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Knights H, Minas E, Khan F, Shaw L, Al Obaidi M, Mankad K, Eleftheriou D. Magnetic resonance imaging findings in children with Parry-Romberg syndrome and en coup de sabre. Pediatr Rheumatol Online J 2021; 19:42. [PMID: 33757522 PMCID: PMC7986399 DOI: 10.1186/s12969-021-00512-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/28/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The aim of this study was to: (i) describe the abnormalities seen on brain imaging in a group of children with en coup de sabre (EDCS) with/without Parry-Romberg syndrome (PRS); and (ii) identify clinical predictors of brain imaging abnormalities. METHODS This was a single centre (Great Ormond Street Hospital, London) retrospective case series of patients with ECDS/PRS seen from 2000 to 2018. We identified patients with cutaneous manifestations consistent with the clinical descriptions of ECDS/PRS. Presenting clinical, laboratory, and radiological brain findings are described. Results are expressed as medians and ranges or frequencies and percentages. Fisher's exact test was used to identify clinical associations with magnetic resonance imaging (MRI) abnormalities. RESULTS Fourteen patients were studied: 6 males and 8 females; median age 14 years (range 3-20). We observed neuroimaging abnormalities in 2/6 ECDS and 5/8 ECDS/PRS patients. White matter signal abnormality, dystrophic calcification, leptomeningeal enhancement, and sulcal crowding were the typical findings on brain imaging. A total of 50% of patients had no MRI abnormality despite some of these patients having neurological symptoms. The presence of seizures was significantly associated with ipsilateral enhanced white matter signalling on MRI (p < 0.05). CONCLUSIONS In summary, we observed several distinct radiographic patterns associated with ECDS/PRS. Seizure disorder was strongly associated with the presence of ipsilateral enhanced white matter signalling. Improved neuroimaging techniques that combine morphological with functional imaging may improve the detection rate of brain involvement in children with ECDS/PRS in the future.
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Affiliation(s)
- Harry Knights
- Department of Paediatric Rheumatology, University College London Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK. .,Imperial College School of Medicine, Imperial College London, London, UK.
| | - Elizabeth Minas
- grid.413820.c0000 0001 2191 5195Department of Radiology, Charing Cross Hospital, London, UK
| | - Faraan Khan
- grid.451349.eDepartment of Radiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Lindsay Shaw
- grid.424537.30000 0004 5902 9895Department of Paediatric Dermatology, University College London Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Muthana Al Obaidi
- grid.424537.30000 0004 5902 9895Department of Paediatric Rheumatology, University College London Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kshitij Mankad
- grid.424537.30000 0004 5902 9895Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Despina Eleftheriou
- grid.424537.30000 0004 5902 9895Department of Paediatric Rheumatology, University College London Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK ,grid.83440.3b0000000121901201Centre for Adolescent Rheumatology Versus Arthritis, University College London, London, UK
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Jairath V, Zou GY, Parker CE, MacDonald JK, AlAmeel T, Al Beshir M, Almadi MA, Al‐Taweel T, Atkinson NSS, Biswas S, Chapman T, Dulai PS, Glaire MA, Hoekman DR, Koutsoumpas A, Minas E, Mosli MH, Samaan M, Khanna R, Travis S, D'Haens G, Sandborn WJ, Feagan BG. Placebo response and remission rates in randomised trials of induction and maintenance therapy for ulcerative colitis. Cochrane Database Syst Rev 2017; 9:CD011572. [PMID: 28886205 PMCID: PMC6483671 DOI: 10.1002/14651858.cd011572.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND It is important to minimize placebo rates in randomised controlled trials (RCTs) to efficiently detect treatment differences between interventions. Historically, high placebo rates have been observed in clinical trials of ulcerative colitis (UC). A better understanding of factors influencing placebo rates may lead to more informed clinical trial design. OBJECTIVES A systematic review and meta-analysis was conducted to evaluate placebo response and remission rates in RCTs evaluating UC treatments in adult patients. SEARCH METHODS Electronic databases (i.e. MEDLINE, EMBASE, and CENTRAL) were searched from inception to 1 March 2017 with no language restrictions applied. Reference lists and conference proceedings of major gastroenterology meetings were also handsearched to identify additional studies. SELECTION CRITERIA Placebo-controlled RCTs of adult patients with UC treated with corticosteroids, aminosalicylates, immunosuppressives or biologics were eligible, provided enrolment and outcome assessment was conducted using the Ulcerative Colitis Disease Activity Index (UCDAI) or the Mayo Clinic Score. The minimum trial duration was two weeks for induction trials and four months maintenance trials. DATA COLLECTION AND ANALYSIS Pairs of authors independently determined study eligibility and extracted data with any disagreements resolved through consensus. Outcomes of interest included the proportion of patients with clinical response and remission. Trial characteristics such as the design, participant demographics and disease history, interventions, and enrolment and assessment criteria were also recorded. The methodological quality of the included studies was evaluated using the Cochrane risk of bias tool. Pooled placebo response and remission rates and 95% confidence intervals (95% CI) were calculated using a binomial normal model for proportions. Induction of remission and maintenance studies were pooled separately. The impact of study-level characteristics on placebo response and remission rates was investigated using mixed-effects meta-regression analyses with logits of event rates as the outcome variables. An assessment of pooled placebo rates over time was conducted using a cumulative meta-analysis based on date of publication. Publication bias was examined using funnel plots. MAIN RESULTS The screening process identified 61 included studies which encompass 58 induction phases (5111 patients randomised to placebo) and 12 maintenance phases (1579 patients randomised to placebo). For induction trials, the pooled estimate of placebo response was 33% (95% CI 30% to 36%) while the pooled estimate of placebo remission was 12% (95% CI 9% to 15%). For maintenance trials, the pooled estimate of placebo response was 23% (95% CI 19% to 28%) while the pooled estimate of placebo remission was 17% (95% CI 10% to 27%).Studies enrolling patients with more active disease confirmed objectively by endoscopy were associated with significantly lower placebo remission and response rates than trials enrolling patients with less active disease (27% versus 4%, OR 2.60, 95% CI 1.25 to 5.42, P = 0.01 for UCDAI endoscopy sub score ≥1 versus ≥ 2 for remission; and 27% versus 4%, OR 1.70, 95% CI 1.02 to 2.82, P = 0.02 for UCDAI endoscopy sub score greater than or equal to one versus greater than or equal to two for response). With respect to drug class, the lowest placebo response and remission rates were observed in trials evaluating corticosteroids (23%; 95% CI 19 to 29%, and 5%; 95% CI 2 to 11%, respectively). Trials of biologics had the highest placebo response rate (35%; 95% CI 30 to 41%), while trials evaluating aminosalicylates had the highest placebo remission rate (18%; 95% CI 12 to 24%). Disease duration of greater than five years prior to enrolment was associated with a significantly lower placebo response rate compared to disease duration of less than or equal to five years (29% versus 47%, respectively; OR 0.54, 95% CI 0.32 to 0.92, P = 0.02). The requirement of a minimum rectal bleeding score for study eligibility was associated with an increased placebo response rate compared to studies that did not use rectal bleeding for trial eligibility (37% versus 32%, respectively; OR 1.70, 95% CI 1.02 to 2.82, P = 0.02). Finally, the time point of primary outcome assessment was found to be significantly associated with placebo remission rates such that every one week increment in endpoint assessment was associated with a 6% increase in the placebo remission rate (OR 1.06, 95% CI 1.02 to 1.10, P = 0.01).Cumulative meta-analysis indicated a consistent increase in the placebo response rate from 1987 to 2007 (from 13% to 33%), although rates have remained constant from 2008 to 2015 (32% to 34%). Similarly, placebo remission rates increased from 1987 to 2007 (5% to 14%) but have remained constant from 2008 to 2015 (12 to 14%). On meta-regression, there were no statistically significant differences between the 1987-2007 and 2008-2015 point estimates for both response (P = 0.81) and remission (P = 0.32). AUTHORS' CONCLUSIONS Placebo response and remission rates vary according to endoscopic disease severity and rectal bleeding score at trial entry, class of agent, disease duration, and the time point at which the primary outcome was measured. These observations have important implications for the design and conduct of future clinical trials in UC and will help researchers design trials, determine required sample sizes and also provide useful information about trial design features which should be considered when planning new trials.
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Affiliation(s)
| | | | | | | | - Turki AlAmeel
- King Fahad Specialist Hospital‐DammamDepartment of MedicineP.O Box 15215DammamSaudi Arabia31444
| | - Mohammad Al Beshir
- King Fahad Specialist Hospital‐DammamDepartment of MedicineP.O Box 15215DammamSaudi Arabia31444
| | | | | | | | - Sujata Biswas
- Wellcome Trust Centre for Human GeneticsTranslational Gastroenterology UnitRoosevelt DriveOxfordUKOX3 7BN
| | - Thomas Chapman
- John Radcliffe HospitalTranslational Gastroenterology UnitHeadley WayOxfordUKOX3 9DU
| | | | | | - Daniël R Hoekman
- Academic Medical CenterMeibergdreef 9AmsterdamNetherlands1105 AZ
| | | | | | - Mahmoud H Mosli
- King Abdulaziz UniversityKing Abdulaziz University HospitalJeddahSaudi Arabia
| | - Mark Samaan
- Academic Medical CenterMeibergdreef 9AmsterdamNetherlands1105 AZ
| | | | - Simon Travis
- University of OxfordTranslational Gastroenterology Unit, Nuffield Department of MedicineOxfordUK
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Jairath V, Zou G, Parker CE, MacDonald JK, Mosli MH, AlAmeel T, Al Beshir M, AlMadi M, Al-Taweel T, Atkinson NSS, Biswas S, Chapman TP, Dulai PS, Glaire MA, Hoekman D, Kherad O, Koutsoumpas A, Minas E, Restellini S, Samaan MA, Khanna R, Levesque BG, D'Haens G, Sandborn WJ, Feagan BG. Systematic review with meta-analysis: placebo rates in induction and maintenance trials of Crohn's disease. Aliment Pharmacol Ther 2017; 45:1021-1042. [PMID: 28164348 DOI: 10.1111/apt.13973] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 07/08/2016] [Accepted: 01/16/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Minimising placebo response is essential for drug development. AIM To conduct a meta-analysis to determine placebo response and remission rates in trials and identify the factors affecting these rates. METHODS MEDLINE, EMBASE and CENTRAL were searched from inception to April 2014 for placebo-controlled trials of pharmacological interventions for Crohn's disease. Placebo response and remission rates for induction and maintenance trials were pooled by random-effects and mixed-effects meta-regression models to evaluate effects of study-level characteristics on these rates. RESULTS In 100 studies containing 67 induction and 40 maintenance phases and 7638 participants, pooled placebo remission and response rates for induction trials were 18% [95% confidence interval (CI) 16-21%] and 28% (95% CI 24-32%), respectively. Corresponding values for maintenance trials were 32% (95% CI 25-39%) and 26% (95% CI 19-35%), respectively. For remission, trials enrolling patients with more severe disease activity, longer disease duration and more study centres were associated with lower placebo rates, whereas more study visits and longer study duration was associated with higher placebo rates. For response, findings were opposite such that trials enrolling patients with less severe disease activity and longer study duration were associated with lower placebo rates. Placebo rates varied by drug class and route of administration, with the highest placebo response rates observed for biologics. CONCLUSIONS Placebo rates vary according to whether trials are designed for induction or maintenance and the factors influencing them differ for the endpoints of remission and response. These findings have important implications for clinical trial design in Crohn's disease.
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Affiliation(s)
| | | | | | | | - M H Mosli
- London, ON, Canada.,Jeddah, Saudi Arabia
| | | | | | | | | | | | | | | | - P S Dulai
- London, ON, Canada.,La Jolla, CA, USA
| | | | | | | | | | | | | | | | | | | | - G D'Haens
- London, ON, Canada.,Amsterdam, The Netherlands
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Jairath V, Zou G, Parker CE, Macdonald JK, Mosli MH, Khanna R, Shackelton LM, Vandervoort MK, AlAmeel T, Al Beshir M, AlMadi M, Al-Taweel T, Atkinson NSS, Biswas S, Chapman TP, Dulai PS, Glaire MA, Hoekman D, Koutsoumpas A, Minas E, Samaan MA, Travis S, D’Haens G, Levesque BG, Sandborn WJ, Feagan BG. Systematic Review and Meta-analysis: Placebo Rates in Induction and Maintenance Trials of Ulcerative Colitis. J Crohns Colitis 2016; 10:607-18. [PMID: 26746169 PMCID: PMC4957452 DOI: 10.1093/ecco-jcc/jjw004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Minimisation of the placebo responses in randomised controlled trials [RCTs] is essential for efficient evaluation of new interventions. Placebo rates have been high in ulcerative colitis [UC] clinical trials, and factors influencing this are poorly understood. We quantify placebo response and remission rates in UC RCTs and identify trial design factors influencing them. METHODS MEDLINE, EMBASE, and the Cochrane Library were searched from inception through April 2014 for placebo-controlled trials in adult patients with UC of a biological agent, corticosteroid, immunosuppressant, or aminosalicylate. Data were independently doubly extracted. Quality was assessed using the Cochrane risk of bias tool. RESULTS In all, 51 trials [48 induction and 10 maintenance phases] were identified. Placebo response and remission rates were pooled according to random-effects models, and mixed-effects meta-regression models were used to evaluate effects of study-level characteristics on these rates. Pooled estimates of placebo remission and response rates for induction trials were 10% (95% confidence interval [CI] 7-13%) and 33% [95% CI 29-37%], respectively. Corresponding values for maintenance trials were 19% [95% CI 11-30%] and 22% [95% CI 17-28%]. Trials enrolling patients with more active disease confirmed by endoscopy [endoscopy subscore ≥ 2] were associated with lower placebo rates. Conversely, placebo rates increased with increasing trial duration and number of study visits. CONCLUSIONS Objective assessment of greater disease activity at trial entry by endoscopy lowered placebo rates, whereas increasing trial duration and more interactions with healthcare providers increased placebo rates. These findings have important implications for design and conduct of clinical trials.
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Affiliation(s)
- Vipul Jairath
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, UK,Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Guangyong Zou
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada
| | - Claire E. Parker
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada
| | - John K. Macdonald
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Mahmoud H. Mosli
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada,Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Reena Khanna
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Lisa M. Shackelton
- Robarts Research Institute, University of Western Ontario, London, ON, Canada
| | | | - Turki AlAmeel
- Department of Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Mohammad Al Beshir
- Department of Medicine, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Majid AlMadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Talal Al-Taweel
- Haya Al-Habeeb Gastroenterology Center, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - Nathan S. S. Atkinson
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, UK
| | - Sujata Biswas
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, UK
| | - Thomas P. Chapman
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, UK
| | - Parambir S. Dulai
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Mark A. Glaire
- Division of Medical Sciences, University of Oxford, Oxford, UK
| | - Daniel Hoekman
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Andreas Koutsoumpas
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, UK
| | - Elizabeth Minas
- Department of Geratology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Mark A. Samaan
- Department of Gastroenterology, Guy’s and St Thomas’ Hospital NHS Trust, London, UK
| | - Simon Travis
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, UK
| | - Geert D’Haens
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Barrett G. Levesque
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - William J. Sandborn
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - Brian G. Feagan
- Robarts Research Institute, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada,Department of Medicine, University of Western Ontario, London, ON, Canada
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