1
|
Lindsay JO, Hind D, Swaby L, Berntsson H, Bradburn M, Bannur C U, Byrne J, Clarke C, Desoysa L, Dickins B, Din S, Emsley R, Foulds GA, Gribben J, Hawkey C, Irving PM, Kazmi M, Lee E, Loban A, Lobo A, Mahida Y, Moran GW, Papaioannou D, Parkes M, Peniket A, Pockley AG, Satsangi J, Subramanian S, Travis S, Turton E, Uttenthal B, Rutella S, Snowden JA. Safety and efficacy of autologous haematopoietic stem-cell transplantation with low-dose cyclophosphamide mobilisation and reduced intensity conditioning versus standard of care in refractory Crohn's disease (ASTIClite): an open-label, multicentre, randomised controlled trial. Lancet Gastroenterol Hepatol 2024; 9:333-345. [PMID: 38340759 DOI: 10.1016/s2468-1253(23)00460-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND A previous controlled trial of autologous haematopoietic stem-cell transplantation (HSCT) in patients with refractory Crohn's disease did not meet its primary endpoint and reported high toxicity. We aimed to assess the safety and efficacy of HSCT with an immune-ablative regimen of reduced intensity versus standard of care in this patient population. METHODS This open-label, multicentre, randomised controlled trial was conducted in nine National Health Service hospital trusts across the UK. Adults (aged 18-60 years) with active Crohn's disease on endoscopy (Simplified Endoscopic Score for Crohn's Disease [SES-CD] ulcer sub-score of ≥2) refractory to two or more classes of biological therapy, with no perianal or intra-abdominal sepsis or clinically significant comorbidity, were recruited. Participants were centrally randomly assigned (2:1) to either HSCT with a reduced dose of cyclophosphamide (intervention group) or standard care (control group). Randomisation was stratified by trial site by use of random permuted blocks of size 3 and 6. Patients in the intervention group underwent stem-cell mobilisation (cyclophosphamide 1 g/m2 with granulocyte colony-stimulating factor (G-CSF) 5 μg/kg) and stem-cell harvest (minimum 2·0 × 106 CD34+ cells per kg), before conditioning (fludarabine 125 mg/m2, cyclophosphamide 120 mg/kg, and rabbit anti-thymocyte globulin [thymoglobulin] 7·5 mg/kg in total) and subsequent stem-cell reinfusion supported by G-CSF. Patients in the control group continued any available conventional, biological, or nutritional therapy. The primary outcome was absence of endoscopic ulceration (SES-CD ulcer sub-score of 0) without surgery or death at week 48, analysed in the intention-to-treat population by central reading. This trial is registered with the ISRCTN registry, 17160440. FINDINGS Between Oct 18, 2018, and Nov 8, 2019, 49 patients were screened for eligibility, of whom 23 (47%) were randomly assigned: 13 (57%) to the intervention group and ten (43%) to the control group. In the intervention group, ten (77%) participants underwent HSCT and nine (69%) reached 48-week follow-up; in the control group, nine (90%) reached 48-week follow-up. The trial was halted in response to nine reported suspected unexpected serious adverse reactions in six (46%) patients in the intervention group, including renal failure due to proven thrombotic microangiopathy in three participants and one death due to pulmonary veno-occlusive disease. At week 48, absence of endoscopic ulceration without surgery or death was reported in three (43%) of seven participants in the intervention group and in none of six participants in the control group with available data. Serious adverse events were more frequent in the intervention group (38 in 13 [100%] patients) than in the control group (16 in four [40%] patients). A second patient in the intervention group died after week 48 of respiratory and renal failure. INTERPRETATION Although HSCT with an immune-ablative regimen of reduced intensity decreased endoscopic disease activity, significant adverse events deem this regimen unsuitable for future clinical use in patients with refractory Crohn's disease. FUNDING Efficacy and Mechanism Evaluation Programme, a Medical Research Council and National Institute for Health Research partnership.
Collapse
Affiliation(s)
- James O Lindsay
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | - Daniel Hind
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Lizzie Swaby
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Hannah Berntsson
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Uday Bannur C
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jennifer Byrne
- Department of Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Christopher Clarke
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lauren Desoysa
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Ben Dickins
- John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, UK
| | - Shahida Din
- Department of Gastroenterology, Western General Hospital, Edinburgh, UK
| | - Richard Emsley
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Gemma A Foulds
- John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, UK
| | - John Gribben
- Barts Cancer Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Christopher Hawkey
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Translational Medical Sciences, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Peter M Irving
- Department of Gastroenterology, Guy's and Saint Thomas' Hospitals NHS Trust, London, UK
| | - Majid Kazmi
- King's College Hospital NHS Foundation Trust, London, UK
| | - Ellen Lee
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Amanda Loban
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Alan Lobo
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Yashwant Mahida
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Translational Medical Sciences, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Gordon W Moran
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Translational Medical Sciences, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Diana Papaioannou
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Miles Parkes
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Andrew Peniket
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Graham Pockley
- John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, UK
| | - Jack Satsangi
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | | | - Simon Travis
- NIHR Biomedical Research Centre, Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Emily Turton
- Sheffield Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Ben Uttenthal
- Department of Clinical Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sergio Rutella
- John van Geest Cancer Research Centre, School of Science and Technology, Nottingham Trent University, Nottingham, UK
| | - John A Snowden
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK; Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| |
Collapse
|
2
|
Bamford E, Berntsson H, Beale S, Desoysa L, Dias J, Hamer-Kiwacz S, Hind D, Johnson N, Loban A, Molloy K, Morvan E, Rombach I, Selby A, Thokala P, Turtle C, Walters S, Drummond A. Flexor Injury Rehabilitation Splint Trial (FIRST): protocol for a pragmatic randomised controlled trial comparing three splints for finger flexor tendon repairs. Trials 2024; 25:193. [PMID: 38493121 PMCID: PMC10943783 DOI: 10.1186/s13063-024-08013-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/23/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Without surgical repair, flexor tendon injuries do not heal and patients' ability to bend fingers and grip objects is impaired. However, flexor tendon repair surgery also requires optimal rehabilitation. There are currently three custom-made splints used in the rehabilitation of zone I/II flexor tendon repairs, each with different assumed harm/benefit profiles: the dorsal forearm and hand-based splint (long), the Manchester short splint (short), and the relative motion flexion splint (mini). There is, however, no robust evidence as to which splint, if any, is most clinical or cost effective. The Flexor Injury Rehabilitation Splint Trial (FIRST) was designed to address this evidence gap. METHODS FIRST is a parallel group, superiority, analyst-blind, multi-centre, individual participant-randomised controlled trial. Participants will be assigned 1:1:1 to receive either the long, short, or mini splint. We aim to recruit 429 participants undergoing rehabilitation following zone I/II flexor tendon repair surgery. Potential participants will initially be identified prior to surgery, in NHS hand clinics across the UK, and consented and randomised at their splint fitting appointment post-surgery. The primary outcome will be the mean post-randomisation score on the patient-reported wrist and hand evaluation measure (PRWHE), assessed at 6, 12, 26, and 52 weeks post randomisation. Secondary outcome measures include blinded grip strength and active range of movement (AROM) assessments, adverse events, adherence to the splinting protocol (measured via temperature sensors inserted into the splints), quality of life assessment, and further patient-reported outcomes. An economic evaluation will assess the cost-effectiveness of each splint, and a qualitative sub-study will evaluate participants' preferences for, and experiences of wearing, the splints. Furthermore, a mediation analysis will determine the relationship between patient preferences, splint adherence, and splint effectiveness. DISCUSSION FIRST will compare the three splints with respect to clinical efficacy, complications, quality of life and cost-effectiveness. FIRST is a pragmatic trial which will recruit from 26 NHS sites to allow findings to be generalisable to current clinical practice in the UK. It will also provide significant insights into patient experiences of splint wear and how adherence to splinting may impact outcomes. TRIAL REGISTRATION ISRCTN: 10236011.
Collapse
Affiliation(s)
- Emma Bamford
- Pulvertaft Hand Centre, Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE, UK
| | - Hannah Berntsson
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK.
| | - Suzanne Beale
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, B15 2GW, Birmingham, UK
| | - Lauren Desoysa
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Joseph Dias
- University Hospitals of Leicester NHS Foundation Trust, LE1, 7RH, Leicester, UK
| | - Sienna Hamer-Kiwacz
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Daniel Hind
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Nick Johnson
- Pulvertaft Hand Centre, Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE, UK
| | - Amanda Loban
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | | | - Emma Morvan
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Ines Rombach
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Anna Selby
- Pulvertaft Hand Centre, Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE, UK
| | - Praveen Thokala
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Chris Turtle
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Stephen Walters
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Avril Drummond
- School of Health Sciences, University of Nottingham, Nottingham, NG7 2QL, UK
| |
Collapse
|
3
|
White DA, Pye C, Ridsdale K, Dimairo M, Mooney C, Wright J, Young TA, Cheong YC, Drakeley A, Mathur R, O'Cathain A, Desoysa L, Sizer A, Lumley E, Chatters R, Metwally M. Outpatient paracentesis for the management of ovarian hyperstimulation syndrome: study protocol for the STOP-OHSS randomised controlled trial. BMJ Open 2024; 14:e076434. [PMID: 38262643 PMCID: PMC10806818 DOI: 10.1136/bmjopen-2023-076434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 12/06/2023] [Indexed: 01/25/2024] Open
Abstract
INTRODUCTION Ovarian hyperstimulation syndrome (OHSS) is the most significant short-term complication of pharmacological ovarian stimulation. Symptoms range from mild abdominal discomfort to rare complications such as renal failure, thromboembolism and respiratory distress syndrome.Currently, clinical practice typically involves monitoring the patient until the condition becomes severe, at which point they are admitted to hospital, where drainage of ascitic fluid (paracentesis) may take place. Preliminary studies have indicated that earlier outpatient paracentesis may reduce the progression of OHSS and prevent hospitalisation in women. METHODS AND ANALYSIS This UK, multicentre, pragmatic, two-arm, parallel-group, adaptive (group sequential with one interim analysis), open-label, superiority, confirmatory, group sequential, individually randomised controlled trial, with internal pilot will assess the clinical and cost-effectiveness and safety of outpatient paracentesis versus conservative management (usual care) for moderate or severe OHSS. 224 women from 20 National Health Service and private fertility units will be randomised (1:1) and followed up for up to 13.5 months. The primary outcome is the rate of OHSS related hospital admission of at least 24 hours within 28 days postrandomisation. The primary analysis will be an intention to treat with difference in hospitalisation rates as measure of treatment effect. Secondary outcomes include time to resolution of symptoms, patient satisfaction, adverse events and cost-effectiveness. A qualitative substudy will facilitate the feasibility of recruitment. Participant recruitment commenced in June 2022. ETHICS AND DISSEMINATION London-Southeast Research Ethics Committee approved the protocol (reference: 22/LO/0015). Findings will be submitted to peer-reviewed journals and abstracts to relevant national and international conferences, as well as being disseminated to trial participants and patient groups. TRIAL REGISTRATION NUMBER ISRCTN71978064.
Collapse
Affiliation(s)
- David Alexander White
- Clinical Trials Research Unit, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Clare Pye
- Jessop Wing, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Katie Ridsdale
- Clinical Trials Research Unit, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Munyaradzi Dimairo
- Clinical Trials Research Unit, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Cara Mooney
- Clinical Trials Research Unit, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Jessica Wright
- Clinical Trials Research Unit, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Tracey Anne Young
- Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Ying C Cheong
- Obstetrics and Gynaecology, University of Southampton, Southampton, UK
| | - Andrew Drakeley
- Hewitt Fertility Centre, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | - Raj Mathur
- Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Alicia O'Cathain
- Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Lauren Desoysa
- Clinical Trials Research Unit, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | | | | | - Robin Chatters
- Clinical Trials Research Unit, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Mostafa Metwally
- The University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| |
Collapse
|
4
|
Swaby L, Perry DC, Walker K, Hind D, Mills A, Jayasuriya R, Totton N, Desoysa L, Chatters R, Young B, Sherratt F, Latimer N, Keetharuth A, Kenison L, Walters S, Gardner A, Ahuja S, Campbell L, Greenwood S, Cole A. Bracing Adolescent Idiopathic Scoliosis (BASIS) study - night-time versus full-time bracing in adolescent idiopathic scoliosis: study protocol for a multicentre, randomized controlled trial. Bone Jt Open 2023; 4:873-880. [PMID: 37972634 PMCID: PMC10655615 DOI: 10.1302/2633-1462.411.bjo-2023-0128] [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] [Indexed: 11/19/2023] Open
Abstract
Aims Scoliosis is a lateral curvature of the spine with associated rotation, often causing distress due to appearance. For some curves, there is good evidence to support the use of a spinal brace, worn for 20 to 24 hours a day to minimize the curve, making it as straight as possible during growth, preventing progression. Compliance can be poor due to appearance and comfort. A night-time brace, worn for eight to 12 hours, can achieve higher levels of curve correction while patients are supine, and could be preferable for patients, but evidence of efficacy is limited. This is the protocol for a randomized controlled trial of 'full-time bracing' versus 'night-time bracing' in adolescent idiopathic scoliosis (AIS). Methods UK paediatric spine clinics will recruit 780 participants aged ten to 15 years-old with AIS, Risser stage 0, 1, or 2, and curve size (Cobb angle) 20° to 40° with apex at or below T7. Patients are randomly allocated 1:1, to either full-time or night-time bracing. A qualitative sub-study will explore communication and experiences of families in terms of bracing and research. Patient and Public Involvement & Engagement informed study design and will assist with aspects of trial delivery and dissemination. Discussion The primary outcome is 'treatment failure' (Cobb angle progression to 50° or more before skeletal maturity); skeletal maturity is at Risser stage 4 in females and 5 in males, or 'treatment success' (Cobb angle less than 50° at skeletal maturity). The comparison is on a non-inferiority basis (non-inferiority margin 11%). Participants are followed up every six months while in brace, and at one and two years after skeletal maturity. Secondary outcomes include the Scoliosis Research Society 22 questionnaire and measures of quality of life, psychological effects of bracing, adherence, anxiety and depression, sleep, satisfaction, and educational attainment. All data will be collected through the British Spine Registry.
Collapse
Affiliation(s)
- Lizzie Swaby
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Daniel C. Perry
- Alder Hey Children’s Hospital, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | - Kerry Walker
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Daniel Hind
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | | | | | - Nikki Totton
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Lauren Desoysa
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Robin Chatters
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Bridget Young
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Frances Sherratt
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Nick Latimer
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Anju Keetharuth
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | | | - Stephen Walters
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Adrian Gardner
- Royal Orthopaedic Hospital, Birmingham, UK
- Aston University, Birmingham, UK
| | - Sashin Ahuja
- Noah’s Ark Children’s Hospital for Wales, Cardiff, UK
- Cardiff University, Cardiff, UK
| | - Laura Campbell
- School of Medicine, Keele University, Keele, UK
- Keele University, Keele, UK
| | | | - Ashley Cole
- Sheffield Children’s Hospital, Sheffield, UK
| | - on behalf of the BASIS study group
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
- Alder Hey Children’s Hospital, Liverpool, UK
- University of Liverpool, Liverpool, UK
- Sheffield Children’s Hospital, Sheffield, UK
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
- Evelina London Children’s Hospital, London, UK
- Royal Orthopaedic Hospital, Birmingham, UK
- Aston University, Birmingham, UK
- Noah’s Ark Children’s Hospital for Wales, Cardiff, UK
- Cardiff University, Cardiff, UK
- School of Medicine, Keele University, Keele, UK
- Keele University, Keele, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| |
Collapse
|