial: Takeshita. Br J Dermatol 2020; 182:1075–1076.
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Affiliation(s)
- S K Mahil
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, U.K
| | - N Wilson
- Institute of Health and Society, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, U.K
| | - N Dand
- Department of Medical and Molecular Genetics, King's College London, London, U.K
| | - N J Reynolds
- Dermatological Sciences, Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, U.K.,Department of Dermatology, Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, U.K
| | - C E M Griffiths
- Dermatology Centre, Salford Royal NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, U.K
| | - R Emsley
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, U.K
| | - A Marsden
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K
| | - I Evans
- Dermatology Centre, Salford Royal NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, U.K
| | - R B Warren
- Dermatology Centre, Salford Royal NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, U.K
| | - D Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, U.K
| | - J N Barker
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, U.K
| | - A D Burden
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, U.K
| | - C H Smith
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, U.K
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25
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Dand N, Duckworth M, Baudry D, Russell A, Curtis CJ, Lee SH, Evans I, Mason KJ, Alsharqi A, Becher G, Burden AD, Goodwin RG, McKenna K, Murphy R, Perera GK, Rotarescu R, Wahie S, Wright A, Reynolds NJ, Warren RB, Griffiths CE, Smith CH, Simpson MA, Barker JN, Benham M, Hussain S, Kirby B, Lawson L, McElhone K, Ormerod A, Owen C, Barnes MR, Di Meglio P, Emsley R, Evans A, Payne K, Stocken D. HLA-C*06:02 genotype is a predictive biomarker of biologic treatment response in psoriasis. J Allergy Clin Immunol 2019; 143:2120-2130. [DOI: 10.1016/j.jaci.2018.11.038] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/13/2018] [Accepted: 11/27/2018] [Indexed: 01/28/2023]
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26
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Jones AD, Waduud MA, Walker P, Stocken D, Bailey MA, Scott DJA. Meta-analysis of fenestrated endovascular aneurysm repair versus open surgical repair of juxtarenal abdominal aortic aneurysms over the last 10 years. BJS Open 2019; 3:572-584. [PMID: 31592091 PMCID: PMC6773647 DOI: 10.1002/bjs5.50178] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 04/01/2019] [Indexed: 11/12/2022] Open
Abstract
Background Juxtarenal abdominal aortic aneurysms pose a significant challenge whether managed endovascularly or by open surgery. Fenestrated endovascular aneurysm repair (FEVAR) is now well established, but few studies have compared it with open surgical repair (OSR). The aim of this systematic review was to compare short‐ and long‐term outcomes of FEVAR and OSR for the management of juxtarenal aortic aneurysms. Methods A literature search was conducted of the Ovid Medline, EMBASE and PubMed databases. Reasons for exclusion were series with fewer than 20 patients, studies published before 2007 and those concerning ruptured aneurysms. Owing to variance in definitions, the terms ‘juxta/para/suprarenal’ were used; thoracoabdominal aortic aneurysms were excluded. Primary outcomes were 30‐day/in‐hospital mortality and renal insufficiency. Secondary outcomes included major complication rates, rate of reintervention and rates of endoleak. Results Twenty‐seven studies were identified, involving 2974 patients. Study designs included 11 case series, 14 series within retrospective cohort studies, one case–control study and a single prospective non‐randomized trial. The pooled early postoperative mortality rate following FEVAR was 3·3 (95 per cent c.i. 2·0 to 5·0) per cent, compared with 4·2 (2·9 to 5·7) per cent after OSR. After FEVAR, the rate of postoperative renal insufficiency was 16·2 (10·4 to 23·0) per cent, compared with 23·8 (15·2 to 33·6) per cent after OSR. The major early complication rate following FEVAR was 23·1 (16·8 to 30·1) per cent versus 43·5 (34·4 to 52·8) per cent after OSR. The rate of late reintervention after FEVAR was higher than that after OSR: 11·1 (6·7 to 16·4) versus 2·0 (0·6 to 4·3) per cent respectively. Conclusion No significant difference was noted in 30‐day mortality; however, FEVAR was associated with significantly lower morbidity than OSR. Long‐term durability is a concern, with far higher reintervention rates after FEVAR.
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Affiliation(s)
- A D Jones
- The Leeds Vascular Institute Leeds General Infirmary Leeds UK
| | - M A Waduud
- The Leeds Vascular Institute Leeds General Infirmary Leeds UK.,The Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine University of Leeds Leeds UK
| | - P Walker
- The Leeds Vascular Institute Leeds General Infirmary Leeds UK
| | - D Stocken
- The Leeds Institute of Clinical Trials Research University of Leeds Leeds UK
| | - M A Bailey
- The Leeds Vascular Institute Leeds General Infirmary Leeds UK.,The Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine University of Leeds Leeds UK
| | - D J A Scott
- The Leeds Vascular Institute Leeds General Infirmary Leeds UK.,The Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine University of Leeds Leeds UK
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27
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Primrose JN, Fox RP, Palmer DH, Malik HZ, Prasad R, Mirza D, Anthony A, Corrie P, Falk S, Finch-Jones M, Wasan H, Ross P, Wall L, Wadsley J, Evans JTR, Stocken D, Praseedom R, Ma YT, Davidson B, Neoptolemos JP, Iveson T, Raftery J, Zhu S, Cunningham D, Garden OJ, Stubbs C, Valle JW, Bridgewater J. Capecitabine compared with observation in resected biliary tract cancer (BILCAP): a randomised, controlled, multicentre, phase 3 study. Lancet Oncol 2019; 20:663-673. [PMID: 30922733 DOI: 10.1016/s1470-2045(18)30915-x] [Citation(s) in RCA: 650] [Impact Index Per Article: 130.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite improvements in multidisciplinary management, patients with biliary tract cancer have a poor outcome. Only 20% of patients are eligible for surgical resection with curative intent, with 5-year overall survival of less than 10% for all patients. To our knowledge, no studies have described a benefit of adjuvant therapy. We aimed to determine whether adjuvant capecitabine improved overall survival compared with observation following surgery for biliary tract cancer. METHODS This randomised, controlled, multicentre, phase 3 study was done across 44 specialist hepatopancreatobiliary centres in the UK. Eligible patients were aged 18 years or older and had histologically confirmed cholangiocarcinoma or muscle-invasive gallbladder cancer who had undergone a macroscopically complete resection (which includes liver resection, pancreatic resection, or, less commonly, both) with curative intent, and an Eastern Cooperative Oncology Group performance status of less than 2. Patients who had not completely recovered from previous surgery or who had previous chemotherapy or radiotherapy for biliary tract cancer were also excluded. Patients were randomly assigned 1:1 to receive oral capecitabine (1250 mg/m2 twice daily on days 1-14 of a 21-day cycle, for eight cycles) or observation commencing within 16 weeks of surgery. Treatment was not masked, and allocation concealment was achieved with a computerised minimisation algorithm that stratified patients by surgical centre, site of disease, resection status, and performance status. The primary outcome was overall survival. As prespecified, analyses were done by intention to treat and per protocol. This study is registered with EudraCT, number 2005-003318-13. FINDINGS Between March 15, 2006, and Dec 4, 2014, 447 patients were enrolled; 223 patients with biliary tract cancer resected with curative intent were randomly assigned to the capecitabine group and 224 to the observation group. The data cutoff for this analysis was March 6, 2017. The median follow-up for all patients was 60 months (IQR 37-60). In the intention-to-treat analysis, median overall survival was 51·1 months (95% CI 34·6-59·1) in the capecitabine group compared with 36·4 months (29·7-44·5) in the observation group (adjusted hazard ratio [HR] 0·81, 95% CI 0·63-1·04; p=0·097). In a protocol-specified sensitivity analysis, adjusting for minimisation factors and nodal status, grade, and gender, the overall survival HR was 0·71 (95% CI 0·55-0·92; p=0·010). In the prespecified per-protocol analysis (210 patients in the capecitabine group and 220 in the observation group), median overall survival was 53 months (95% CI 40 to not reached) in the capecitabine group and 36 months (30-44) in the observation group (adjusted HR 0·75, 95% CI 0·58-0·97; p=0·028). In the intention-to-treat analysis, median recurrence-free survival was 24·4 months (95% CI 18·6-35·9) in the capecitabine group and 17·5 months (12·0-23·8) in the observation group. In the per-protocol analysis, median recurrence-free survival was 25·9 months (95% CI 19·8-46·3) in the capecitabine group and 17·4 months (12·0-23·7) in the observation group. Adverse events were measured in the capecitabine group only, and of the 213 patients who received at least one cycle, 94 (44%) had at least one grade 3 toxicity, the most frequent of which were hand-foot syndrome in 43 (20%) patients, diarrhoea in 16 (8%) patients, and fatigue in 16 (8%) patients. One (<1%) patient had grade 4 cardiac ischaemia or infarction. Serious adverse events were observed in 47 (21%) of 223 patients in the capecitabine group and 22 (10%) of 224 patients in the observation group. No deaths were deemed to be treatment related. INTERPRETATION Although this study did not meet its primary endpoint of improving overall survival in the intention-to-treat population, the prespecified sensitivity and per-protocol analyses suggest that capecitabine can improve overall survival in patients with resected biliary tract cancer when used as adjuvant chemotherapy following surgery and could be considered as standard of care. Furthermore, the safety profile is manageable, supporting the use of capecitabine in this setting. FUNDING Cancer Research UK and Roche.
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Affiliation(s)
- John N Primrose
- Department of Surgery, University of Southampton, Southampton, UK.
| | - Richard P Fox
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Daniel H Palmer
- University of Liverpool and Clatterbridge Cancer Centre, Liverpool, UK
| | | | - Raj Prasad
- Department of Surgery, University of Leeds, Leeds, UK
| | - Darius Mirza
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Women's Children's Hospital NHS Foundation Trust, Birmingham, UK
| | | | - Pippa Corrie
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen Falk
- University of Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Meg Finch-Jones
- University of Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | | | - Paul Ross
- Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Lucy Wall
- Lothian University Hospitals NHS Trust, Edinburgh, UK
| | | | - Jeff T R Evans
- Department of Oncology, University of Glasgow, Glasgow, UK
| | - Deborah Stocken
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | | | - Yuk Ting Ma
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Brian Davidson
- Department of General Surgery, University College London Hospital, London, UK
| | | | - Tim Iveson
- University Hospitals Southampton, Southampton, UK
| | - James Raftery
- Health Economics Analysis Team, University of Southampton, Southampton, UK
| | - Shihua Zhu
- Health Economics Analysis Team, University of Southampton, Southampton, UK
| | | | - O James Garden
- Department of Medicine, University of Edinburgh, Edinburgh, UK
| | - Clive Stubbs
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Juan W Valle
- University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
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28
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Paleri V, Patterson J, Rousseau N, Moloney E, Craig D, Tzelis D, Wilkinson N, Franks J, Hynes AM, Heaven B, Hamilton D, Guerrero-Urbano T, Donnelly R, Barclay S, Rapley T, Stocken D. Gastrostomy versus nasogastric tube feeding for chemoradiation patients with head and neck cancer: the TUBE pilot RCT. Health Technol Assess 2019; 22:1-144. [PMID: 29650060 DOI: 10.3310/hta22160] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Approximately 9000 new cases of head and neck squamous cell cancers (HNSCCs) are treated by the NHS each year. Chemoradiation therapy (CRT) is a commonly used treatment for advanced HNSCC. Approximately 90% of patients undergoing CRT require nutritional support via gastrostomy or nasogastric tube feeding. Long-term dysphagia following CRT is a primary concern for patients. The effect of enteral feeding routes on swallowing function is not well understood, and the two feeding methods have, to date (at the time of writing), not been compared. The aim of this pilot randomised controlled trial (RCT) was to compare these two options. METHODS This was a mixed-methods multicentre study to establish the feasibility of a RCT comparing oral feeding plus pre-treatment gastrostomy with oral feeding plus as-required nasogastric tube feeding in patients with HNSCC. Patients were recruited from four tertiary centres treating cancer and randomised to the two arms of the study (using a 1 : 1 ratio). The eligibility criteria were patients with advanced-staged HNSCC who were suitable for primary CRT with curative intent and who presented with no swallowing problems. MAIN OUTCOME MEASURES The primary outcome was the willingness to be randomised. A qualitative process evaluation was conducted alongside an economic modelling exercise. The criteria for progression to a Phase III trial were based on a hypothesised recruitment rate of at least 50%, collection of outcome measures in at least 80% of those recruited and an economic value-of-information analysis for cost-effectiveness. RESULTS Of the 75 patients approached about the trial, only 17 consented to be randomised [0.23, 95% confidence interval (CI) 0.13 to 0.32]. Among those who were randomised, the compliance rate was high (0.94, 95% CI 0.83 to 1.05). Retention rates were high at completion of treatment (0.94, 95% CI 0.83 to 1.05), at the 3-month follow-up (0.88, 95% CI 0.73 to 1.04) and at the 6-month follow-up (0.88, 95% CI 0.73 to 1.04). No serious adverse events were recorded in relation to the trial. The qualitative substudy identified several factors that had an impact on recruitment, many of which are amenable to change. These included organisational factors, changing cancer treatments and patient and clinician preferences. A key reason for the differential recruitment between sites was the degree to which the multidisciplinary team gave a consistent demonstration of equipoise at all patient interactions at which supplementary feeding was discussed. An exploratory economic model generated from published evidence and expert opinion suggests that, over the 6-month model time horizon, pre-treatment gastrostomy tube feeding is not a cost-effective option, although this should be interpreted with caution and we recommend that this should not form the basis for policy. The economic value-of-information analysis indicates that additional research to eliminate uncertainty around model parameters is highly likely to be cost-effective. STUDY LIMITATIONS The recruitment issues identified for this cohort may not be applicable to other populations undergoing CRT. There remains substantial uncertainty in the economic evaluation. CONCLUSIONS The trial did not meet one of the three criteria for progression, as the recruitment rate was lower than hypothesised. Once patients were recruited to the trial, compliance and retention in the trial were both high. The implementation of organisational and operational measures can increase the numbers recruited. The economic analysis suggests that further research in this area is likely to be cost-effective. FUTURE WORK The implementation of organisational and operational measures can increase recruitment. The appropriate research question and design of a future study needs to be identified. More work is needed to understand the experiences of nasogastric tube feeding in patients undergoing CRT. TRIAL REGISTRATION Current Controlled Trials ISRCTN48569216. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Vinidh Paleri
- Head and Neck Unit, The Royal Marsden Hospital, London, UK.,Division of Clinical Studies, Institute of Cancer Research, London, UK.,Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Joanne Patterson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Eoin Moloney
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Dawn Craig
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Dimitrios Tzelis
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nina Wilkinson
- Biostatistics Research group, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Jeremy Franks
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Marie Hynes
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Ben Heaven
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - David Hamilton
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Rachael Donnelly
- Department of Radiation Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Stewart Barclay
- Department of Restorative Dentistry, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Tim Rapley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah Stocken
- Biostatistics Research group, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.,Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Wilkinson N, Tsakok T, Dand N, Bloem K, Duckworth M, Baudry D, Pushpa-Rajah A, Griffiths CEM, Reynolds NJ, Barker J, Warren RB, Burden AD, Rispens T, Stocken D, Smith C. Defining the Therapeutic Range for Adalimumab and Predicting Response in Psoriasis: A Multicenter Prospective Observational Cohort Study. J Invest Dermatol 2019; 139:115-123. [PMID: 30130616 PMCID: PMC6300405 DOI: 10.1016/j.jid.2018.07.028] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/28/2018] [Accepted: 07/15/2018] [Indexed: 12/21/2022]
Abstract
Biologics have transformed management of inflammatory diseases. To optimize outcomes and reduce costs, dose adjustment informed by circulating drug levels has been proposed. We aimed to determine the real-world clinical utility of therapeutic drug monitoring in psoriasis. Within a multicenter (n = 60) prospective observational cohort, 544 psoriasis patients were included who were receiving adalimumab monotherapy and had at least one serum sample and Psoriasis Area and Severity Index (PASI) score available within the first year. We present models giving individualized probabilities of response for any given drug level: a minimally effective drug level of 3.2 μg/ml discriminates responders (PASI75 indicates 75% improvement in baseline PASI) from nonresponders, and gives an estimated PASI75 probability of 65% (95% confidence interval = 60-71). At 7 μg/ml, PASI75 probability is 81% (95% CI = 76-86); beyond 7 μg/ml, the drug level/response curve plateaus. Crucially, drug levels are predictive of response 6 months later, whether sampled early or at steady state. We confirm serum drug level to be the most important factor determining treatment response, highlighting the need to take drug levels into account when searching for biomarkers of response. This real-world study with pragmatic drug level sampling provides evidence to support the proactive measurement of adalimumab levels in psoriasis to direct treatment strategy, and is relevant to other inflammatory diseases.
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Key Words
- ada, anti-drug antibody
- badbir, british association of dermatologists biologic interventions registry
- bstop, biomarkers of systemic treatment outcomes in psoriasis
- ci, confidence interval
- ibd, inflammatory bowel disease
- imid, immune-mediated inflammatory disease
- pasi, psoriasis area and severity index
- pasi75, 75% improvement in baseline psoriasis area and severity index
- pasi90, 90% improvement in baseline psoriasis area and severity index
- ra, rheumatoid arthritis
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Affiliation(s)
- Nina Wilkinson
- Institute of Health and Society, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | - Teresa Tsakok
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nick Dand
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Karien Bloem
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Michael Duckworth
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David Baudry
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Angela Pushpa-Rajah
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Christopher E M Griffiths
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - Nick J Reynolds
- Dermatological Sciences, Institute of Cellular Medicine, Medical School, Newcastle University, and Department of Dermatology, Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jonathan Barker
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Richard B Warren
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - A David Burden
- Institute of Infection, Immunity and Inflammation, University of Glasgow, UK
| | - Theo Rispens
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Deborah Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Catherine Smith
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; St. John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
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Warren RB, Marsden A, Tomenson B, Mason KJ, Soliman MM, Burden AD, Reynolds NJ, Stocken D, Emsley R, Griffiths CEM, Smith C. Identifying demographic, social and clinical predictors of biologic therapy effectiveness in psoriasis: a multicentre longitudinal cohort study. Br J Dermatol 2018; 180:1069-1076. [PMID: 30155885 PMCID: PMC6519065 DOI: 10.1111/bjd.16776] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2018] [Indexed: 01/28/2023]
Abstract
Background Biologic therapies have revolutionized the treatment of moderate‐to‐severe psoriasis. However, for reasons largely unknown, many patients do not respond or lose response to these drugs. Objectives To evaluate demographic, social and clinical factors that could be used to predict effectiveness and stratify response to biologic therapies in psoriasis. Methods Using a multicentre, observational, prospective pharmacovigilance study (BADBIR), we identified biologic‐naive patients starting biologics with outcome data at 6 (n = 3079) and 12 (n = 3110) months. Associations between 31 putative predictors and outcomes were investigated in univariate and multivariable regression analyses. Potential stratifiers of treatment response were investigated with statistical interactions. Results Eight factors associated with reduced odds of achieving ≥ 90% improvement in Psoriasis Area and Severity Index (PASI 90) at 6 months were identified (described as odds ratio and 95% confidence interval): demographic (female sex, 0·78, 0·66–0·93); social (unemployment, 0·67, 0·45–0·99); unemployment due to ill health (0·62, 0·48–0·82); ex‐ and current smoking (0·81, 0·66–0·99 and 0·79, 0·63–0·99, respectively); clinical factors (high weight, 0·99, 0·99–0·99); psoriasis of the palms and/or soles (0·75, 0·61–0·91); and presence of small plaques only compared with small and large plaques (0·78, 0·62–0·96). White ethnicity (1·48, 1·12–1·97) and higher baseline PASI (1·04, 1·03–1·04) were associated with increased odds of achieving PASI 90. The findings were largely consistent at 12 months. There was little evidence for predictors of differential treatment response. Conclusions Psoriasis phenotype and potentially modifiable factors are associated with poor outcomes with biologics, underscoring the need for lifestyle management. Effect sizes suggest that these factors alone cannot inform treatment selection. What's already known about this topic? Biologic therapy used in the treatment of moderate‐to‐severe psoriasis differs in its effectiveness across patients. Previous research has indicated that patients with a higher body mass index, who smoke or who have smoked, and with a lower baseline Psoriasis Area and Severity Index (PASI) are less likely to have a good outcome with biologic therapy for the treatment of moderate‐to‐severe psoriasis.
What does this study add? This large‐scale study in a real‐world setting confirms that weight, smoking status and baseline PASI are associated with effectiveness of biologic therapy. There is evidence that non‐white ethnicity, female sex, unemployment, psoriasis of the palms and soles and the presence of small chronic plaques are associated with poor outcomes with biologics. There is some evidence that men have a comparatively worse response to etanercept, relative to adalimumab, than women. Otherwise, most factors do not appear to be predictors of differential treatment response.
Respond to this article
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Affiliation(s)
- R B Warren
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, U.K
| | - A Marsden
- Centre for Biostatistics, School of Health Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K
| | - B Tomenson
- Centre for Biostatistics, School of Health Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K
| | - K J Mason
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, U.K
| | - M M Soliman
- Department of Pharmacy Practice, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
| | - A D Burden
- Department of Dermatology, Royal Infirmary of Edinburgh, Edinburgh, U.K
| | - N J Reynolds
- Dermatological Sciences, Institute of Cellular Medicine, Medical School, Newcastle University, NIHR Newcastle Biomedical Research Centre and Department of Dermatology, Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, U.K
| | - D Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, U.K
| | - R Emsley
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, U.K
| | - C E M Griffiths
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, U.K
| | - C Smith
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, U.K
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Paleri V, Sawant R, Mehanna H, Ainsworth H, Stocken D. Laryngeal dysplasia and narrow band imaging: Secondary analysis of published data supports the role in patient follow-up. Clin Otolaryngol 2018; 43:1439-1442. [PMID: 29972728 DOI: 10.1111/coa.13182] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 12/01/2017] [Accepted: 06/17/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinicians have recognised the role of narrow band imaging (NBI) in the management of head and neck cancer in several studies. However, a recent systematic review was unable to pool the data on diagnostic efficacy in this setting owing to the heterogeneity in the published data. METHODS Secondary analysis of data, utilising Bayes' theorem, from meta-analyses and randomised trials. RESULTS In patients with a histological diagnosis of mild dysplasia who show no abnormalities on NBI, the post-test probability of malignancy is estimated to be 2.3%, compared to 10.3% with conventional white light imaging (WLI). For severe dysplasia, similar post-test probabilities after NBI and WLI are estimated to be 8.0% and 29.7%, respectively. Post-test probabilities in this setting indicate the chance of missing malignancy following a negative NBI or WLI in patients who undergo no further intervention. This study also provides a nomogram designed for use in this setting. CONCLUSIONS This study identifies the evidence base for use of NBI in the follow-up for laryngeal dysplasia.
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Affiliation(s)
| | - Rupali Sawant
- Biostatistics Research Group, Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Holly Ainsworth
- Institute of Head and Neck Studies and Education, University of Birmingham, Birmingham, UK
| | - Deborah Stocken
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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Kunadian V, Chan D, Ali H, Wilkinson N, Howe N, McColl E, Thornton J, von Wilamowitz-Moellendorff A, Holstein EM, Burns G, Fisher A, Stocken D, De Soyza A. Antiplatelet therapy in the primary prevention of cardiovascular disease in patients with chronic obstructive pulmonary disease: protocol of a randomised controlled proof-of-concept trial (APPLE COPD-ICON 2). BMJ Open 2018; 8:e020713. [PMID: 29804061 PMCID: PMC5988059 DOI: 10.1136/bmjopen-2017-020713] [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] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The antiplatelet therapy in the primary prevention of cardiovascular disease in patients with chronic obstructive pulmonary disease (APPLE COPD-ICON2) trial is a prospective 2×2 factorial, double-blinded proof-of-concept randomised controlled trial targeting patients with chronic obstructive pulmonary disease (COPD) at high risk of cardiovascular disease. The primary goal of this trial is to investigate if treatment with antiplatelet therapy will produce the required response in platelet function measured using the Multiplate test in patients with COPD. METHODS AND ANALYSIS Patients with COPD are screened for eligibility using inclusion and exclusion criteria. Eligible patients are randomised and allocated into one of four groups to receive aspirin plus placebo, ticagrelor plus placebo, aspirin plus ticagrelor or placebo only. Markers of systemic inflammation, platelet reactivity, arterial stiffness, carotid intima-media thickness (CIMT), lung function and quality of life questionnaires are assessed. The primary outcome consists of inhibition (binary response) of aspirin and ADP-induced platelet function at 6 months. Secondary outcomes include changes in inflammatory markers, CIMT, non-invasive measures of vascular stiffness, quality of life using questionnaires (EuroQol-five dimensions-five levels of perceived problems (EQ5D-5L), St. George's COPD questionnaire) and to record occurrence of repeat hospitalisation, angina, myocardial infarction or death from baseline to 6 months. Safety outcomes will be rates of major and minor bleeding, forced expiratory volume in 1 s, forced vital capacity and Medical Research Council dyspnoea scale. ETHICS AND DISSEMINATION The study was approved by the North East-Tyne and Wear South Research Ethics Committee (15/NE/0155). Findings of the study will be presented in scientific sessions and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN43245574; Pre-results.
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Affiliation(s)
- Vijay Kunadian
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Danny Chan
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Hani Ali
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Nina Wilkinson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nicola Howe
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Elaine McColl
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Jared Thornton
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | | | - Eva-Maria Holstein
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Graham Burns
- Royal Victoria Infirmary, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew Fisher
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Deborah Stocken
- Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, UK
| | - Anthony De Soyza
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
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Parr JR, Todhunter E, Pennington L, Stocken D, Cadwgan J, O’Hare AE, Tuffrey C, Williams J, Cole M, Colver AF. Drooling Reduction Intervention randomised trial (DRI): comparing the efficacy and acceptability of hyoscine patches and glycopyrronium liquid on drooling in children with neurodisability. Arch Dis Child 2018; 103:371-376. [PMID: 29192000 PMCID: PMC5890631 DOI: 10.1136/archdischild-2017-313763] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/22/2017] [Accepted: 10/02/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Investigate whether hyoscine patch or glycopyrronium liquid is more effective and acceptable to treat drooling in children with neurodisability. DESIGN Multicentre, single-blind, randomised controlled trial. SETTING Recruitment through neurodisability teams; treatment by parents. PARTICIPANTS Ninety children with neurodisability who had never received medication for drooling (55 boys, 35 girls; median age 4 years). EXCLUSION CRITERIA medication contraindicated; in a trial that could affect drooling or management. INTERVENTION Children were randomised to receive a hyoscine skin patch or glycopyrronium liquid. Dose was increased over 4 weeks to achieve optimum symptom control with minimal side-effects; steady dose then continued to 12 weeks. PRIMARY AND SECONDARY OUTCOMES Primary outcome: Drooling Impact Scale (DIS) score at week-4. SECONDARY OUTCOMES change in DIS scores over 12 weeks, Drooling Severity and Frequency Scale and Treatment Satisfaction Questionnaire for Medication; adverse events; children's perception about treatment. RESULTS Both medications yielded clinically and statistically significant reductions in mean DIS at week-4 (25.0 (SD 22.2) for hyoscine and 26.6 (SD 16) for glycopyrronium). There was no significant difference in change in DIS scores between treatment groups. By week-12, 26/47 (55%) children starting treatment were receiving hyoscine compared with 31/38 (82%) on glycopyrronium. There was a 42% increased chance of being on treatment at week-12 for children randomised to glycopyrronium relative to hyoscine (1.42, 95% CI 1.04 to 1.95). CONCLUSIONS Hyoscine and glycopyrronium are clinically effective in treating drooling in children with neurodisability. Hyoscine produced more problematic side effects leading to a greater chance of treatment cessation. TRIAL REGISTRATION NUMBERS ISRCTN 75287237; EUDRACT: 2013-000863-94; Medicines and Healthcare Products Regulatory Agency: 17136/0264/001-0003.
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Affiliation(s)
- Jeremy R Parr
- Institute of Neuroscience, Newcastle University, Newcastle Upon Tyne, UK,The Great North Children’s Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Emma Todhunter
- Institute of Neuroscience, Newcastle University, Newcastle Upon Tyne, UK
| | - Lindsay Pennington
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Deborah Stocken
- Biostatistics Research Group, Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Jill Cadwgan
- Institute of Neuroscience, Newcastle University, Newcastle Upon Tyne, UK,The Great North Children’s Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Anne E O’Hare
- Salvesen Mindroom Centre, University of Edinburgh, Edinburgh, UK
| | | | - Jane Williams
- Nottingham Children’s Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mike Cole
- Biostatistics Research Group, Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Allan F Colver
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
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Newsome PN, Fox R, King AL, Barton D, Than NN, Moore J, Corbett C, Townsend S, Thomas J, Guo K, Hull D, Beard HA, Thompson J, Atkinson A, Bienek C, McGowan N, Guha N, Campbell J, Hollyman D, Stocken D, Yap C, Forbes SJ. Granulocyte colony-stimulating factor and autologous CD133-positive stem-cell therapy in liver cirrhosis (REALISTIC): an open-label, randomised, controlled phase 2 trial. Lancet Gastroenterol Hepatol 2018; 3:25-36. [PMID: 29127060 PMCID: PMC5738975 DOI: 10.1016/s2468-1253(17)30326-6] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 09/05/2017] [Accepted: 09/14/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Results of small-scale studies have suggested that stem-cell therapy is safe and effective in patients with liver cirrhosis, but no adequately powered randomised controlled trials have been done. We assessed the safety and efficacy of granulocyte colony-stimulating factor (G-CSF) and haemopoietic stem-cell infusions in patients with liver cirrhosis. METHODS This multicentre, open-label, randomised, controlled phase 2 trial was done in three UK hospitals and recruited patients with compensated liver cirrhosis and MELD scores of 11·0-15·5. Patients were randomly assigned (1:1:1) to receive standard care (control), treatment with subcutaneous G-CSF (lenograstim) 15 μg/kg for 5 days, or treatment with G-CSF for 5 days followed by leukapheresis and intravenous infusion of three doses of CD133-positive haemopoietic stem cells (0·2 × 106 cells per kg per infusion). Randomisation was done by Cancer Research UK Clinical Trials Unit staff with a minimisation algorithm that stratified by trial site and cause of liver disease. The coprimary outcomes were improvement in severity of liver disease (change in MELD) at 3 months and the trend of change in MELD score over time. Analyses were done in the modified intention-to-treat population, which included all patients who received at least one day of treatment. Safety was assessed on the basis of the treatment received. This trial was registered at Current Controlled Trials on Nov 18, 2009; ISRCTN, number 91288089; and the European Clinical Trials Database, number 2009-010335-41. FINDINGS Between May 18, 2010, and Feb 26, 2015, 27 patients were randomly assigned to the standard care, 26 to the G-CSF group, and 28 to the G-CSF plus stem-cell infusion group. Median change in MELD from day 0 to 90 was -0·5 (IQR -1·5 to 1·1) in the standard care group, -0·5 (-1·7 to 0·5) in the G-CSF group, and -0·5 (-1·3 to 1·0) in the G-CSF plus stem-cell infusion group. We found no evidence of differences between the treatment groups and control group in the trends of MELD change over time (p=0·55 for the G-CSF group vs standard care and p=0·75 for the G-CSF plus stem-cell infusion group vs standard care). Serious adverse events were more frequent the in G-CSF and stem-cell infusion group (12 [43%] patients) than in the G-CSF (three [11%] patients) and standard care (three [12%] patients) groups. The most common serious adverse events were ascites (two patients in the G-CSF group and two patients in the G-CSF plus stem-cell infusion group, one of whom was admitted to hospital with ascites twice), sepsis (four patients in the G-CSF plus stem-cell infusion group), and encephalopathy (three patients in the G-CSF plus stem-cell infusion group, one of whom was admitted to hospital with encephalopathy twice). Three patients died, including one in the standard care group (variceal bleed) and two in the G-CSF and stem-cell infusion group (one myocardial infarction and one progressive liver disease). INTERPRETATION G-CSF with or without haemopoietic stem-cell infusion did not improve liver dysfunction or fibrosis and might be associated with increased frequency of adverse events compared with standard care. FUNDING National Institute of Health Research, The Sir Jules Thorn Charitable Trust.
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Affiliation(s)
- Philip Noel Newsome
- National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK; Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK; Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Richard Fox
- National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK; University of Birmingham, NIHR Liver BRU Clinical trials group, Cancer Research UK Clinical Trials Unit, Birmingham, UK
| | - Andrew L King
- National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK; Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK; Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Darren Barton
- National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK; University of Birmingham, NIHR Liver BRU Clinical trials group, Cancer Research UK Clinical Trials Unit, Birmingham, UK
| | - Nwe-Ni Than
- National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK; Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK; Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Joanna Moore
- Medical Research Council Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, UK
| | - Christopher Corbett
- National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK
| | - Sarah Townsend
- National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK; Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James Thomas
- Medical Research Council Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, UK
| | - Kathy Guo
- National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK; Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Diana Hull
- National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK; Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Heather A Beard
- National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK; Cellular and Molecular Therapies, NHSBlood and Transplant, Birmingham, UK
| | - Jacqui Thompson
- Cellular and Molecular Therapies, NHSBlood and Transplant, Birmingham, UK
| | - Anne Atkinson
- Scottish National Blood Transfusion Service, Edinburgh, UK
| | - Carol Bienek
- Scottish National Blood Transfusion Service, Edinburgh, UK
| | - Neil McGowan
- Scottish National Blood Transfusion Service, Edinburgh, UK
| | - Neil Guha
- National Institute for Health Research Biomedical Research Unit in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - John Campbell
- Scottish National Blood Transfusion Service, Edinburgh, UK
| | - Dan Hollyman
- Cellular and Molecular Therapies, NHSBlood and Transplant, Birmingham, UK
| | - Deborah Stocken
- Newcastle University, Newcastle Clinical Trial Unit, Institute of Health and Society, Newcastle, UK
| | - Christina Yap
- University of Birmingham, NIHR Liver BRU Clinical trials group, Cancer Research UK Clinical Trials Unit, Birmingham, UK
| | - Stuart John Forbes
- Medical Research Council Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, UK
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Gamble C, Krishan A, Stocken D, Lewis S, Juszczak E, Doré C, Williamson PR, Altman DG, Montgomery A, Lim P, Berlin J, Senn S, Day S, Barbachano Y, Loder E. Guidelines for the Content of Statistical Analysis Plans in Clinical Trials. JAMA 2017; 318:2337-2343. [PMID: 29260229 DOI: 10.1001/jama.2017.18556] [Citation(s) in RCA: 243] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance While guidance on statistical principles for clinical trials exists, there is an absence of guidance covering the required content of statistical analysis plans (SAPs) to support transparency and reproducibility. Objective To develop recommendations for a minimum set of items that should be addressed in SAPs for clinical trials, developed with input from statisticians, previous guideline authors, journal editors, regulators, and funders. Design Funders and regulators (n = 39) of randomized trials were contacted and the literature was searched to identify existing guidance; a survey of current practice was conducted across the network of UK Clinical Research Collaboration-registered trial units (n = 46, 1 unit had 2 responders) and a Delphi survey (n = 73 invited participants) was conducted to establish consensus on SAPs. The Delphi survey was sent to statisticians in trial units who completed the survey of current practice (n = 46), CONSORT (Consolidated Standards of Reporting Trials) and SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) guideline authors (n = 16), pharmaceutical industry statisticians (n = 3), journal editors (n = 9), and regulators (n = 2) (3 participants were included in 2 groups each), culminating in a consensus meeting attended by experts (N = 12) with representatives from each group. The guidance subsequently underwent critical review by statisticians from the surveyed trial units and members of the expert panel of the consensus meeting (N = 51), followed by piloting of the guidance document in the SAPs of 5 trials. Findings No existing guidance was identified. The registered trials unit survey (46 responses) highlighted diversity in current practice and confirmed support for developing guidance. The Delphi survey (54 of 73, 74% participants completing both rounds) reached consensus on 42% (n = 46) of 110 items. The expert panel (N = 12) agreed that 63 items should be included in the guidance, with an additional 17 items identified as important but may be referenced elsewhere. Following critical review and piloting, some overlapping items were combined, leaving 55 items. Conclusions and Relevance Recommendations are provided for a minimum set of items that should be addressed and included in SAPs for clinical trials. Trial registration, protocols, and statistical analysis plans are critically important in ensuring appropriate reporting of clinical trials.
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Affiliation(s)
- Carrol Gamble
- Biostatistics Department, University of Liverpool, Liverpool, England
| | - Ashma Krishan
- Clinical Trials Research Centre, University of Liverpool, Liverpool, England
| | - Deborah Stocken
- Newcastle University, Newcastle, England
- Currently with Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, England
| | | | | | - Caroline Doré
- UCL Comprehensive Clinical Trials Unit, London, England
| | | | - Douglas G Altman
- Centre for Statistics in Medicine, University of Oxford, Oxford, England
| | | | - Pilar Lim
- Janssen Research & Development LLC, Raritan, New Jersey
| | | | - Stephen Senn
- Luxembourg Institute of Health, Strassen, Luxembourg
| | - Simon Day
- Clinical Trials Consulting & Training Limited, Buckingham, England
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Creasey T, Lannon M, Stocken D, Swieton J, Cuthbert G, Osborne W. Double hit lymphoma in the northern region of England-A retrospective analysis of patient and disease characteristics, treatment delivered and survival. Hematol Oncol 2017. [DOI: 10.1002/hon.2439_86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- T. Creasey
- Haematology department; Freeman Hospital; Newcastle-upon-Tyne UK
| | - M. Lannon
- Haematology department; Freeman Hospital; Newcastle-upon-Tyne UK
| | - D. Stocken
- Institute of Health and Society; Newcastle University; Newcastle-upon-Tyne UK
| | - J. Swieton
- Haematology department; Freeman Hospital; Newcastle-upon-Tyne UK
| | - G. Cuthbert
- Northern Genetics Service; Institute of Genetic Medicine; Newcastle-upon-Tyne UK
| | - W. Osborne
- Haematology department; Freeman Hospital; Newcastle-upon-Tyne UK
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Primrose JN, Fox R, Palmer DH, Prasad R, Mirza D, Anthoney DA, Corrie P, Falk S, Wasan HS, Ross PJ, Wall LR, Wadsley J, Evans TJ, Stocken D, Praseedom R, Cunningham D, Garden OJ, Stubbs C, Valle JW, Bridgewater JA. Adjuvant capecitabine for biliary tract cancer: The BILCAP randomized study. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.4006] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
4006 Background: Despite improvements in multidisciplinary management, BTC has a poor outcome. Approximately 20% of cases are suitable for surgical resection with a 5 year survival of < 10%. BILCAP aimed to determine whether capecitabine (Cape) improves overall survival (OS) compared to observation (Obs) following radical surgery. Methods: Patients with completely-resected cholangiocarcinoma (CCA) or gallbladder cancer (including liver and pancreatic resection, as appropriate), with adequate biliary drainage, no ongoing infection, adequate renal, haematological and liver function, and ECOG PS ≤2, were randomized 1:1 to Cape (1250 mg/m2 D1-14 every 21 days, for 8 cycles) or Obs. Randomization was minimized on tumor site, resection status, ECOG PS and surgical center. The primary outcome was OS in the intention to treat (ITT) population. 410 patients were needed to detect a hazard ratio (HR) of 0.69 (2-sided α = 0.05 and 80% power). HR was estimated by Cox survival model with adjustment for the minimization factors. Primary analysis performed with at least 24 months (m) follow-up. Results: 447 participants were randomized to Cape (n = 223) or Obs (n = 224) from 44 UK sites between 2006-2014. Median age was 63y (IQR 55, 69) and 201 (45%), 232 (52%), and 14 (3%) patients were ECOG PS 0, 1 and 2 respectively. Primary site: 84 (19%) intrahepatic, 128 (28%) hilar, 156 (35%) extrahepatic CCA and 79 (18%) muscle-invasive gallbladder cancers. Resection margins: R0 in 279 (62%) and R1 in 168 (38%); 207 (46%) were node-negative. Follow up was at least 36m in > 80% of surviving patients. By ITT analysis (n = 447), median OS was 51m (95%CI 35, 59) for Cape and 36m (95%CI 30, 45) for Obs, HR 0.80 (95%CI 0.63, 1.04; p = 0.097). Sensitivity analyses with adjustment for nodal status, grade of disease and gender indicated HR 0.71 (95%CI 0.55, 0.92 p < 0.01). In the per-protocol analysis (Cape n = 210, Obs n = 220) median OS was 53m (95%CI 40, NR) for Cape and 36m (95%CI 30, 44) for Obs, HR 0.75 (95%CI 0.58, 0.97; p = 0.028). Median RFS (ITT) was 25m (95%CI 19, 37) for Cape and 18m (95%CI 13, 28) for Obs. Grade 3-4 toxicity was less than anticipated. Conclusions: Cape improves OS in BTC when used as adjuvant and should become standard of care. Clinical trial information: ISRCTN72785446.
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Affiliation(s)
| | - Richard Fox
- University of Birmingham, Birmingham, United Kingdom
| | - Daniel H. Palmer
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool and Clatterbridge Cancer Centre, Liverpool, United Kingdom
| | - Raj Prasad
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Darius Mirza
- Birmingham Queen Elizabeth Hospital, Birmingham, United Kingdom
| | | | | | - Stephen Falk
- Bristol Haematology and Oncology Centre, Bristol, United Kingdom
| | | | | | - Lucy R. Wall
- Western General Hospital, Edinburgh, United Kingdom
| | | | - T.R. Jeffry Evans
- University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | | | - Raaj Praseedom
- Cambridge University Hospitals, Cambridge, United Kingdom
| | | | | | - Clive Stubbs
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Juan W. Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
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Camilleri N, McArdle P, Newbury-Birch D, Stocken D, LeCouteur A. A Case Control and Follow-up Study of “Hard to Reach” Young People Who also Suffered from Multiple Complex Mental Disorders. Eur Psychiatry 2017. [DOI: 10.1016/j.eurpsy.2017.01.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AimsTo describe the mental disorders and social function of the hard to reach young people (HTRYP) from the innovations project (IP) and compare to a matched sample from a community mental health team (CMHT).BackgroundIP was a new multidisciplinary team based within an inner city, walk-in health centre, North East England (throughout 2011).MethodsPhase 1 and 2: retrospective review of clinical case notes of YP who attended the IP and CMHT. Phase 3: 24-months follow-up evaluation of the mental state and social function, using Health of the Nation Outcome Scales for Child and Adolescent Mental Health (HoNOSCA) and Children's Global Assessment Scale (CGAS).ResultsOverall, 36 referrals accepted by the IP, 31 met criteria for HTRYP, 15 were offered individually tailored therapy. IP group experienced more deprivation compared to the CMHT matched sample (n = 115). At baseline, the HTRYP had more mental disorders, higher severity scores and lower levels of social function (HTRYP HoNOSCA mean: 19.1 and CMHT mean: 11.2 P = < 0.001 and HTRYP CGAS mean: 51.0, CMHT mean: 58.9, P = 0.05). The HTRYP made significantly greater improvement compared to CMHTYP; (HoNOSCA P = < 0.001 and CGAS P = < 0.002). Thirteen HTRYP attended the follow-up review at 24 months compared with nine of CMHTYP. There was great variability in terms of social function between the YP within each sample.ConclusionThe term “HTR” describes a state, which the YP may be at a particular point their lives. A service, which utilises a developmental theoretical framework, offers regular reviews and an individualised care plan, could reduce longer-term morbidity and mortality suffered by HTRYP.Disclosure of interestThe authors have not supplied their declaration of competing interest.
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Dyson JK, Wilkinson N, Jopson L, Mells G, Bathgate A, Heneghan MA, Neuberger J, Hirschfield GM, Ducker SJ, Sandford R, Alexander G, Stocken D, Jones DEJ. The inter-relationship of symptom severity and quality of life in 2055 patients with primary biliary cholangitis. Aliment Pharmacol Ther 2016; 44:1039-1050. [PMID: 27640331 PMCID: PMC5082554 DOI: 10.1111/apt.13794] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 06/06/2016] [Accepted: 08/15/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Age at presentation with primary biliary cholangitis (PBC) is associated with differential response to ursodeoxycholic acid (UDCA) therapy. Younger-presenting patients are less likely to respond to treatment and more likely to need transplant or die from the disease. PBC has a complex impact on quality of life (QoL), with systemic symptoms often having significant impact. AIM To explain the impact of age at presentation on perceived QoL and the inter-related symptoms which impact upon it. METHODS Using the UK-PBC cohort, symptoms were assessed using the PBC-40 and other validated tools. Data were available on 2055 patients. RESULTS Of the 1990 patients reporting a global PBC-QoL score, 66% reported good/neutral scores and 34% reported poor scores. Each 10-year increase in age at presentation was associated with a 14% decrease in risk of poor perceived QoL (OR = 0.86, 95% CI: 0.75-0.98, P < 0.05). All symptom domains were similarly age-associated (P < 0.01). Social dysfunction was the symptom factor with the greatest impact on QoL. Median (interquartile range) PBC-40 social scores for patients with good perceived QoL were 18 (14-23) compared with 34 (29-39) for those with poor QoL. CONCLUSION The majority of patients with primary biliary cholangitis do not feel their QoL is impaired, although impairment is reported by a sizeable minority. Age at presentation is associated with impact on perceived QoL and the symptoms impairing it, with younger patients being more affected. Social dysfunction makes the greatest contribution to QoL impairment, and it should be targeted in trials aimed at improving life quality.
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Affiliation(s)
- J. K Dyson
- Institute of Cellular MedicineNewcastle UniversityNewcastle‐upon‐TyneUK,NIHR Newcastle Biomedical Research CentreNewcastle UniversityNewcastle‐upon‐TyneUK
| | - N. Wilkinson
- Institute of Health and SocietyNewcastle UniversityNewcastle‐upon‐TyneUK
| | - L. Jopson
- Institute of Cellular MedicineNewcastle UniversityNewcastle‐upon‐TyneUK
| | - G. Mells
- Department of HepatologyCambridge University Hospitals NHS Foundation TrustCambridgeUK,Academic Department of Medical GeneticsUniversity of CambridgeCambridgeUK
| | - A. Bathgate
- Scottish Liver Transplant UnitRoyal Infirmary of EdinburghEdinburghUK
| | - M. A. Heneghan
- Institute of Liver StudiesKing's College Hospital NHS Foundation TrustLondonUK
| | - J. Neuberger
- Centre for Liver ResearchNIHR Biomedical Research UnitUniversity of BirminghamBirminghamUK
| | - G. M. Hirschfield
- Centre for Liver ResearchNIHR Biomedical Research UnitUniversity of BirminghamBirminghamUK
| | - S. J. Ducker
- Institute of Cellular MedicineNewcastle UniversityNewcastle‐upon‐TyneUK,NIHR Newcastle Biomedical Research CentreNewcastle UniversityNewcastle‐upon‐TyneUK
| | | | - R. Sandford
- Academic Department of Medical GeneticsUniversity of CambridgeCambridgeUK
| | - G. Alexander
- Department of HepatologyCambridge University Hospitals NHS Foundation TrustCambridgeUK,Academic Department of Medical GeneticsUniversity of CambridgeCambridgeUK
| | - D. Stocken
- Institute of Health and SocietyNewcastle UniversityNewcastle‐upon‐TyneUK
| | - D. E. J. Jones
- Institute of Cellular MedicineNewcastle UniversityNewcastle‐upon‐TyneUK,NIHR Newcastle Biomedical Research CentreNewcastle UniversityNewcastle‐upon‐TyneUK
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40
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Watson G, O'Hara J, Carding P, Lecouturier J, Stocken D, Fouweather T, Wilson J. TOPPITS: Trial Of Proton Pump Inhibitors in Throat Symptoms. Study protocol for a randomised controlled trial. Trials 2016; 17:175. [PMID: 27036555 PMCID: PMC4818442 DOI: 10.1186/s13063-016-1267-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/24/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Persistent throat symptoms and Extra Oesophageal Reflux (EOR) are among the commonest reasons for attendance at a secondary care throat or voice clinic. There is a growing trend to treat throat symptom patients with proton pump inhibitors (PPIs) to suppress stomach acid, but most controlled studies fail to demonstrate a significant benefit of PPI over placebo. In addition, patient views on PPI use vary widely. METHODS/DESIGN A UK multi-centre, randomised, controlled trial for adults with persistent throat symptoms to compare the effectiveness of treatment with the proton pump inhibitor (PPI) lansoprazole versus placebo. The trial includes a six-month internal pilot, during which three sites will recruit 30 participants in total, to assess the practicality of the trial and assess the study procedures and willingness of the patient population to participate. If the pilot is successful, three additional sites will be opened to recruitment, and a further 302 participants recruited across the six main trial sites. Further trial sites may be opened, as necessary. The main trial will continue for a further 18 months. Participants will be followed up for 12 months from randomisation, throughout which both primary and secondary outcome data will be collected. The primary outcome is change in Reflux Symptom Index (RSI) score, the 'area standard' for this type of assessment, after 16 weeks (four months) of treatment. Secondary outcomes are RSI changes at 12 months after randomisation, Quality of Life assessment at four and 12 months, laryngeal mucosal changes, assessments of compliance and side effects, and patient-reported satisfaction. DISCUSSION TOPPITS is designed to evaluate the relative effectiveness of treatment with a proton pump inhibitor versus placebo in patients with persistent throat symptoms. This will provide valuable information to clinicians and GPs regarding the treatment and management of care for these patients, on changes in symptoms, and in Quality of Life, over time. TRIAL REGISTRATION ISRCTN38578686 . Registered 17 April 2014.
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Affiliation(s)
- Gillian Watson
- Newcastle Clinical Trials Unit, Faculty of Medical Sciences, Newcastle upon Tyne, NE2 4AE, UK.
| | - James O'Hara
- Ear, Nose and Throat Department, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
| | - Paul Carding
- School of Allied and Public Health, Faculty of Health Sciences, Australian National Catholic University, Brisbane Campus, Queensland, 4014, Australia
| | - Jan Lecouturier
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AZ, UK
| | - Deborah Stocken
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AZ, UK
| | - Tony Fouweather
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AZ, UK
| | - Janet Wilson
- Ear, Nose and Throat Department, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK.,Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AZ, UK
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Armstrong MJ, Gaunt P, Aithal GP, Barton D, Hull D, Parker R, Hazlehurst JM, Guo K, Abouda G, Aldersley MA, Stocken D, Gough SC, Tomlinson JW, Brown RM, Hübscher SG, Newsome PN. Liraglutide safety and efficacy in patients with non-alcoholic steatohepatitis (LEAN): a multicentre, double-blind, randomised, placebo-controlled phase 2 study. Lancet 2016; 387:679-690. [PMID: 26608256 DOI: 10.1016/s0140-6736(15)00803-x] [Citation(s) in RCA: 1175] [Impact Index Per Article: 146.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Glucagon-like peptide-1 (GLP-1) analogues reduce hepatic steatosis, concentrations of liver enzymes, and insulin resistance in murine models of fatty liver disease. These analogues are licensed for type 2 diabetes, but their efficacy in patients with non-alcoholic steatohepatitis is unknown. We assessed the safety and efficacy of the long-acting GLP-1 analogue, liraglutide, in patients with non-alcoholic steatohepatitis. METHODS This multicentre, double-blinded, randomised, placebo-controlled phase 2 trial was conducted in four UK medical centres to assess subcutaneous injections of liraglutide (1·8 mg daily) compared with placebo for patients who are overweight and show clinical evidence of non-alcoholic steatohepatitis. Patients were randomly assigned (1:1) using a computer-generated, centrally administered procedure, stratified by trial centre and diabetes status. The trial was designed using A'Hern's single-group method, which required eight (38%) of 21 successes in the liraglutide group for the effect of liraglutide to be considered clinically significant. Patients, investigators, clinical trial site staff, and pathologists were masked to treatment assignment throughout the study. The primary outcome measure was resolution of definite non-alcoholic steatohepatitis with no worsening in fibrosis from baseline to end of treatment (48 weeks), as assessed centrally by two independent pathologists. Analysis was done by intention-to-treat analysis, which included all patients who underwent end-of-treatment biopsy. The trial was registered with ClinicalTrials.gov, number NCT01237119. FINDINGS Between Aug 1, 2010, and May 31, 2013, 26 patients were randomly assigned to receive liraglutide and 26 to placebo. Nine (39%) of 23 patients who received liraglutide and underwent end-of-treatment liver biopsy had resolution of definite non-alcoholic steatohepatitis compared with two (9%) of 22 such patients in the placebo group (relative risk 4·3 [95% CI 1·0-17·7]; p=0·019). Two (9%) of 23 patients in the liraglutide group versus eight (36%) of 22 patients in the placebo group had progression of fibrosis (0·2 [0·1-1·0]; p=0·04). Most adverse events were grade 1 (mild) to grade 2 (moderate) in severity, transient, and similar in the two treatment groups for all organ classes and symptoms, with the exception of gastrointestinal disorders in 21 (81%) of 23 patients in the liraglutide group and 17 (65%) of 22 patients in the placebo group, which included diarrhoea (ten [38%] patients in the liraglutide group vs five [19%] in the placebo group), constipation (seven [27%] vs none), and loss of appetite (eight [31%] vs two [8%]). INTERPRETATION Liraglutide was safe, well tolerated, and led to histological resolution of non-alcoholic steatohepatitis, warranting extensive, longer-term studies. FUNDING Wellcome Trust, National Institute of Health Research, and Novo Nordisk.
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Affiliation(s)
- Matthew James Armstrong
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK; Liver and Hepatobiliary Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Piers Gaunt
- NIHR Birmingham Liver Biomedical Research Unit Clinical Trial group (EDD), CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Guruprasad P Aithal
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospital NHS Trust and University of Nottingham, Nottingham, UK
| | - Darren Barton
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK; NIHR Birmingham Liver Biomedical Research Unit Clinical Trial group (EDD), CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Diana Hull
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK; NIHR Birmingham Liver Biomedical Research Unit Clinical Trial group (EDD), CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Richard Parker
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK; Liver and Hepatobiliary Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jonathan M Hazlehurst
- Oxford Centre for Diabetes, Endocrinology and Metabolism, and NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - Kathy Guo
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK; NIHR Birmingham Liver Biomedical Research Unit Clinical Trial group (EDD), CRUK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - George Abouda
- Department of Hepatology and Gastroenterology, Hull Royal Infirmary, Hull, UK
| | | | - Deborah Stocken
- Newcastle University, Newcastle Clinical Trial Unit, Institute of Health and Society, Newcastle, UK
| | - Stephen C Gough
- Oxford Centre for Diabetes, Endocrinology and Metabolism, and NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, and NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - Rachel M Brown
- Department of Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Stefan G Hübscher
- Department of Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK; School of Cancer Sciences, University of Birmingham, Birmingham, UK
| | - Philip N Newsome
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK; Liver and Hepatobiliary Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK.
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Adams J, Goffe L, Adamson AJ, Halligan J, O'Brien N, Purves R, Stead M, Stocken D, White M. Prevalence and socio-demographic correlates of cooking skills in UK adults: cross-sectional analysis of data from the UK National Diet and Nutrition Survey. Int J Behav Nutr Phys Act 2015; 12:99. [PMID: 26242297 PMCID: PMC4524366 DOI: 10.1186/s12966-015-0261-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 07/27/2015] [Indexed: 11/17/2022] Open
Abstract
Background Poor cooking skills may be a barrier to healthy eating and a contributor to overweight and obesity. Little population-representative data on adult cooking skills has been published. We explored prevalence and socio-demographic correlates of cooking skills among adult respondents to wave 1 of the UK National Diet and Nutrition Survey (2008–9). Methods Socio-demographic variables of interest were sex, age group, occupational socio-economic group and whether or not respondents had the main responsibility for food in their households. Cooking skills were assessed as self-reported confidence in using eight cooking techniques, confidence in cooking ten foods, and ability to prepare four types of dish (convenience foods, a complete meal from ready-made ingredients, a main meal from basic ingredients, and cake or biscuits from basic ingredients). Frequency of preparation of main meals was also reported. Results Of 509 respondents, almost two-thirds reported cooking a main meal at least five times per week. Around 90 % reported being able to cook convenience foods, a complete meal from ready-made ingredient, and a main dish from basic ingredients without help. Socio-demographic differences in all markers of cooking skills were scattered and inconsistent. Where these were found, women and main food providers were most likely to report confidence with foods, techniques or dishes, and respondents in the youngest age (19–34 years) and lowest socio-economic group least likely. Conclusions This is the only exploration of the prevalence and socio-demographic correlates of adult cooking skills using recent and population-representative UK data and adds to the international literature on cooking skills in developed countries. Reported confidence with using most cooking techniques and preparing most foods was high. There were few socio-demographic differences in reported cooking skills. Adult cooking skills interventions are unlikely to have a large population impact, but may have important individual effects if clearly targeted at: men, younger adults, and those in the least affluent social groups. Electronic supplementary material The online version of this article (doi:10.1186/s12966-015-0261-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jean Adams
- Centre for Diet & Activity Research, MRC Epidemiology Unit, University of Cambridge, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK. .,Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
| | - Louis Goffe
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK. .,Human Nutrition Research Centre, Newcastle University, William Leech Building, Newcastle upon Tyne, NE2 4HH, UK.
| | - Ashley J Adamson
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK. .,Human Nutrition Research Centre, Newcastle University, William Leech Building, Newcastle upon Tyne, NE2 4HH, UK.
| | - Joel Halligan
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK. .,Human Nutrition Research Centre, Newcastle University, William Leech Building, Newcastle upon Tyne, NE2 4HH, UK.
| | - Nicola O'Brien
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK. nicki.o'
| | - Richard Purves
- Institute for Social Marketing, Stirling University, Stirling, FK9 4LA, UK.
| | - Martine Stead
- Institute for Social Marketing, Stirling University, Stirling, FK9 4LA, UK.
| | - Deborah Stocken
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
| | - Martin White
- Centre for Diet & Activity Research, MRC Epidemiology Unit, University of Cambridge, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK. .,Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
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King A, Barton D, Beard HA, Than N, Moore J, Corbett C, Thomas J, Guo K, Guha I, Hollyman D, Stocken D, Yap C, Fox R, Forbes SJ, Newsome PN. REpeated AutoLogous Infusions of STem cells In Cirrhosis (REALISTIC): a multicentre, phase II, open-label, randomised controlled trial of repeated autologous infusions of granulocyte colony-stimulating factor (GCSF) mobilised CD133+ bone marrow stem cells in patients with cirrhosis. A study protocol for a randomised controlled trial. BMJ Open 2015; 5:e007700. [PMID: 25795699 PMCID: PMC4368910 DOI: 10.1136/bmjopen-2015-007700] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Liver disease mortality and morbidity are rapidly rising and liver transplantation is limited by organ availability. Small scale human studies have shown that stem cell therapy is safe and feasible and has suggested clinical benefit. No published studies have yet examined the effect of stem cell therapy in a randomised controlled trial and evaluated the effect of repeated therapy. METHODS AND ANALYSIS Patients with liver cirrhosis will be randomised to one of three trial groups: group 1: Control group, Standard conservative management; group 2 treatment: granulocyte colony-stimulating factor (G-CSF; lenograstim) 15 µg/kg body weight daily on days 1-5; group 3 treatment: G-CSF 15 µg/kg body weight daily on days 1-5 followed by leukapheresis, isolation and aliquoting of CD133+ cells. Patients will receive an infusion of freshly isolated CD133+ cells immediately and frozen doses at days 30 and 60 via peripheral vein (0.2×10(6) cells/kg for each of the three doses). Primary objective is to demonstrate an improvement in the severity of liver disease over 3 months using either G-CSF alone or G-CSF followed by repeated infusions of haematopoietic stem cells compared with standard conservative management. The trial is powered to answer two hypotheses of each treatment compared to control but not powered to detect smaller expected differences between the two treatment groups. As such, the overall α=0.05 for the trial is split equally between the two hypotheses. Conventionally, to detect a relevant standardised effect size of 0.8 point reduction in Model for End-stage Liver Disease score using two-sided α=0.05(overall α=0.1 split equally between the two hypotheses) and 80% power requires 27 participants to be randomised per group (81 participants in total). ETHICS AND DISSEMINATION The trial is registered at Current Controlled Trials on 18 November 2009 (ISRCTN number 91288089, EuDRACT number 2009-010335-41). The findings of this trial will be disseminated to patients and through peer-reviewed publications and international presentations.
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Affiliation(s)
- A King
- NIHR Centre for Liver Research and Biomedical Research Unit, University of Birmingham, Birmingham, UK Liver Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - D Barton
- NIHR Liver BRU Clinical trials group (EDD), CRUK clinical trials unit, University of Birmingham, Birmingham, UK
| | - H A Beard
- NIHR Centre for Liver Research and Biomedical Research Unit, University of Birmingham, Birmingham, UK Cellular and Molecular Therapies, NHS Blood and Transplant, Birmingham, UK
| | - N Than
- NIHR Centre for Liver Research and Biomedical Research Unit, University of Birmingham, Birmingham, UK
| | - J Moore
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, UK
| | - C Corbett
- NIHR Centre for Liver Research and Biomedical Research Unit, University of Birmingham, Birmingham, UK
| | - J Thomas
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, UK
| | - K Guo
- NIHR Centre for Liver Research and Biomedical Research Unit, University of Birmingham, Birmingham, UK
| | - I Guha
- National Institute for Health Research Biomedical Research Unit in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - D Hollyman
- Cellular and Molecular Therapies, NHS Blood and Transplant, Birmingham, UK
| | - D Stocken
- Newcastle Clinical Trial Unit, Institute of Health and Society, Newcastle University, Newcastle, UK
| | - C Yap
- NIHR Liver BRU Clinical trials group (EDD), CRUK clinical trials unit, University of Birmingham, Birmingham, UK
| | - R Fox
- NIHR Liver BRU Clinical trials group (EDD), CRUK clinical trials unit, University of Birmingham, Birmingham, UK
| | - S J Forbes
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, UK
| | - P N Newsome
- NIHR Centre for Liver Research and Biomedical Research Unit, University of Birmingham, Birmingham, UK Liver Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
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Teng M, Pirrie S, Ward DG, Assi LK, Hughes RG, Stocken D, Johnson PJ. Diagnostic and mechanistic implications of serum free light chains, albumin and alpha-fetoprotein in hepatocellular carcinoma. Br J Cancer 2014; 110:2277-82. [PMID: 24603305 PMCID: PMC4007223 DOI: 10.1038/bjc.2014.121] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 01/15/2014] [Accepted: 02/11/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Mass spectroscopy analysis suggested low serum albumin and high immunoglobulin free light chain (sFLC) levels may have diagnostic value in hepatocellular carcinoma (HCC). Our aims were to apply quantitative assays to confirm these observations, determine their diagnostic utility, and investigate the mechanisms involved. METHODS Albumin, sFLC, routine liver and renal function tests were measured in patients with chronic liver disease with (n=102) and without (n=113) HCC. The discriminant performance was compared with the current standard serological test alpha-fetoprotein (AFP) using receiver operating characteristic (ROC) and area under the curve (AUC) analyses. RESULTS sFLC and serum albumin were each confirmed to have discriminatory utility in HCC with AUC values of 0.7 and 0.8, respectively. sFLC were strongly correlated with gammaglobulin levels and both these were inversely related to serum albumin levels. The discriminatory utility of sFLC was retained after adjusting for renal and liver function. CONCLUSIONS Serum levels of sFLC and albumin were strongly associated with HCC as predicted by mass spectroscopy. Discrimination of HCC by AFP was improved by the addition of either albumin or sFLC. Larger prospective studies are required to determine how AFP, sFLC and albumin might be combined in a useful diagnostic approach for HCC.
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Affiliation(s)
- M Teng
- Cancer Research UK, Institute for Cancer Studies, School of Cancer Sciences, University of Birmingham, Vincent Drive, Edgbaston B15 2TT, UK
| | - S Pirrie
- Cancer Research UK, Institute for Cancer Studies, School of Cancer Sciences, University of Birmingham, Vincent Drive, Edgbaston B15 2TT, UK
| | - D G Ward
- Cancer Research UK, Institute for Cancer Studies, School of Cancer Sciences, University of Birmingham, Vincent Drive, Edgbaston B15 2TT, UK
| | - L K Assi
- The Binding Site Group Limited, 8 Calthorpe Road, Edgbaston B15 1QT, UK
| | - R G Hughes
- The Binding Site Group Limited, 8 Calthorpe Road, Edgbaston B15 1QT, UK
| | - D Stocken
- Cancer Research UK, Institute for Cancer Studies, School of Cancer Sciences, University of Birmingham, Vincent Drive, Edgbaston B15 2TT, UK
| | - P J Johnson
- Cancer Research UK, Institute for Cancer Studies, School of Cancer Sciences, University of Birmingham, Vincent Drive, Edgbaston B15 2TT, UK
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Armstrong MJ, Barton D, Gaunt P, Hull D, Guo K, Stocken D, Gough SCL, Tomlinson JW, Brown RM, Hübscher SG, Newsome PN. Liraglutide efficacy and action in non-alcoholic steatohepatitis (LEAN): study protocol for a phase II multicentre, double-blinded, randomised, controlled trial. BMJ Open 2013; 3:e003995. [PMID: 24189085 PMCID: PMC3822302 DOI: 10.1136/bmjopen-2013-003995] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Non-alcoholic steatohepatitis (NASH) is now the commonest cause of chronic liver disease. Despite this, there are no universally accepted pharmacological therapies for NASH. Liraglutide (Victoza), a human glucagon-like peptide-1 (GLP-1) analogue, has been shown to improve weight loss, glycaemic control and liver enzymes in type 2 diabetes. There is currently a lack of prospective-controlled studies investigating the efficacy of GLP-1 analogues in patients with NASH. METHODS AND ANALYSIS Liraglutide efficacy and action in NASH (LEAN) is a phase II, multicentre, double-blinded, placebo-controlled, randomised clinical trial designed to investigate whether a 48-week treatment with 1.8 mg liraglutide will result in improvements in liver histology in patients with NASH. Adult, overweight (body mass index ≥25 kg/m(2)) patients with biopsy-confirmed NASH were assessed for eligibility at five recruitment centres in the UK. Patients who satisfied the eligibility criteria were randomly assigned (1:1) to receive once-daily subcutaneous injections of either 1.8 mg liraglutide or liraglutide-placebo (control). Using A'Hern's single stage phase II methodology (significance level 0.05; power 0.90) and accounting for an estimated 20% withdrawal rate, a minimum of 25 patients were randomised to each treatment group. The primary outcome measure will be centrally assessed using an intention-to-treat analysis of the proportion of evaluable patients achieving an improvement in liver histology between liver biopsies at baseline and after 48 weeks of treatment. Histological improvement will be defined as a combination of the disappearance of active NASH and no worsening in fibrosis. ETHICS AND DISSEMINATION The protocol was approved by the National Research Ethics Service (East Midlands-Northampton committee; 10/H0402/32) and the Medicines and Healthcare products Regulatory Agency. Recruitment into the LEAN started in August 2010 and ended in May 2013, with 52 patients randomised. The treatment follow-up of LEAN participants is currently ongoing and is due to finish in July 2014. The findings of this trial will be disseminated through peer-reviewed publications and international presentations. TRIAL REGISTRATION clinicaltrials.gov NCT01237119.
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Affiliation(s)
- Matthew J Armstrong
- NIHR Liver BRU and Centre for Liver Research, University of Birmingham, Birmingham, UK
- Liver and Hepatobiliary Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Darren Barton
- NIHR Liver BRU Clinical trials group (EDD), CRUK clinical trials unit, University of Birmingham, Birmingham, UK
| | - Piers Gaunt
- NIHR Liver BRU Clinical trials group (EDD), CRUK clinical trials unit, University of Birmingham, Birmingham, UK
| | - Diana Hull
- NIHR Liver BRU and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Kathy Guo
- NIHR Liver BRU and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Deborah Stocken
- Newcastle Clinical Trial Unit, Institute of Health and Society, Baddiley-Clark Building, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen C L Gough
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Churchill Hospital, Oxford, UK
| | - Jeremy W Tomlinson
- Centre for Diabetes, Endocrinology and Metabolism, University of Birmingham, Birmingham, UK
| | - Rachel M Brown
- Department of Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Stefan G Hübscher
- Department of Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- School of Cancer Sciences, University of Birmingham, Birmingham, UK
| | - Philip N Newsome
- NIHR Liver BRU and Centre for Liver Research, University of Birmingham, Birmingham, UK
- Liver and Hepatobiliary Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Snell K, Billingham L, Stocken D, Riley R. Challenges in the development of prognostic models utilising clinical trials data. Trials 2013. [PMCID: PMC3980439 DOI: 10.1186/1745-6215-14-s1-p115] [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: 11/18/2022] Open
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Bartlett JMS, Brookes CL, Piper T, van de Velde CJH, Stocken D, Lyttle N, Hasenburg A, Quintayo MA, Kieback DG, Putter H, Markopoulos C, Kranenbarg EMK, Mallon EA, Dirix LY, Seynaeve C, Rea DW. Do type 1 receptor tyrosine kinases inform treatment choice? A prospectively planned analysis of the TEAM trial. Br J Cancer 2013; 109:2453-61. [PMID: 24091623 PMCID: PMC3817340 DOI: 10.1038/bjc.2013.609] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 09/03/2013] [Accepted: 09/12/2013] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Epidermal growth factor receptors contribute to breast cancer relapse during endocrine therapy. Substitution of aromatase inhibitors (AIs) may improve outcomes in HER-positive cancers. METHODS Tissue microarrays were constructed. Quantitative analysis of HER1, HER2, and HER3 was performed. Data were analysed relative to disease-free survival and treatment using outcomes at 2.75 and 6.5 years. RESULTS Among 4541 eligible samples, 4225 (93%) had complete HER1-3 data. Overall, 5% were HER1-positive, 13% HER2-positive, and 21% HER3-positive; 32% (n=1351) overexpressed at least one HER receptor. In the HER1-3-negative subgroup, the hazard ratio (HR) for upfront exemestane vs tamoxifen at 2.75 years was 0.67 (95% confidence interval (CI), 0.52-0.87), in the HER1-3-positive subgroup, the HR was 1.15 (95% CI, 0.85-1.56). A prospectively planned treatment-by-marker analysis demonstrated a significant interaction between HER1-3 and treatment at 2.75 years (HR=0.58; 95% CI, 0.39-0.87; P=0.008), as confirmed by multivariate regression analysis adjusting for prognostic factors (HR=0.55; 95% CI, 0.36-0.85; P=0.005). This effect was time dependent. CONCLUSION In the 2.75 years prior to switching patients initially treated with tamoxifen to exemestane, a significant treatment-by-marker effect exists between AI/tamoxifen treatment and HER1-3 expression, suggesting HER expression could be used to select appropriate endocrine treatment at diagnosis to prevent or delay early relapses.
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Affiliation(s)
- J M S Bartlett
- Transformative Pathology, Ontario Institute for Cancer Research, Toronto, Canada M5G 0A3
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh EH4 2XR, UK
| | - C L Brookes
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham B15 2TT, UK
| | - T Piper
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh EH4 2XR, UK
| | | | - D Stocken
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham B15 2TT, UK
| | - N Lyttle
- Transformative Pathology, Ontario Institute for Cancer Research, Toronto, Canada M5G 0A3
| | - A Hasenburg
- Department of Obstetrics, University Hospital, Freiburg D-79106, Germany
| | - M A Quintayo
- Transformative Pathology, Ontario Institute for Cancer Research, Toronto, Canada M5G 0A3
| | - D G Kieback
- Department of Obstetrics & Gynecology, Elblandklinikum, Riesa 01589, Germany
| | - H Putter
- Leiden University Medical Center, Leiden 2300 RC, The Netherlands
| | - C Markopoulos
- Department of Surgery, Athens University Medical School, Athens 11521, Greece
| | - E M-K Kranenbarg
- Leiden University Medical Center, Leiden 2300 RC, The Netherlands
| | - E A Mallon
- Department of Pathology, Western Infirmary, Glasgow G11 6NT, UK
| | - L Y Dirix
- Oncology Center, St Augustinus, Antwerp 2610, Belgium
| | - C Seynaeve
- Department of Medical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam 3075EA, The Netherlands
| | - D W Rea
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh EH4 2XR, UK
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Meyer T, Fox R, Bird D, Watkinson A, Hacking N, Stocken D, Johnson PJ, Palmer DH. TACE 2: A randomized placebo-controlled, double-blinded, phase III trial evaluating sorafenib in combination with transarterial chemoembolisation (TACE) in patients with unresectable hepatocellular carcinoma (HCC). J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.tps4150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS4150 Background: TACE is regarded as the standard of care for patients with intermediate stage HCC (BCLC B), while sorafenib (S) is the current standard for advanced disease (BCLC C). The combination of S with TACE for intermediate disease is rational since sorafenib inhibits the action of VEGF which may be induced by tumour hypoxia following TACE, and S also has direct anti-tumour effect. The combination has been shown to be safe in and active in phase I and II studies. Phase III trials are now required to determine whether TACE + S is superior to TACE alone in terms of survival. Methods: We are conducting a double blind multicentre trial to determine if the addition of S to TACE is superior to TACE alone. This is a UK NCRI trial sponsored by University College London (UCL) (EudraCT 2008-005073-36). Patients with intermediate stage HCC are randomised 1:1 to continuous S (400mg BD) or placebo (P). Key inclusion criteria include unresectable HCC confined to the liver, patent main portal vein, ECOG PS ≤1 and Child Pugh A liver score. After randomisation patients commence study drug and TACE is performed at 2-5 weeks using drug eluting beads loaded with 150mg doxorubicin (Biocompatibles UK Ltd) according to a standard protocol. Further TACE is performed at the discretion of the investigator based on radiological response and patient tolerance. The primary outcome measure is progression free survival and central, external, real time radiology review is required to confirm progression. Secondary outcome measures are overall survival, time to progression, toxicity, disease control, quality of life and number of TACE procedures performed in 12 months. The target recruitment is 412 in order to detect a hazard ratio of 0.72 using a 2-sided level of significance of α=0.05 with 85% power. The trial was reviewed by the IDMC after the presentation of the SPACE trial (Lencioni et al J Clin Oncol 30, 2012). The IDMC concurred with the conclusion of the SPACE investigators that the combination is tolerated and results required confirmation in a phase III trial. Thus recruitment into the TACE2 trial will continue as planned.
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Affiliation(s)
- Tim Meyer
- University College London, London, United Kingdom
| | - Richard Fox
- University of Birmingham, Birmingham, United Kingdom
| | - Deborah Bird
- University of Birmingham, Birmingham, United Kingdom
| | | | - Nigel Hacking
- Southampton University Hospitals NHS Trust, Southampton, United Kingdom
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Bartlett JMS, Stocken D, van de Velde CJH, Brookes CL, Robson T, Hasenburg A, Hille ETM, Kiebeck D, Markopoulos C, Mallon EA, Dirix L, Campbell FM, Seynaeve C, Rea DW. Abstract P3-10-04: An Integration of Biological and Pathological Marker Panel in the TEAM Pathology Sub-Study: The Impact of Different Parameters on Risk Estimation of Relapse at Both 2.75 and 5 Years. Cancer Res 2010. [DOI: 10.1158/0008-5472.sabcs10-p3-10-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Recent evidence confirms the importance of both biological and pathological risk markers in predicting early relapse for breast cancer patients treated with endocrine therapy. Most studies use a two step process integrating biological markers into a “biological predictor (e.g. Oncotype Dx, “IHC4” etc) followed by assessment of the predictive value of such tests in the context of pathological markers (grade, nodal status etc). We have taken a one step process integrating both biological and pathological markers into a single model to assess key factors for predicting outcome at 2.75 years and 5 years of endocrine therapy; to inform choices between switching, upfront and extended adjuvant treatment with AIs. Patients & Methods: Pathology blocks from 4598 TEAM patients were collected and tissue microarrays constructed. Quantitative analysis ER, PgR, Ki67, HER1, HER2, and HER3 was performed centrally. A prognostic model, integrating data from biological and pathological markers was created to assess risk (disease-free survival) after 2.75 and 5 years of follow up in the TEAM trial.
Results: Of 4595 eligible cases samples received, 16 were excluded, and 3993 had complete biomarker data for all markers for the final biomarker analysis. In univariate analysis nodal status, grade, size, age at diagnosis, HER1, HER2, PgR, ER and Ki67 were all prognostic. At 2.75 years nodal status, age, PgR histoscore, size, grade, HER2, ER histoscore and HER1 positivity were significant prognostic variables (ranked by WaldX2 statistic), Ki67 and HER3 were not included in this model. At 5 years median follow up; age, nodal status, size, PgR histoscore, grade, Ki67, HER2, and HER1 positivity were significant prognostic variables (ranked by WaldX2 statistic), ER and HER3 were not included in this model. Conclusion: Combined biological and pathological marker panels are of significant value in predicting early relapse in breast cancer patients treated with endocrine therapy, however duration of follow-up may impact on the inclusion of variables in the model. This provides significant information relevant to the choice of different adjuvant endocrine therapies.
Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-04.
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Affiliation(s)
- JMS Bartlett
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - D Stocken
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - CJH van de Velde
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - CL Brookes
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - T Robson
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - A Hasenburg
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - ETM Hille
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - D Kiebeck
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - C Markopoulos
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - EA Mallon
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - L Dirix
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - FM Campbell
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - C Seynaeve
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - DW. Rea
- University of Edinburgh, United Kingdom; University of Birmingham, United Kingdom; Leiden University Medical Centre, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Centre, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; AZ Augustinus, Antwerp, Belgium; Erasmus MC, Rotterdam, Netherlands
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Bartlett JMS, Gustavson M, Stocken D, Rimm D, Christiansen J, van de Velde CJH, Hasenburg A, Kieback D, Putter H, Brookes C, Markopoulos C, Dirix L, Robson T, Seynaeve C, Dolled-Filhart M, Jones C, Graves L, McGuire J, Rea D. Abstract P4-08-02: A Comparison between AQUA Quantitative Fluorescent Immunohistochemistry and Conventional Immunohistochemistry for Hormone Receptors. Cancer Res 2010. [DOI: 10.1158/0008-5472.sabcs10-p4-08-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: We have previous data showing that quantitation of hormone receptors can be highly informative in determining risk of early relapse in ER positive early breast cancer treated with tamoxifen or exemestane. Both quantitative immunohistochemistry (QIHC) and flouresecent immunohistochemistry (F-IHC as measured by AQUA technology) are highly prognostic over a wide expression range. We have explored the results of both assays to determine if current assays provide maximum information using current approaches.
Patients &
Methods: Pathology blocks from 4598 TEAM patients were collected and tissue microarrays constructed. Quantitative AQUA and IHC analysis (using image quantitation) of ER and PgR was performed centrally (Edinburgh & HistoRx). Results from both assays were compared and their prognostic impact on DFS at 2.75 years examined.
Results: Both AQUA and QIHC demonstrated linear relationships between intensity of staining for either ER or PgR and DFS at 2.75 years. For both PgR and ER AQUA provided significantly greater prognostic information that QIHC. However AQUA staining explained only 29% and 68% of the variability in ER and PgR QIHC results by logistic regression. Using both AQUA and QIHC data in a forward stepwise selection survival model demonstrated that AQUA and QIHC provided similar prognostic information over 70% and 50% of the range for ER and PgR respectively. High ER QIHC and low ER AQUA scores, and low PgR IHC and high PgR AQUA scores provided prognostic information unique to either platform.
Conclusion: Both QIHC and AQUA analysis of HR expression provides significant and highly important information on DFS risk in early breast cancer. It appears that these two platforms provide overlapping prognostic information and that the range of ER and PgR expression which impacts patient outcome is wider than measured by either system alone. Further investigation of the clinical significance of this broader range of hormone receptor expression in treatment decisions is warranted.
Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-08-02.
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Affiliation(s)
- JMS Bartlett
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - M Gustavson
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - D Stocken
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - D Rimm
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - J Christiansen
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - CJH van de Velde
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - A Hasenburg
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - D Kieback
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - H Putter
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - C Brookes
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - C Markopoulos
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - L Dirix
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - T Robson
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - C Seynaeve
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - M Dolled-Filhart
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - C Jones
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - L Graves
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - J McGuire
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
| | - D. Rea
- Edinburgh University, Edinburgh, United Kingdom; HistoRx Inc, Branford, CT; Yale University, New Haven, CT; Leiden University Medical Center, Netherlands; University Hospital, Freiburg, Germany; Helios Medical Center, Aue, Germany; Athens University Medical School, Athens, Greece; Western Infirmary, Glasgow, United Kingdom; UZ Gasthuisberg, Leuven, Belgium; Erasmus MC, Rotterdam, Netherlands
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