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Rich BS, Dicken BJ, Billmire DF, Weil BR, Ross J, Fallahazad N, Krailo M, Shaikh F, Frazier AL, Hazard FK, Nuño MM. Characterizing Lymphovascular Invasion in Pediatric and Adolescent Malignant Ovarian Nongerminomatous Germ Cell Tumors: A Report from the Children's Oncology Group. J Pediatr Surg 2023; 58:2399-2404. [PMID: 37699777 PMCID: PMC10872999 DOI: 10.1016/j.jpedsurg.2023.08.008] [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: 03/19/2023] [Revised: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Lymphovascular invasion (LVI) has been identified as a poor prognostic factor for a variety of tumors; however, its significance in malignant ovarian germ cell tumors (MOGCT) in pediatric and adolescent patients is not well described. We aim to clarify the significance of LVI in the subset of patients with nongerminomatous MOGCT. METHODS Records of patients 0-20 years of age with MOGCT enrolled on Children's Oncology Group study AGCT0132 were reviewed. Patients with documented presence or absence of LVI in either institutional or central review pathology reports were included. RESULTS Of 130 patients with MOGCTs, 83 patients had of the presence or absence of LVI documented in their pathology report. 42/83 patients (50.6%) were found to have LVI present. The estimated odds of having LVI was higher in patients with stage II and III disease, 11 years and older and with the presence of choriocarcinoma. Event-free survival (EFS) and overall survival (OS) remained high in patients with LVI. Approximately 50% of patients with a documented LVI status in either institutional pathology report or central review were found to have LVI. CONCLUSIONS The presence of LVI was higher in tumors with adverse risk factors including higher stage and age greater than 11 years. While LVI was not associated with EFS or OS in the intermediate risk group, further work is necessary to determine the effect of LVI on long-term disease-free survival. We, therefore, recommend routinely incorporating LVI status into institutional pathology reports for pediatric and adolescent patients with MOGCT. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Barrie S Rich
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA.
| | - Bryan J Dicken
- Division of Pediatric Surgery, University of Alberta, Edmonton Canada
| | - Deborah F Billmire
- Division of Pediatric Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Brent R Weil
- Division of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Ross
- Department of Urology, Department of Pediatrics, Rush Medical College, Chicago, IL, USA
| | - Negar Fallahazad
- Children's Oncology Group, Public Health Institute, Monrovia, CA, USA
| | - Mark Krailo
- Children's Oncology Group, Public Health Institute, Monrovia, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Furqan Shaikh
- Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - A Lindsay Frazier
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center Harvard Medical School, Boston, MA, USA
| | - Florette K Hazard
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Michelle M Nuño
- Children's Oncology Group, Public Health Institute, Monrovia, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
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Nishida MK, Nuño MM, Grill JD, Gillen DL. Effects of informant replacement in Alzheimer's disease clinical trials. Alzheimers Dement (N Y) 2023; 9:e12439. [PMID: 38093736 PMCID: PMC10716564 DOI: 10.1002/trc2.12439] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/13/2023] [Accepted: 11/16/2023] [Indexed: 01/10/2024]
Abstract
INTRODUCTION Alzheimer's disease (AD) trials require enrollment with an informant. METHODS We assessed relationships between informant replacement and Alzheimer's Disease Cooperative Study Activities of Daily Living (ADCS-ADL) scores across four AD trials. Using generalized estimating equations, we examined associations between replacement and change in ADCS-ADL between successive visits. We used analysis of covariance to estimate the association between replacement and 18-month change from baseline, and an F-test to compare the variance of this change. RESULTS Among 1336 participants, 63 (≈5%) experienced replacement. Between-visit mean change in ADCS-ADL was 2.44 points lower comparing replacement to stable informants (95% confidence interval [CI]: -3.91, -0.98). The difference in between-visit mean absolute change was 2.38 points (95% CI: 1.24, 3.52). Replacement was not significantly associated with an 18-month change from baseline. The ratio of variances (replacement/stable) was 1.80 (95% CI: 1.19, 2.99). DISCUSSION Informant replacement is associated with bias and increased variability between visits and increased variance for overall ADCS-ADL.
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Affiliation(s)
- Mikaela K. Nishida
- Department of StatisticsDonald Bren School of Information and Computer SciencesUniversity of California, IrvineIrvineCaliforniaUSA
| | - Michelle M. Nuño
- Department of Population and Public Health SciencesUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Joshua D. Grill
- Institute for Memory Impairments and Neurological DisordersUniversity of California, IrvineIrvineCaliforniaUSA
- Alzheimer's Disease Research Center, University of California, IrvineIrvineCaliforniaUSA
- Department of Neurobiology and BehaviorUniversity of California, IrvineIrvineCaliforniaUSA
- Department of Psychiatry and Human BehaviorUniversity of California, UCI HealthIrvineCaliforniaUSA
| | - Daniel L. Gillen
- Department of StatisticsDonald Bren School of Information and Computer SciencesUniversity of California, IrvineIrvineCaliforniaUSA
- Institute for Memory Impairments and Neurological DisordersUniversity of California, IrvineIrvineCaliforniaUSA
- Alzheimer's Disease Research Center, University of California, IrvineIrvineCaliforniaUSA
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Nuño MM, Gillen DL, Grill J. Retention of Participant and Study Partner Dyads in Alzheimer’s Disease Clinical Trials. Alzheimers Dement 2022. [DOI: 10.1002/alz.065189] [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: 12/24/2022]
Affiliation(s)
- Michelle M Nuño
- University of Southern California Los Angeles CA USA
- Institute for Memory Impairments and Neurological Disorders, University of California Irvine Irvine CA USA
| | - Daniel L. Gillen
- Institute for Memory Impairments and Neurological Disorders, University of California Irvine Irvine CA USA
- University of California, Irvine Irvine CA USA
| | - Joshua Grill
- Institute for Memory Impairments and Neurological Disorders, University of California Irvine Irvine CA USA
- University of California, Irvine Irvine CA USA
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Fankhauser CD, Nuño MM, Murray MJ, Frazier L, Bagrodia A. Circulating MicroRNAs for Detection of Germ Cell Tumours: A Narrative Review. Eur Urol Focus 2022; 8:660-662. [DOI: 10.1016/j.euf.2022.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/21/2022] [Accepted: 04/24/2022] [Indexed: 11/15/2022]
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Ritchie M, Witbracht M, Nuño MM, Hoang D, Gillen DL, Grill JD. Effect of Aducanumab Approval on Willingness to Participate in Preclinical Alzheimer's Disease Trials. J Alzheimers Dis 2022; 90:1291-1300. [PMID: 36245381 DOI: 10.3233/jad-220801] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clinical trials now test promising therapies in the preclinical stages of Alzheimer's disease (AD). Participant willingness to enroll in different types of preclinical AD trials is understudied and whether the FDA approval of aducanumab affected these attitudes is unknown. OBJECTIVE To evaluate preferences toward three preclinical AD trial scenarios and whether the FDA approval of aducanumab changed willingness to participate among potential trial participants. METHODS Through an electronic survey, we asked enrollees in a recruitment registry age 50-79 to rate their willingness (using a 6-point Likert scale) to enroll in three hypothetical preclinical AD trial scenarios: an in-clinic infused monoclonal antibody intervention, a home-infused monoclonal antibody intervention, and an oral BACE inhibitor intervention. We administered the survey before and after the FDA approval of aducanumab. We used a generalized estimating equation model to assess group differences in preference for the trial scenarios. We used a paired t-test to determine if willingness to participate (using total willingness across three scenarios as the outcome) changed after the FDA decision. RESULTS At baseline, the mean participant willingness was highest in the in-clinic infusion scenario. There was no significant change in willingness to participate, overall, after the FDA decision. Participants who were independently aware of the FDA's decision (prior to the second survey) demonstrated reduced willingness to participate; participants unaware of the FDA decision demonstrated no change. CONCLUSION Willingness to participate in preclinical AD trials may have been negatively affected by the FDA's decision to approve aducanumab among those aware of the decision.
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Affiliation(s)
- Marina Ritchie
- UC Irvine Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, CA, USA
- Department of Neurobiology and Behavior, University of California, Irvine, CA, USA
| | - Megan Witbracht
- UC Irvine Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, CA, USA
| | - Michelle M Nuño
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Dan Hoang
- UC Irvine Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, CA, USA
| | - Daniel L Gillen
- UC Irvine Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, CA, USA
- Department of Statistics, University of California, Irvine, CA, USA
| | - Joshua D Grill
- UC Irvine Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, CA, USA
- Department of Neurobiology and Behavior, University of California, Irvine, CA, USA
- Department of Psychiatry and Human Behavior, University of California, Irvine, CA, USA
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Nuño MM, Gillen DL. Censoring-robust time-dependent receiver operating characteristic curve estimators. Stat Med 2021; 40:6885-6899. [PMID: 34658036 PMCID: PMC8671363 DOI: 10.1002/sim.9216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 05/05/2021] [Revised: 09/03/2021] [Accepted: 09/18/2021] [Indexed: 01/01/2023]
Abstract
Time-dependent receiver operating characteristic curves are often used to evaluate the classification performance of continuous measures when considering time-to-event data. When one is interested in evaluating the predictive performance of multiple covariates, it is common to use the Cox proportional hazards model to obtain risk scores; however, previous work has shown that when the model is mis-specified, the estimand corresponding to the partial likelihood estimator depends on the censoring distribution. In this manuscript, we show that when the risk score model is mis-specified, the AUC will also depend on the censoring distribution, leading to either over- or under-estimation of the risk score's predictive performance. We propose the use of censoring-robust estimators to remove the dependence on the censoring distribution and provide empirical results supporting the use of censoring-robust risk scores.
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Affiliation(s)
- Michelle M. Nuño
- Department of Preventive Medicine, University of Southern California, CA, United States
- Children’s Oncology Group, CA, United States
| | - Daniel L. Gillen
- Department of Statistics, University of California, Irvine, CA, United States
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Abstract
BACKGROUND/AIMS The focus of Alzheimer's disease studies has shifted to earlier disease stages, including mild cognitive impairment. Biomarker inclusion criteria are often incorporated into mild cognitive impairment clinical trials to identify individuals with "prodromal Alzheimer's disease" to ensure appropriate drug targets and enrich for participants likely to develop Alzheimer's disease dementia. The use of these eligibility criteria may affect study power. METHODS We investigated outcome variability and study power in the setting of proof-of-concept prodromal Alzheimer's disease trials that incorporate cerebrospinal fluid levels of total tau (t-tau) and phosphorylated (p-tau) as primary outcomes and how differing biomarker inclusion criteria affect power. We used data from the Alzheimer's Disease Neuroimaging Initiative to model trial scenarios and to estimate the variance and within-subject correlation of total and phosphorylated tau. These estimates were then used to investigate the differences in study power for trials considering these two surrogate outcomes. RESULTS Patient characteristics were similar for all eligibility criteria. The lowest outcome variance and highest within-subject correlation were obtained when phosphorylated tau was used as an eligibility criterion, compared to amyloid beta or total tau, regardless of whether total tau or phosphorylated tau were used as primary outcomes. Power increased when eligibility criteria were broadened to allow for enrollment of subjects with either low amyloid beta or high phosphorylated tau. CONCLUSION Specific biomarker inclusion criteria may impact statistical power in trials using total tau or phosphorylated tau as the primary outcome. In concert with other important considerations such as treatment target and population of clinical interest, these results may have implications to the integrity and efficiency of prodromal Alzheimer's disease trial designs.
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Affiliation(s)
- Michelle M. Nuño
- Children’s Oncology Group, Monrovia, CA, USA
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA
| | - Joshua D. Grill
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, Irvine, CA, USA
- Department of Neurobiology and Behavior, University of California, Irvine, Irvine, CA, USA
- Department of Psychiatry and Human Behavior, University of California, Irvine, Irvine, CA, USA
| | - Daniel L. Gillen
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, Irvine, CA, USA
- Department of Statistics, University of California, Irvine, Irvine, CA, USA
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Piao J, Lafin JT, Scarpini CG, Nuño MM, Syring I, Dieckmann KP, Belge G, Ellinger J, Amatruda JF, Bagrodia A, Coleman N, Krailo MD, Frazier AL, Murray MJ. A Multi-institutional Pooled Analysis Demonstrates That Circulating miR-371a-3p Alone is Sufficient for Testicular Malignant Germ Cell Tumor Diagnosis. Clin Genitourin Cancer 2021; 19:469-479. [PMID: 34629299 PMCID: PMC9084514 DOI: 10.1016/j.clgc.2021.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 08/26/2021] [Accepted: 08/28/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Circulating microRNAs have clear potential for improving malignant germ-cell-tumor (MGCT) diagnosis. Here, we address the central issue of whether measurement of a single microRNA is sufficient for detecting testicular MGCTs, or whether there is added benefit in quantifying other members of the 4-microRNA panel previously identified (miR-371a-3p/miR-372-3p/miR-373-3p and miR-367-3p). PATIENTS AND METHODS We performed a pooled analysis of available published raw data where all 4 panel miRNAs had been assessed using pre-amplification PCR technology (4 studies; total 329 patients). Two studies using identical methodology (and identical normalization using endogenous miR-30b-5p) were used in the discovery phase (n = 51 patients: 17 MGCT, 34 controls). The 2 other studies (n = 278 patients: 140 MGCT, 138 controls), which assessed the same test panel but with different normalization approaches (endogenous miR-93-5p, exogenous cel-miR-39-3p), were used for the validation phase. We derived sensitivity, specificity, positive- and negative-predictive-values (PPV/NPV) for the detection thresholds that maximised the Youden Index (YI). RESULTS In the discovery-phase, the YI was 0.97 for miR-371a-3p (sensitivity = 1, specificity = 0.97), 0.71 (miR-367-3p), 0.68 (miR-372-3p), and 0.50 (miR-373-3p). These findings were confirmed in the validation-phase, with YI of 0.75 for miR-371a-3p (sensitivity = 0.90, specificity 0.85), 0.55 (miR-367-3p), 0.47 (miR-372-3p), and 0.51 (miR-373-3p). Importantly, no combination of markers added additional diagnostic benefit to miR-371a-3p alone, in either the discovery or the validation phase. CONCLUSION Quantifying circulating miR-371a-3p alone is sufficient for testicular MGCT diagnosis. PCR measurement of this single miRNA marker will be more cost-effective and easier to interpret, facilitating future incorporation into routine clinical practice.
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Affiliation(s)
- Jin Piao
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - John T Lafin
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Michelle M Nuño
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | | | | | - Gazanfer Belge
- Faculty of Biology and Chemistry, University of Bremen, Bremen, Germany
| | | | - James F Amatruda
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles; and Keck School of Medicine University of Southern California, Los Angeles, CA
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Nicholas Coleman
- Department of Pathology, University of Cambridge, Cambridge, UK; Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Mark D Krailo
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - A Lindsay Frazier
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA
| | - Matthew J Murray
- Department of Pathology, University of Cambridge, Cambridge, UK; Department of Paediatric Haematology and Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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Nuño MM, Gillen DL. On estimation in the nested case‐control design under nonproportional hazards. Scand Stat Theory Appl 2021. [DOI: 10.1111/sjos.12510] [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: 11/28/2022]
Affiliation(s)
- Michelle M. Nuño
- Department of Preventive Medicine University of Southern California Los Angeles California USA
- Childrens Oncology Group Monrovia California USA
| | - Daniel L. Gillen
- Department of Statistics University of California, Irvine Irvine California USA
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Nuño MM, Gillen DL. Robust estimation in the nested case-control design under a misspecified covariate functional form. Stat Med 2020; 40:299-311. [PMID: 33105514 DOI: 10.1002/sim.8775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 12/01/2019] [Revised: 09/24/2020] [Accepted: 09/26/2020] [Indexed: 11/07/2022]
Abstract
The Cox proportional hazards model is typically used to analyze time-to-event data. If the event of interest is rare and covariates are difficult or expensive to collect, the nested case-control (NCC) design provides consistent estimates at reduced costs with minimal impact on precision if the model is specified correctly. If our scientific goal is to conduct inference regarding an association of interest, it is essential that we specify the model a priori to avoid multiple testing bias. We cannot, however, be certain that all assumptions will be satisfied so it is important to consider robustness of the NCC design under model misspecification. In this manuscript, we show that in finite sample settings where the functional form of a covariate of interest is misspecified, the estimates resulting from the partial likelihood estimator under the NCC design depend on the number of controls sampled at each event time. To account for this dependency, we propose an estimator that recovers the results obtained using using the full cohort, where full covariate information is available for all study participants. We present the utility of our estimator using simulation studies and show the theoretical properties. We end by applying our estimator to motivating data from the Alzheimer's Disease Neuroimaging Initiative.
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Affiliation(s)
- Michelle M Nuño
- Department of Preventive Medicine, University of Southern California, Los Angeles, California, USA.,Children's Oncology Group in Monrovia, CA
| | - Daniel L Gillen
- Department of Statistics, University of California Irvine, Irvine, California, USA
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Nuño MM, Gillen DL, Grill JD. Study partner types and prediction of cognitive performance: implications to preclinical Alzheimer's trials. Alzheimers Res Ther 2019; 11:92. [PMID: 31775871 PMCID: PMC6881999 DOI: 10.1186/s13195-019-0544-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 05/30/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Alzheimer's disease (AD) clinical trials require enrollment of a participant and a study partner, whose role includes assessing participant cognitive and functional performance. AD trials now investigate early stages of the disease, when participants are not cognitively impaired. This gives rise to the question of whether study partners or participants provide more information in these trials. METHODS We used data from the AD Cooperative Study Prevention Instrument Project (ADCS-PI) to compare participant and study partner predictions of the participant's current and future cognitive state. We used the Cognitive Function Instrument (CFI) as a measure of evaluation of the participant's cognitive status and the modified ADCS Preclinical Alzheimer's Cognitive Composite (mADCS-PACC) as an objective measure of cognition. Stratifying by cognitive status and study partner type and adjusting for other predictors of the participant's cognitive state, we used random forests along with estimated mean variable importance (eMVI) to assess how well each member of the dyad can predict cognitive state at current and later visits. We also fit linear regression models at each time point and for each scenario. RESULTS Participants were better at predicting future cognitive status compared to their study partners regardless of study partner type, though the difference between participants and partners was greatest for non-spousal dyads in the lowest-performing quartile. Cross-sectional assessments differed substantially by dyad type. Within the lowest cognitive performance quartile, participants having a non-spousal study partner outperformed their partners in assessing cognition at later times. Spousal partners, in contrast, outperformed participants later in the study in predicting current cognitive performance. CONCLUSIONS These results indicate that participants tend to be better at predicting future cognition compared to their study partners regardless of the study partner type. When assessing current cognition, however, spousal study partners perform better at later time points and non-spousal study partners do not provide as much information regarding participant cognitive state.
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Affiliation(s)
- Michelle M. Nuño
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, Irvine, CA USA
- Department of Statistics, University of California, Irvine, Irvine, CA USA
| | - Daniel L. Gillen
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, Irvine, CA USA
- Department of Statistics, University of California, Irvine, Irvine, CA USA
| | - Joshua D. Grill
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, Irvine, CA USA
- Department of Neurobiology and Behavior, University of California, Irvine, Irvine, CA USA
- Department of Psychiatry and Human Behavior, University of California, Irvine, Irvine, CA USA
| | - for the Alzheimer’s Disease Cooperative Study
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, Irvine, CA USA
- Department of Statistics, University of California, Irvine, Irvine, CA USA
- Department of Neurobiology and Behavior, University of California, Irvine, Irvine, CA USA
- Department of Psychiatry and Human Behavior, University of California, Irvine, Irvine, CA USA
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Abstract
BACKGROUND Prodromal Alzheimer disease (AD) clinical trials enroll patients with mild cognitive impairment (MCI) meeting biomarker criteria, but specific enrollment criteria vary among trials. METHODS We used data from AD Neuroimaging Initiative (ADNI) MCI participants to assess AD biomarker eligibility, variation in trial outcome measures, and statistical power. RESULTS Most (65%) participants meet eligibility criteria based on low cerebrospinal fluid amyloid beta (Aβ). Relative to trials enrolling exclusively based on low cerebrospinal fluid Aβ, trials including participants with a high ratio of phosphorylated tau to Aβ would include an additional 15% of participants. Fewer (34% to 62%) participants met criteria for Aβ and tau. Differences in clinical and demographic characteristics of modeled trial samples were minimal. Those with low Aβ and high tau showed the greatest change over time on outcome measures. CONCLUSIONS Eligibility rates for prodromal trials vary depending on the specific biomarker criteria, though differences in demographics and the variation associated with outcome measures are minimal. Broadening inclusion criteria beyond amyloid alone may facilitate recruitment but include patients showing slower progression over time. Biomarker criteria selection should be informed by the goal of enrolling individuals most likely to utilize and benefit from the intervention under investigation in a particular setting.
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Affiliation(s)
- Joshua D. Grill
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, Irvine,
CA
- Department of Psychiatry and Human Behavior, University of California, Irvine, Irvine, CA, USA
- Department of Neurobiology and Behavior, University of California, Irvine, Irvine, CA, USA
| | - Michelle M. Nuño
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, Irvine,
CA
- Department of Statistics, University of California, Irvine, Irvine, CA, USA
| | - Daniel L. Gillen
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, Irvine,
CA
- Department of Statistics, University of California, Irvine, Irvine, CA, USA
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13
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Nuño MM, Gillen DL, Dosanjh KK, Brook J, Elashoff D, Ringman JM, Grill JD. Attitudes toward clinical trials across the Alzheimer's disease spectrum. Alzheimers Res Ther 2017; 9:81. [PMID: 28978335 PMCID: PMC5628443 DOI: 10.1186/s13195-017-0311-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 06/09/2017] [Accepted: 09/20/2017] [Indexed: 12/04/2022]
Abstract
BACKGROUND Research has revealed that manifest Alzheimer's disease (AD) dementia is preceded by preclinical and prodromal phases during which pathology is accumulating but function remains intact. This understanding and concern that disease-modifying interventions initiated at the dementia stage may come too late in the neurodegenerative process to be successful has led to a paradigm shift in AD clinical trials. AD trials now enroll patients with mild cognitive impairment (MCI) and persons with no cognitive symptoms. Trial designs are similar to those enrolling dementia participants. We set out to test the hypothesis that attitudes towards trial design features differ among different potential AD trial populations. METHODS We sent a survey composed of 37 items assessing specific trial elements to 246 cognitively normal, MCI, and AD dementia participants at the University of California Los Angeles (UCLA) Alzheimer's Disease Research Center (ADRC), from whom we received 91 responses (37 cognitively normal, 32 MCI, and 22 dementia). To quantify willingness to enroll, we created three composite scenarios by summing responses and fitting proportional odds models with a binary outcome variable for whether patients were highly willing to participate in low-, moderate-, or high-risk and burden trials. RESULTS MCI participants less frequently correctly self-identified their diagnoses than those with dementia or normal cognition. Compared to dementia patients, the odds of participating in a low-risk, low-burden trial were 12% lower for MCI patients (odds ratio (OR) = 0.88, 95% confidence interval (CI) 0.23-3.29) and 70% lower (OR = 0.30, 95% CI 0.08-1.09) for cognitively normal participants. With increasing risk and burden, willingness to enroll decreased and the gap in relative willingness between diagnostic groups increased. In the medium-risk, medium-burden scenario, the estimated OR was 0.64 (95% CI 0.17-2.40) for MCI and 0.21 for the cognitively normal (95% CI 0.06-0.77). In the high-risk, high-burden scenario, the estimated OR indicated reduced willingness for MCI (OR = 0.27, 95% CI 0.06-1.15) and cognitively normal respondents (OR = 0.12, 95% CI 0.03-0.54). CONCLUSIONS These results suggest that AD trials enrolling predementia populations, especially those requiring frequent visits and implementing biomarker testing procedures, may encounter challenges to enrollment.
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Affiliation(s)
- Michelle M Nuño
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, CA, USA
- Department of Statistics, University of California, Irvine, CA, USA
| | - Daniel L Gillen
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, CA, USA
- Department of Statistics, University of California, Irvine, CA, USA
| | - Kulwant K Dosanjh
- Division of General Internal Medicine/Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
| | - Jenny Brook
- Department of Medicine, University of California, Los Angeles, CA, USA
| | - David Elashoff
- Department of Medicine, University of California, Los Angeles, CA, USA
| | - John M Ringman
- Department of Neurology, University of Southern California, Los Angeles, CA, USA
| | - Joshua D Grill
- Institute for Memory Impairments and Neurological Disorders, University of California, Irvine, CA, USA.
- Department of Psychiatry and Human Behavior, University of California, Irvine, CA, USA.
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