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Harris E. Safety Concerns Put a Stop to Maternal RSV Vaccine Study. JAMA 2024; 331:1439. [PMID: 38607635 DOI: 10.1001/jama.2024.5155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
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Haine LMF, Murray TA, Koopmeiners JS. Optimal timing for an accelerated interim futility analysis incorporating real world data. Contemp Clin Trials 2024; 140:107489. [PMID: 38461938 DOI: 10.1016/j.cct.2024.107489] [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: 11/12/2023] [Revised: 02/21/2024] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Randomized controlled trials include interim monitoring guidelines to stop early for safety, efficacy, or futility. Futility monitoring facilitates re-allocation of limited resources. However, conventional methods for interim futility monitoring require a trial to accrue nearly half of the outcome data to make a reliable early stopping decision, limiting its benefit. As early stopping for futility will not inflate type-I error, these analyses are an appealing venue for incorporating external data to improve efficiency. METHODS We propose a Bayesian approach to futility monitoring leveraging real world data using Semi-Supervised MIXture Multi-source Exchangeability Models, which accounts for both measured and unmeasured differences between data sources. We implement futility monitoring using predictive probabilities and investigate the optimal timing with respect to the expected sample size under the null hypothesis. Because we only incorporate external data during the interim futility analysis the proposed design is not limited by type-I error inflation. RESULTS When the external and trial data are exchangeable, the proposed method provides a roughly 70 person reduction in expected sample size under the null. Under scenarios where exchangeability does not hold, our approach still provides a 10-20 person reduction in expected sample size under the null with about 80% power. CONCLUSIONS External data borrowing in interim futility monitoring is a promising venue to improve trial efficiency without type-I error inflation. Approaches that are acceptable to regulatory authorities and leverage the complementary strengths of real world and trial data are vital to more efficiently allocate limited resources amongst clinical trials.
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Affiliation(s)
- Lillian M F Haine
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States.
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Joseph S Koopmeiners
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
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3
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Affiliation(s)
- Jakov Tiefenbach
- Edinburgh Spinal Surgery Outcome Studies Group, Royal Infirmary of Edinburgh, Edinburgh, Scotland
- Cleveland Clinic, Cleveland, OH
| | - Jay J Park
- Edinburgh Spinal Surgery Outcome Studies Group, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Andreas K Demetriades
- Edinburgh Spinal Surgery Outcome Studies Group, Royal Infirmary of Edinburgh, Edinburgh, Scotland
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Rizk JG, Lewin JC. FDA's dilemma with the aducanumab approval: public pressure and hope, surrogate markers and efficacy, and possible next steps. BMJ Evid Based Med 2023; 28:78-82. [PMID: 35450946 DOI: 10.1136/bmjebm-2022-111914] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2022] [Indexed: 11/03/2022]
Abstract
Accelerating Food and Drug Administration (FDA) product approval to market based on surrogate markers in the absence of proven efficacy creates a risk of adverse outcomes for affected patients, even in response to a life-threatening condition, such as in this case, Alzheimer's disease. FDA's recent unexpected approval of aducanumab, despite the unified opposition of its own highly respected advisory committee after the early termination of two efficacy trials, creates the potential risk of adverse effects and lack of clinical efficacy at very high costs. In view of these concerns, a thorough review of the issues and pressures that led to this decision is worth the careful consideration of the clinical and scientific communities with regard to whether this approval represents a calculated and balanced compassionate decision versus a disturbing precedent.
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Affiliation(s)
- John G Rizk
- University of Maryland, Baltimore, Department of Pharmaceutical Health Services Research, Baltimore, Maryland, USA
| | - John C Lewin
- National Coalition on Health Care, Washington, District of Columbia, USA
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Connors JM, Brooks MM, Sciurba FC, Krishnan JA, Bledsoe JR, Kindzelski A, Baucom AL, Kirwan BA, Eng H, Martin D, Zaharris E, Everett B, Castro L, Shapiro NL, Lin JY, Hou PC, Pepine CJ, Handberg E, Haight DO, Wilson JW, Majercik S, Fu Z, Zhong Y, Venugopal V, Beach S, Wisniewski S, Ridker PM. Effect of Antithrombotic Therapy on Clinical Outcomes in Outpatients With Clinically Stable Symptomatic COVID-19: The ACTIV-4B Randomized Clinical Trial. JAMA 2021; 326:1703-1712. [PMID: 34633405 PMCID: PMC8506296 DOI: 10.1001/jama.2021.17272] [Citation(s) in RCA: 156] [Impact Index Per Article: 52.0] [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: 07/17/2021] [Accepted: 09/14/2021] [Indexed: 12/13/2022]
Abstract
Importance Acutely ill inpatients with COVID-19 typically receive antithrombotic therapy, although the risks and benefits of this intervention among outpatients with COVID-19 have not been established. Objective To assess whether anticoagulant or antiplatelet therapy can safely reduce major adverse cardiopulmonary outcomes among symptomatic but clinically stable outpatients with COVID-19. Design, Setting, and Participants The ACTIV-4B Outpatient Thrombosis Prevention Trial was designed as a minimal-contact, adaptive, randomized, double-blind, placebo-controlled trial to compare anticoagulant and antiplatelet therapy among 7000 symptomatic but clinically stable outpatients with COVID-19. The trial was conducted at 52 US sites between September 2020 and June 2021; final follow-up was August 5, 2021. Prior to initiating treatment, participants were required to have platelet count greater than 100 000/mm3 and estimated glomerular filtration rate greater than 30 mL/min/1.73 m2. Interventions Random allocation in a 1:1:1:1 ratio to aspirin (81 mg orally once daily; n = 164), prophylactic-dose apixaban (2.5 mg orally twice daily; n = 165), therapeutic-dose apixaban (5 mg orally twice daily; n = 164), or placebo (n = 164) for 45 days. Main Outcomes and Measures The primary end point was a composite of all-cause mortality, symptomatic venous or arterial thromboembolism, myocardial infarction, stroke, or hospitalization for cardiovascular or pulmonary cause. The primary analyses for efficacy and bleeding events were limited to participants who took at least 1 dose of trial medication. Results On June 18, 2021, the trial data and safety monitoring board recommended early termination because of lower than anticipated event rates; at that time, 657 symptomatic outpatients with COVID-19 had been randomized (median age, 54 years [IQR, 46-59]; 59% women). The median times from diagnosis to randomization and from randomization to initiation of study treatment were 7 days and 3 days, respectively. Twenty-two randomized participants (3.3%) were hospitalized for COVID-19 prior to initiating treatment. Among the 558 patients who initiated treatment, the adjudicated primary composite end point occurred in 1 patient (0.7%) in the aspirin group, 1 patient (0.7%) in the 2.5-mg apixaban group, 2 patients (1.4%) in the 5-mg apixaban group, and 1 patient (0.7%) in the placebo group. The risk differences compared with placebo for the primary end point were 0.0% (95% CI not calculable) in the aspirin group, 0.7% (95% CI, -2.1% to 4.1%) in the 2.5-mg apixaban group, and 1.4% (95% CI, -1.5% to 5.0%) in the 5-mg apixaban group. Risk differences compared with placebo for bleeding events were 2.0% (95% CI, -2.7% to 6.8%), 4.5% (95% CI, -0.7% to 10.2%), and 6.9% (95% CI, 1.4% to 12.9%) among participants who initiated therapy in the aspirin, prophylactic apixaban, and therapeutic apixaban groups, respectively, although none were major. Findings inclusive of all randomized patients were similar. Conclusions and Relevance Among symptomatic clinically stable outpatients with COVID-19, treatment with aspirin or apixaban compared with placebo did not reduce the rate of a composite clinical outcome. However, the study was terminated after enrollment of 9% of participants because of an event rate lower than anticipated. Trial Registration ClinicalTrials.gov Identifier: NCT04498273.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Heather Eng
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | - Peter C. Hou
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | | | | | | | - Zhuxuan Fu
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yongqi Zhong
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Scott Beach
- University of Pittsburgh, Pittsburgh, Pennsylvania
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Anderson TS, Ayanian JZ, Souza J, Landon BE. Representativeness of Participants Eligible to Be Enrolled in Clinical Trials of Aducanumab for Alzheimer Disease Compared With Medicare Beneficiaries With Alzheimer Disease and Mild Cognitive Impairment. JAMA 2021; 326:1627-1629. [PMID: 34499725 PMCID: PMC8430904 DOI: 10.1001/jama.2021.15286] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [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
This study evaluates whether patients enrolled in trials of aducanumab, EMERGE and ENGAGE, were representative of patients with dementia enrolled in Medicare by estimating the proportions of Medicare beneficiaries with Alzheimer disease (AD) or mild cognitive impairment (MCI) who would have been excluded from these trials.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - John Z. Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Editor, JAMA Health Forum
| | - Jeffrey Souza
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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McNamee JJ, Gillies MA, Barrett NA, Perkins GD, Tunnicliffe W, Young D, Bentley A, Harrison DA, Brodie D, Boyle AJ, Millar JE, Szakmany T, Bannard-Smith J, Tully RP, Agus A, McDowell C, Jackson C, McAuley DF. Effect of Lower Tidal Volume Ventilation Facilitated by Extracorporeal Carbon Dioxide Removal vs Standard Care Ventilation on 90-Day Mortality in Patients With Acute Hypoxemic Respiratory Failure: The REST Randomized Clinical Trial. JAMA 2021; 326:1013-1023. [PMID: 34463700 PMCID: PMC8408762 DOI: 10.1001/jama.2021.13374] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [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] [Indexed: 01/08/2023]
Abstract
IMPORTANCE In patients who require mechanical ventilation for acute hypoxemic respiratory failure, further reduction in tidal volumes, compared with conventional low tidal volume ventilation, may improve outcomes. OBJECTIVE To determine whether lower tidal volume mechanical ventilation using extracorporeal carbon dioxide removal improves outcomes in patients with acute hypoxemic respiratory failure. DESIGN, SETTING, AND PARTICIPANTS This multicenter, randomized, allocation-concealed, open-label, pragmatic clinical trial enrolled 412 adult patients receiving mechanical ventilation for acute hypoxemic respiratory failure, of a planned sample size of 1120, between May 2016 and December 2019 from 51 intensive care units in the UK. Follow-up ended on March 11, 2020. INTERVENTIONS Participants were randomized to receive lower tidal volume ventilation facilitated by extracorporeal carbon dioxide removal for at least 48 hours (n = 202) or standard care with conventional low tidal volume ventilation (n = 210). MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality 90 days after randomization. Prespecified secondary outcomes included ventilator-free days at day 28 and adverse event rates. RESULTS Among 412 patients who were randomized (mean age, 59 years; 143 [35%] women), 405 (98%) completed the trial. The trial was stopped early because of futility and feasibility following recommendations from the data monitoring and ethics committee. The 90-day mortality rate was 41.5% in the lower tidal volume ventilation with extracorporeal carbon dioxide removal group vs 39.5% in the standard care group (risk ratio, 1.05 [95% CI, 0.83-1.33]; difference, 2.0% [95% CI, -7.6% to 11.5%]; P = .68). There were significantly fewer mean ventilator-free days in the extracorporeal carbon dioxide removal group compared with the standard care group (7.1 [95% CI, 5.9-8.3] vs 9.2 [95% CI, 7.9-10.4] days; mean difference, -2.1 [95% CI, -3.8 to -0.3]; P = .02). Serious adverse events were reported for 62 patients (31%) in the extracorporeal carbon dioxide removal group and 18 (9%) in the standard care group, including intracranial hemorrhage in 9 patients (4.5%) vs 0 (0%) and bleeding at other sites in 6 (3.0%) vs 1 (0.5%) in the extracorporeal carbon dioxide removal group vs the control group. Overall, 21 patients experienced 22 serious adverse events related to the study device. CONCLUSIONS AND RELEVANCE Among patients with acute hypoxemic respiratory failure, the use of extracorporeal carbon dioxide removal to facilitate lower tidal volume mechanical ventilation, compared with conventional low tidal volume mechanical ventilation, did not significantly reduce 90-day mortality. However, due to early termination, the study may have been underpowered to detect a clinically important difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02654327.
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Affiliation(s)
- James J. McNamee
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Michael A. Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Nicholas A. Barrett
- Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, United Kingdom
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - William Tunnicliffe
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Duncan Young
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, United Kingdom
| | - Andrew Bentley
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - David A. Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
| | - Andrew J. Boyle
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | | | - Tamas Szakmany
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
- Critical Care Directorate, Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, Gwent, United Kingdom
| | - Jonathan Bannard-Smith
- Department of Critical Care, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, United Kingdom
| | - Redmond P. Tully
- Department of Anaesthetics and Intensive Care, Royal Oldham Hospital, Northern Care Alliance, Oldham, United Kingdom
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | - Clíona McDowell
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | - Colette Jackson
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | - Daniel F. McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
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Andrews LM, de Winter BCM, Cornelissen EAM, de Jong H, Hesselink DA, Schreuder MF, Brüggemann RJM, van Gelder T, Cransberg K. A Population Pharmacokinetic Model Does Not Predict the Optimal Starting Dose of Tacrolimus in Pediatric Renal Transplant Recipients in a Prospective Study: Lessons Learned and Model Improvement. Clin Pharmacokinet 2021; 59:591-603. [PMID: 31654367 PMCID: PMC7217818 DOI: 10.1007/s40262-019-00831-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background and Objective Bodyweight-based dosing of tacrolimus is considered standard care. Currently, at first steady state, a third of pediatric kidney transplant recipients has a tacrolimus pre-dose concentration within the target range. We investigated whether adaptation of the starting dose according to a validated dosing algorithm could increase this proportion. Methods This was a multi-center, single-arm, prospective trial with a planned interim analysis after 16 patients, in which the tacrolimus starting dose was based on bodyweight, cytochrome P450 3A5 genotype, and donor status (living vs. deceased donor). Results At the interim analysis, 31% of children had a tacrolimus pre-dose concentration within the target range. As the original dosing algorithm was poorly predictive of tacrolimus exposure, the clinical trial was terminated prematurely. Next, the original model was improved by including the data of the children included in this trial, thereby doubling the number of children in the model building cohort. Data were best described with a two-compartment model with inter-individual variability, allometric scaling, and inter-occasion variability on clearance. Cytochrome P450 3A5 genotype, hematocrit, and creatinine influenced the tacrolimus clearance. A new starting dose model was developed in which the cytochrome P450 3A5 genotype was incorporated. Both models were successfully internally and externally validated. Conclusions The weight-normalized starting dose of tacrolimus should be higher in patients with a lower bodyweight and in those who are cytochrome P450 3A5 expressers. Electronic supplementary material The online version of this article (10.1007/s40262-019-00831-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Louise M Andrews
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Elisabeth A M Cornelissen
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Huib de Jong
- Department of Pediatric Nephrology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | | | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Karlien Cransberg
- Department of Pediatric Nephrology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Kemmler W, Hettchen M, Kohl M, Murphy M, Bragonzoni L, Julin M, Risto T, von Stengel S. Detraining Effects on Musculoskeletal Parameters in Early Postmenopausal Osteopenic Women: 3-Month Follow-Up of the Randomized Controlled ACTLIFE Study. Calcif Tissue Int 2021; 109:1-11. [PMID: 33712920 PMCID: PMC7954366 DOI: 10.1007/s00223-021-00829-0] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/19/2021] [Indexed: 12/20/2022]
Abstract
Periods of absence from supervised group exercise while maintaining physical activity might be a frequent pattern in adults' exercise habits. The aim of the present study was to determine detraining effects on musculoskeletal outcomes after a 3-month detraining period in early post-menopausal, osteopenic women. Due to the COVID-19 pandemic, we terminated the 18-month randomized controlled ACTLIFE exercise intervention immediately after the 13-month follow-up assessment. This put an abrupt stop to the high-intensity aerobic and resistance group exercise sessions undertaken three times per week by the exercise group (EG: n = 27) and the gentle exercise program performed once per week for the attention control group (CG: n = 27); but both groups were permitted to conduct individual outdoor activity for the 3-month lock-down period. Study endpoints were lean body mass (LBM), bone mineral density (BMD) at the lumbar spine (LS), maximum hip-/leg extension strength and power. Detraining-induced reductions of LBM, hip/leg strength and power (but not BMD-LS) were significantly greater (p < 0.001 to p = 0.044) compared with the CG. Significant exercise effects, i.e. differences between EG and CG, present after 13 months of exercise, were lost after 3 months of detraining for LBM (p = 0.157) and BMD-LS (p = 0.065), but not for strength (p < 0.001) and power (p < 0.001). Of note, self-reported individual outdoor activities and exercise increased by about 40% in both groups during the lock-down period. Three months' absence from a supervised group exercise protocol resulted in considerable detraining effects for musculoskeletal parameters. Thus, exercise programs for adults should be continuous rather than intermittent.Trial registration number: ClinicalTrials.gov: NCT04420806, 06.05.2020.
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Affiliation(s)
- Wolfgang Kemmler
- Institute of Medical Physics, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Henkestrasse 91, 91052, Erlangen, Germany.
| | - Michael Hettchen
- Institute of Medical Physics, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Henkestrasse 91, 91052, Erlangen, Germany
| | - Matthias Kohl
- Department of Medical and Life Sciences, University of Furtwangen, Schwenningen, Germany
| | - Marie Murphy
- Doctoral College, Ulster University, Newtownabbey, Co. Antrim, Northern Ireland, UK
| | | | - Mikko Julin
- Laurea University of Applied Sciences, Espoo, Finland
| | - Tapani Risto
- Laurea University of Applied Sciences, Espoo, Finland
| | - Simon von Stengel
- Institute of Medical Physics, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Henkestrasse 91, 91052, Erlangen, Germany
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Abstract
BACKGROUND Unruptured intracranial aneurysms are relatively common lesions in the general population, with a prevalence of 3.2%, and are being diagnosed with greater frequency as non-invasive techniques for imaging of intracranial vessels have become increasingly available and used. If not treated, an intracranial aneurysm can be catastrophic. Morbidity and mortality in aneurysmal subarachnoid hemorrhage are substantial: in people with subarachnoid hemorrhage, 12% die immediately, more than 30% die within one month, 25% to 50% die within six months, and 30% of survivors remain dependent. However, most intracranial aneurysms do not bleed, and the best treatment approach is still a matter of debate. OBJECTIVES To assess the risks and benefits of interventions for people with unruptured intracranial aneurysms. SEARCH METHODS We searched CENTRAL (Cochrane Library 2020, Issue 5), MEDLINE Ovid, Embase Ovid, and Latin American and Caribbean Health Science Information database (LILACS). We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform from inception to 25 May 2020. There were no language restrictions. We contacted experts in the field to identify further studies and unpublished trials. SELECTION CRITERIA Unconfounded, truly randomized trials comparing conservative treatment versus interventional treatments (microsurgical clipping or endovascular coiling) and microsurgical clipping versus endovascular coiling for individuals with unruptured intracranial aneurysms. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion according to the above criteria, assessed trial quality and risk of bias, performed data extraction, and applied the GRADE approach to the evidence. We used an intention-to-treat analysis strategy. MAIN RESULTS We included two trials in the review: one prospective randomized trial involving 80 participants that compared conservative treatment to endovascular coiling, and one randomized controlled trial involving 136 participants that compared microsurgical clipping to endovascular coiling for unruptured intracranial aneurysms. There was no difference in outcome events between conservative treatment and endovascular coiling groups. New perioperative neurological deficits were more common in participants treated surgically (16/65, 24.6%; 15.8% to 36.3%) versus 7/69 (10.1%; 5.0% to 19.5%); odds ratio (OR) 2.87 (95% confidence interval (CI) 1.02 to 8.93; P = 0.038). Hospitalization for more than five days was more common in surgical participants (30/65, 46.2%; 34.6% to 58.1%) versus 6/69 (8.7%; 4.0% to 17.7%); OR 8.85 (95% CI 3.22 to 28.59; P < 0.001). Clinical follow-up to one year showed 1/48 clipped versus 1/58 coiled participants had died, and 1/48 clipped versus 1/58 coiled participants had become disabled (modified Rankin Scale > 2). All the evidence is of very low quality. AUTHORS' CONCLUSIONS There is currently insufficient good-quality evidence to support either conservative treatment or interventional treatments (microsurgical clipping or endovascular coiling) for individuals with unruptured intracranial aneurysms. Further randomized trials are required to establish if surgery is a better option than conservative management, and if so, which surgical approach is preferred for which patients. Future studies should include consideration of important characteristics such as participant age, gender, aneurysm size, aneurysm location (anterior circulation and posterior circulation), grade of ischemia (major stroke), and duration of hospitalizations.
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Affiliation(s)
| | - Edina Mk da Silva
- Emergency Medicine and Evidence Based Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Cc Baptista-Silva
- Evidence Based Medicine, Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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Schwartz I, Boesen ME, Cerchiaro G, Doram C, Edwards BD, Ganesh A, Greenfield J, Jamieson S, Karnik V, Kenney C, Lim R, Menon BK, Mponponsuo K, Rathwell S, Ryckborst KJ, Stewart B, Yaskina M, Metz L, Richer L, Hill MD. Assessing the efficacy and safety of hydroxychloroquine as outpatient treatment of COVID-19: a randomized controlled trial. CMAJ Open 2021; 9:E693-E702. [PMID: 34145052 PMCID: PMC8248582 DOI: 10.9778/cmajo.20210069] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Identification of therapies to prevent severe COVID-19 remains a priority. We sought to determine whether hydroxychloroquine treatment for outpatients with SARS-CoV-2 infection could prevent hospitalization, mechanical ventilation or death. METHODS This randomized controlled trial was conducted in Alberta during the first wave of the COVID-19 pandemic without direct contact with participants. Community-dwelling individuals with confirmed SARS-CoV-2 infection (by reverse transcription polymerase chain reaction [RT-PCR] viral ribonucleic acid test) within the previous 4 days, and symptom onset within the previous 12 days, were randomly assigned to oral hydroxychloroquine or matching placebo for 5 days. Enrolment began Apr. 15, 2020. The primary outcome was the composite of hospitalization, invasive mechanical ventilation or death within 30 days. Secondary outcomes included symptom duration and disposition at 30 days. Safety outcomes, such as serious adverse events and mortality, were also ascertained. Outcomes were determined by telephone follow-up and administrative data. RESULTS Among 4919 individuals with a positive RT-PCR test, 148 (10.2% of a planned 1446 patients) were randomly assigned, 111 to hydroxychloroquine and 37 to placebo. Of the 148 participants, 24 (16.2%) did not start the study drug. Four participants in the hydroxychloroquine group met the primary outcome (4 hospitalizations, 0 mechanical ventilation, 4 survived to 30 days) and none in the placebo group. Hydroxychloroquine did not reduce symptom duration (hazard ratio 0.77, 95% confidence interval 0.49-1.21). Recruitment was paused on May 22, 2020, when a since-retracted publication raised concerns about the safety of hydroxychloroquine for hospitalized patients with COVID-19. Although we had not identified concerns in a safety review, enrolment was slower than expected among those eligible for the study, and cases within the community were decreasing. Recruitment goals were deemed to be unattainable and the trial was not resumed, resulting in a study underpowered to assess the effect of treatment with hydroxychloroquine and safety. INTERPRETATION There was no evidence that hydroxychloroquine reduced symptom duration or prevented severe outcomes among outpatients with proven COVID-19, but the early termination of our study meant that it was underpowered. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT04329611.
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Affiliation(s)
- Ilan Schwartz
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Mari E Boesen
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Graziela Cerchiaro
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Craig Doram
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Brett D Edwards
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Aravind Ganesh
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Jamie Greenfield
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Scott Jamieson
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Vikram Karnik
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Carol Kenney
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Rachel Lim
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Bijoy K Menon
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Kwadwo Mponponsuo
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Sarah Rathwell
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Karla J Ryckborst
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Breanne Stewart
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Maryna Yaskina
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Luanne Metz
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Lawrence Richer
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Michael D Hill
- Division of Infectious Diseases (Schwartz, Mponponsuo), Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Alberta Strategy for Patient Oriented Research SUPPORT Unit (Boesen); Cumming School of Medicine (Boesen, Cerchiaro, Greenfield, Kenney, Ryckborst), University of Calgary; Section of Infectious Diseases (Edwards), Department of Medicine, and Department of Clinical Neurosciences (Doram, Ganesh, Karnik), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Quality Management in Clinical Research Office (Jamieson, Stewart), University of Alberta, Edmonton, Alta.; Division of Respirology (Lim), Department of Medicine, Cumming School of Medicine, and Departments of Clinical Neurosciences and Community Health Sciences (Menon, Metz), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Women and Children's Research Institute (Rathwell, Yaskina), and Department of Pediatrics (Richer), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Departments of Clinical Neurosciences, Community Health Sciences, and Medicine (Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alta.
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Behr J, Prasse A, Kreuter M, Johow J, Rabe KF, Bonella F, Bonnet R, Grohe C, Held M, Wilkens H, Hammerl P, Koschel D, Blaas S, Wirtz H, Ficker JH, Neumeister W, Schönfeld N, Claussen M, Kneidinger N, Frankenberger M, Hummler S, Kahn N, Tello S, Freise J, Welte T, Neuser P, Günther A. Pirfenidone in patients with progressive fibrotic interstitial lung diseases other than idiopathic pulmonary fibrosis (RELIEF): a double-blind, randomised, placebo-controlled, phase 2b trial. Lancet Respir Med 2021; 9:476-486. [PMID: 33798455 DOI: 10.1016/s2213-2600(20)30554-3] [Citation(s) in RCA: 203] [Impact Index Per Article: 67.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 11/13/2020] [Accepted: 11/13/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pirfenidone has been shown to slow disease progression in patients with idiopathic pulmonary fibrosis (IPF). However, there are few treatment options for progressive fibrotic interstitial lung diseases (ILDs)) other than IPF. In view of the pathomechanistic and clinical similarities between IPF and other progressive fibrotic ILDs, we aimed to assess the efficacy and safety of pirfenidone in patients with four non-IPF progressive fibrotic ILDs. METHODS We did a multicentre, double-blind, randomised, placebo-controlled, parallel phase 2b trial (RELIEF) in 17 centres with expertise in ILD in Germany. Eligible participants were patients aged 18-80 years with progressive fibrotic ILD due to four diagnoses: collagen or vascular diseases (ie, connective tissue disease-associated ILDs), fibrotic non-specific interstitial pneumonia, chronic hypersensitivity pneumonitis, or asbestos-induced lung fibrosis. Other eligibility criteria included a forced vital capacity (FVC) of 40-90% predicted, a diffusing capacity of the lung for carbon monoxide of 10-90% predicted, and an annual decline of FVC of at least 5% predicted despite conventional therapy, based on at least three measurements within 6-24 months before enrolment. Patients who had received any previous antifibrotic therapy were excluded. We randomly assigned patients (1:1) to either oral pirfenidone (267 mg three times per day in week 1, 534 mg three times per day in week 2, and 801 mg three times per day thereafter) or matched placebo, added to their ongoing medication. Randomisation was done centrally using permuted block randomisation with varying block sizes stratified by the four diagnostic groups. Patients, investigators, statisticians, monitors, and the study coordinator were masked to treatment assignment until database closure. The placebo-controlled study period was 48 weeks (including up-titration). The primary endpoint was absolute change in percentage of predicted FVC (FVC % predicted) from baseline to week 48 in the intention-to-treat population, with imputation of missing data by the smallest sum of squared differences and attribution of deceased patients to the lowest rank in a rank ANCOVA model. Additionally, we did linear mixed-model repeated measures slope analyses of FVC % predicted longitudinal data over the course of the study as a prespecified sensitivity analysis and post-hoc sensitivity analyses of the primary endpoint in the intention-to-treat population using imputation methods of last observation carried forward [LOCF] and a regression-based multiple imputation procedure. Safety was assessed in all patients who received at least one dose of study medication. This trial is registered with EudraCT 2014-000861-32; DRKS00009822 and is no longer recruiting. FINDINGS Between April 5, 2016, and Oct 4, 2018, we randomly assigned 127 patients to treatment: 64 to pirfenidone, 63 to placebo. After 127 patients had been randomised, the study was prematurely terminated on the basis of an interim analysis for futility triggered by slow recruitment. After 48 weeks and in the overall population of 127 patients, rank ANCOVA with diagnostic group included as a factor showed a significantly lower decline in FVC % predicted in the pirfenidone group compared with placebo (p=0·043); the result was similar when the model was stratified by diagnostic group (p=0·042). A significant treatment effect was also observed when applying the LOCF and multiple imputation methods to analyses of the primary endpoint. The median difference (Hodges-Lehmann estimate) between pirfenidone and placebo groups for the primary endpoint was 1·69 FVC % predicted (95% CI -0·65 to 4·03). In the linear mixed-model repeated measures slope analysis of FVC % predicted, the estimated difference between treatment and placebo groups from baseline to week 48 was 3·53 FVC % predicted (95% CI 0·21 to 6·86) with imputation of deaths as prespecified, or 2·79 FVC % predicted (95% CI 0·03 to 5·54) without imputation. One death (non-respiratory) occurred in the pirfenidone group (2%) and five deaths (three of which were respiratory) occurred in the placebo group (8%). The most frequent serious adverse events in both groups were infections and infestations (five [8%] in the pirfenidone group, ten [16%] in the placebo group); general disorders including disease worsening (two [3%] in the pirfenidone group, seven [11%] in the placebo group); and cardiac disorders (one ([2%] in the pirfenidone group, 5 [8%] in the placebo group). Adverse events (grade 3-4) of nausea (two patients on pirfenidone, two on placebo), dyspnoea (one patient on pirfenidone, one on placebo), and diarrhoea (one patient on pirfenidone) were also observed. INTERPRETATION In view of the premature study termination, results should be interpreted with care. Nevertheless, our data suggest that in patients with fibrotic ILDs other than IPF who deteriorate despite conventional therapy, adding pirfenidone to existing treatment might attenuate disease progression as measured by decline in FVC. FUNDING German Center for Lung Research, Roche Pharma.
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Affiliation(s)
- Jürgen Behr
- Department of Internal Medicine V, University Hospital, Ludwig Maximilian University (LMU) Munich, Member of the German Center for Lung Research (DZL), Munich, Germany; Asklepios Lung Center Gauting, DZL, Munich, Germany.
| | - Antje Prasse
- Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover Medical School, Hannover, Germany
| | - Michael Kreuter
- Center for Interstitial And Rare Lung Diseases, Department of Pneumology, Thoraxklinik Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Johow
- Coordinating Center for Clinical Trials, Philipps University Marburg, Marburg, Member of the German Center for Lung Research, Germany
| | - Klaus F Rabe
- Lung Clinic Grosshansdorf, Grosshansdorf, Germany
| | - Francesco Bonella
- Department of Pulmonary Medicine, Ruhrlandklinik, University Essen, Essen, Germany
| | - Reiner Bonnet
- Zentralklinik Bad Berka, Department of Pulmonary Medicine, Bad Berka, Germany
| | | | - Matthias Held
- Department of Pulmonary Medicine, KWM Missio Clinic, Würzburg, Würzburg, Germany
| | - Heinrike Wilkens
- Department of Pulmonary Medicine, Saarland University Medical Center, Homburg, Germany
| | | | - Dirk Koschel
- Lung Clinic Coswig, University Carl Gustav Carus Dresden, Dresden, Germany
| | - Stefan Blaas
- Donaustauf Hospital, Center for Pneumology, Donaustauf, Germany
| | - Hubert Wirtz
- Department of Pulmonary Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Joachim H Ficker
- Paracelsus Medical University Nuernberg, Nuernberg General Hospital, Nuernberg, Germany
| | - Wolfgang Neumeister
- Department of Pulmonary Medicine, Catholic Clinic Koblenz Montabaur, Koblenz, Germany
| | - Nicolas Schönfeld
- Helios Klinikum Emil von Behring, Lungenklinik Heckeshorn, Berlin, Germany
| | | | - Nikolaus Kneidinger
- Department of Internal Medicine V, University Hospital, Ludwig Maximilian University (LMU) Munich, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Marion Frankenberger
- Comprehensive Pneumology Center, Helmholtz Center Munich, Ludwig Maximilian University Munich, Munich, Germany; Asklepios Clinic Gauting, Munich, Germany
| | - Simone Hummler
- Center for Interstitial And Rare Lung Diseases, Department of Pneumology, Thoraxklinik Heidelberg University Hospital, Heidelberg, Germany
| | - Nicolas Kahn
- Center for Interstitial And Rare Lung Diseases, Department of Pneumology, Thoraxklinik Heidelberg University Hospital, Heidelberg, Germany
| | - Silke Tello
- Center for Interstitial and Rare Lung Diseases, Justus-Liebig University Giessen, Giessen, Germany
| | - Julia Freise
- Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover Medical School, Hannover, Germany
| | - Petra Neuser
- Coordinating Center for Clinical Trials, Philipps University Marburg, Marburg, Member of the German Center for Lung Research, Germany
| | - Andreas Günther
- Center for Interstitial and Rare Lung Diseases, Justus-Liebig University Giessen, Giessen, Germany; Member of the German Center for Lung Research and Cardiopulmonary Institute, and Agaplesion Lung Clinic Waldhof-Elgershausen, Greifenstein, Germany
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13
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Brown PA, Ji L, Xu X, Devidas M, Hogan LE, Borowitz MJ, Raetz EA, Zugmaier G, Sharon E, Bernhardt MB, Terezakis SA, Gore L, Whitlock JA, Pulsipher MA, Hunger SP, Loh ML. Effect of Postreinduction Therapy Consolidation With Blinatumomab vs Chemotherapy on Disease-Free Survival in Children, Adolescents, and Young Adults With First Relapse of B-Cell Acute Lymphoblastic Leukemia: A Randomized Clinical Trial. JAMA 2021; 325:833-842. [PMID: 33651090 PMCID: PMC7926290 DOI: 10.1001/jama.2021.0669] [Citation(s) in RCA: 161] [Impact Index Per Article: 53.7] [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: 12/11/2022]
Abstract
IMPORTANCE Standard chemotherapy for first relapse of B-cell acute lymphoblastic leukemia (B-ALL) in children, adolescents, and young adults is associated with high rates of severe toxicities, subsequent relapse, and death, especially for patients with early relapse (high risk) or late relapse with residual disease after reinduction chemotherapy (intermediate risk). Blinatumomab, a bispecific CD3 to CD19 T cell-engaging antibody construct, is efficacious in relapsed/refractory B-ALL and has a favorable toxicity profile. OBJECTIVE To determine whether substituting blinatumomab for intensive chemotherapy in consolidation therapy would improve survival in children, adolescents, and young adults with high- and intermediate-risk first relapse of B-ALL. DESIGN, SETTING, AND PARTICIPANTS This trial was a randomized phase 3 clinical trial conducted by the Children's Oncology Group at 155 hospitals in the US, Canada, Australia, and New Zealand with enrollment from December 2014 to September 2019 and follow-up until September 30, 2020. Eligible patients included those aged 1 to 30 years with B-ALL first relapse, excluding those with Down syndrome, Philadelphia chromosome-positive ALL, prior hematopoietic stem cell transplant, or prior blinatumomab treatment (n = 669). INTERVENTIONS All patients received a 4-week reinduction chemotherapy course, followed by randomized assignment to receive 2 cycles of blinatumomab (n = 105) or 2 cycles of multiagent chemotherapy (n = 103), each followed by transplant. MAIN OUTCOME AND MEASURES The primary end point was disease-free survival and the secondary end point was overall survival, both from the time of randomization. The threshold for statistical significance was set at a 1-sided P <.025. RESULTS Among 208 randomized patients (median age, 9 years; 97 [47%] females), 118 (57%) completed the randomized therapy. Randomization was terminated at the recommendation of the data and safety monitoring committee without meeting stopping rules for efficacy or futility; at that point, 80 of 131 planned events occurred. With 2.9 years of median follow-up, 2-year disease-free survival was 54.4% for the blinatumomab group vs 39.0% for the chemotherapy group (hazard ratio for disease progression or mortality, 0.70 [95% CI, 0.47-1.03]); 1-sided P = .03). Two-year overall survival was 71.3% for the blinatumomab group vs 58.4% for the chemotherapy group (hazard ratio for mortality, 0.62 [95% CI, 0.39-0.98]; 1-sided P = .02). Rates of notable serious adverse events included infection (15%), febrile neutropenia (5%), sepsis (2%), and mucositis (1%) for the blinatumomab group and infection (65%), febrile neutropenia (58%), sepsis (27%), and mucositis (28%) for the chemotherapy group. CONCLUSIONS AND RELEVANCE Among children, adolescents, and young adults with high- and intermediate-risk first relapse of B-ALL, postreinduction treatment with blinatumomab compared with chemotherapy, followed by transplant, did not result in a statistically significant difference in disease-free survival. However, study interpretation is limited by early termination with possible underpowering for the primary end point. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02101853.
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Affiliation(s)
- Patrick A. Brown
- Departments of Oncology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lingyun Ji
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles
| | - Xinxin Xu
- Children's Oncology Group, Monrovia, California
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Laura E. Hogan
- Department of Pediatrics, Stony Brook Children’s, Stony Brook, New York
| | - Michael J. Borowitz
- Departments of Pathology and Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Elad Sharon
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, Maryland
| | - Melanie B. Bernhardt
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - Lia Gore
- University of Colorado School of Medicine and Center for Cancer and Blood Disorders, Children’s Hospital Colorado, Aurora
| | - James A. Whitlock
- Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Michael A. Pulsipher
- Transplantation and Cellular Therapy, Children's Hospital Los Angeles Cancer and Blood Diseases Institute, Los Angeles, California
| | - Stephen P. Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia and The Perelman School of Medicine at The University of Pennsylvania, Philadelphia
| | - Mignon L. Loh
- Department of Pediatrics, Benioff Children’s Hospital and the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco
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14
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Koriyama Y, Hori A, Ito H, Yonezawa S, Baba Y, Tanimoto N, Ueno T, Yamamoto S, Yamamoto T, Asada N, Morimoto K, Einaru S, Sakai K, Kanazu T, Matsuda A, Yamaguchi Y, Oguma T, Timmers M, Tritsmans L, Kusakabe KI, Kato A, Sakaguchi G. Discovery of Atabecestat (JNJ-54861911): A Thiazine-Based β-Amyloid Precursor Protein Cleaving Enzyme 1 Inhibitor Advanced to the Phase 2b/3 EARLY Clinical Trial. J Med Chem 2021; 64:1873-1888. [PMID: 33588527 DOI: 10.1021/acs.jmedchem.0c01917] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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: 01/05/2023]
Abstract
Accumulation of amyloid β peptides (Aβ) is thought to be one of the causal factors of Alzheimer's disease (AD). The aspartyl protease β-site amyloid precursor protein cleaving enzyme 1 (BACE1) is the rate-limiting protease for Aβ production, and therefore, BACE1 inhibition is a promising therapeutic approach for the treatment of AD. Starting with a dihydro-1,3-thiazine-based lead, Compound J, we discovered atabecestat 1 (JNJ-54861911) as a centrally efficacious BACE1 inhibitor that was advanced into the EARLY Phase 2b/3 clinical trial for the treatment of preclinical AD patients. Compound 1 demonstrated robust and dose-dependent Aβ reduction and showed sufficient safety margins in preclinical models. The potential of reactive metabolite formation was evaluated in a covalent binding study to assess its irreversible binding to human hepatocytes. Unfortunately, the EARLY trial was discontinued due to significant elevation of liver enzymes, and subsequent analysis of the clinical outcomes showed dose-related cognitive worsening.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Maarten Timmers
- Janssen Research & Development, a division of Janssen Pharmaceutica N.V., Turnhoutseweg 30, B-2340 Beerse, Belgium
| | - Luc Tritsmans
- Janssen Research & Development, a division of Janssen Pharmaceutica N.V., Turnhoutseweg 30, B-2340 Beerse, Belgium
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15
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Sevransky JE, Rothman RE, Hager DN, Bernard GR, Brown SM, Buchman TG, Busse LW, Coopersmith CM, DeWilde C, Ely EW, Eyzaguirre LM, Fowler AA, Gaieski DF, Gong MN, Hall A, Hinson JS, Hooper MH, Kelen GD, Khan A, Levine MA, Lewis RJ, Lindsell CJ, Marlin JS, McGlothlin A, Moore BL, Nugent KL, Nwosu S, Polito CC, Rice TW, Ricketts EP, Rudolph CC, Sanfilippo F, Viele K, Martin GS, Wright DW. Effect of Vitamin C, Thiamine, and Hydrocortisone on Ventilator- and Vasopressor-Free Days in Patients With Sepsis: The VICTAS Randomized Clinical Trial. JAMA 2021; 325:742-750. [PMID: 33620405 PMCID: PMC7903252 DOI: 10.1001/jama.2020.24505] [Citation(s) in RCA: 144] [Impact Index Per Article: 48.0] [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] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Sepsis is a common syndrome with substantial morbidity and mortality. A combination of vitamin C, thiamine, and corticosteroids has been proposed as a potential treatment for patients with sepsis. OBJECTIVE To determine whether a combination of vitamin C, thiamine, and hydrocortisone every 6 hours increases ventilator- and vasopressor-free days compared with placebo in patients with sepsis. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized, double-blind, adaptive-sample-size, placebo-controlled trial conducted in adult patients with sepsis-induced respiratory and/or cardiovascular dysfunction. Participants were enrolled in the emergency departments or intensive care units at 43 hospitals in the United States between August 2018 and July 2019. After enrollment of 501 participants, funding was withheld, leading to an administrative termination of the trial. All study-related follow-up was completed by January 2020. INTERVENTIONS Participants were randomized to receive intravenous vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) every 6 hours (n = 252) or matching placebo (n = 249) for 96 hours or until discharge from the intensive care unit or death. Participants could be treated with open-label corticosteroids by the clinical team, with study hydrocortisone or matching placebo withheld if the total daily dose was greater or equal to the equivalent of 200 mg of hydrocortisone. MAIN OUTCOMES AND MEASURES The primary outcome was the number of consecutive ventilator- and vasopressor-free days in the first 30 days following the day of randomization. The key secondary outcome was 30-day mortality. RESULTS Among 501 participants randomized (median age, 62 [interquartile range {IQR}, 50-70] years; 46% female; 30% Black; median Acute Physiology and Chronic Health Evaluation II score, 27 [IQR, 20.8-33.0]; median Sequential Organ Failure Assessment score, 9 [IQR, 7-12]), all completed the trial. Open-label corticosteroids were prescribed to 33% and 32% of the intervention and control groups, respectively. Ventilator- and vasopressor-free days were a median of 25 days (IQR, 0-29 days) in the intervention group and 26 days (IQR, 0-28 days) in the placebo group, with a median difference of -1 day (95% CI, -4 to 2 days; P = .85). Thirty-day mortality was 22% in the intervention group and 24% in the placebo group. CONCLUSIONS AND RELEVANCE Among critically ill patients with sepsis, treatment with vitamin C, thiamine, and hydrocortisone, compared with placebo, did not significantly increase ventilator- and vasopressor-free days within 30 days. However, the trial was terminated early for administrative reasons and may have been underpowered to detect a clinically important difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03509350.
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Affiliation(s)
- Jonathan E. Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David N. Hager
- Division of Pulmonary Critical Care, Johns Hopkins University, Baltimore, Maryland
| | - Gordon R. Bernard
- Division of Pulmonary Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samuel M. Brown
- Division of Pulmonary Critical Care, Intermountain Medical Center and University of Utah, Salt Lake City
| | - Timothy G. Buchman
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Laurence W. Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - Craig M. Coopersmith
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Christine DeWilde
- Division of Pulmonary Critical Care, Virginia Commonwealth University, Richmond
| | - E. Wesley Ely
- Division of Pulmonary Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
- Johns Hopkins Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Baltimore, Maryland
- Veteran’s Affairs Tennessee Valley Geriatric Research Education Clinical Center (GRECC), Nashville
| | | | - Alpha A. Fowler
- Division of Pulmonary Critical Care, Virginia Commonwealth University, Richmond
| | - David F. Gaieski
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Michelle N. Gong
- Department of Critical Care, Montefiore Medical Center, Bronx, New York
| | - Alex Hall
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Jeremiah S. Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Michael H. Hooper
- Division of Pulmonary Critical Care, Sentara Healthcare, Norfolk, Virginia
| | - Gabor D. Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Akram Khan
- Division of Pulmonary Critical Care, Oregon Health & Science University, Portland
| | - Mark A. Levine
- Molecular and Clinical Nutrition Section, National Institutes of Health, Bethesda, Maryland
| | - Roger J. Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
- Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Chris J. Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jessica S. Marlin
- Vanderbilt Coordinating Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Brooks L. Moore
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | | | - Samuel Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carmen C. Polito
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - Todd W. Rice
- Division of Pulmonary Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Erin P. Ricketts
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Fred Sanfilippo
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kert Viele
- Berry Consultants LLC, Austin, Texas
- Department of Biostatistics, University of Kentucky, Lexington
| | - Greg S. Martin
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Emory University School of Medicine, Atlanta, Georgia
- Emory Critical Care Center, Emory Healthcare, Atlanta, Georgia
| | - David W. Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
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16
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Rabinstein AA, Hellickson JD, Macedo TA, Lewis BD, Mandrekar J, McBane RD. Sequential Pneumatic Compression in the Arm in Neurocritical Patients with a Peripherally Inserted Central Venous Catheter: A Randomized Trial. Neurocrit Care 2021; 32:187-192. [PMID: 31236782 DOI: 10.1007/s12028-019-00765-w] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Peripherally inserted central venous catheters (PICCs) are increasingly used for parenteral access in critically ill hospitalized patients, but they increase the incidence of upper extremity deep venous thrombosis (UE DVT). Sequential compression devices (SCDs) applied to the legs effectively reduce lower extremity DVT, but have not been tested in the arms. Our objective was to determine whether SCDs applied to the arm may reduce the risk of PICC-associated UE DVT. METHODS This was a retrospective study of randomized, single-center, controlled clinical trial on patients hospitalized in the intensive care unit with critical neurological illness who had a PICC and were not receiving anticoagulants. Between January 2014 and October 2016, patients were randomized 1:1 to an intervention group having a custom SCD applied to the arm harboring the PICC or to a control group. The primary endpoint was ultrasound-detected UE DVT. RESULTS Following randomization of 77 subjects, the study was terminated due to excess DVT in the treatment arm. UE DVT was detected in 18 subjects (29.0%), and it was more frequent among those in the SCD group (13/31 [41.9%] vs. the control group 5/31 [16.1%]; p = 0.049). After accounting for crossovers, the difference was still significant (12/28 [43.0%] vs. 6/34 [17.6%]; p = 0.048). Yet, symptomatic UE DVT (n = 3) and pulmonary embolism without evidence of lower extremity DVT (n = 2) were only observed in patients who were not wearing the SCD on the arm. CONCLUSIONS Although UE DVT is commonly associated with PICC use, the results of this trial do not support the use of SCD on the arm for DVT prevention. Further research on this strategy may nonetheless be justified. TRIAL REGISTRATION This trial was registered in ClinicalTrials.gov under the identifier NCT01670188.
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Affiliation(s)
| | | | | | | | - Jay Mandrekar
- Department of Health Sciences Research (Division of Biomedical Statistics and Informatics), Mayo Clinic, Rochester, MN, USA
| | - Robert D McBane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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17
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Roman A, Zork N, Haeri S, Schoen CN, Saccone G, Colihan S, Zelig C, Gimovsky AC, Seligman NS, Zullo F, Berghella V. Physical examination-indicated cerclage in twin pregnancy: a randomized controlled trial. Am J Obstet Gynecol 2020; 223:902.e1-902.e11. [PMID: 32592693 DOI: 10.1016/j.ajog.2020.06.047] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [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: 01/01/2020] [Revised: 05/19/2020] [Accepted: 06/22/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Women with twin pregnancies and a dilated cervix in the second trimester are at increased risk of pregnancy loss and early preterm birth; there is currently no proven therapy to prevent preterm birth in this group of women. OBJECTIVE This study aimed to determine whether physical examination-indicated cerclage reduces the incidence of preterm birth in women with a diagnosis of twin pregnancies and asymptomatic cervical dilation before 24 weeks of gestation. STUDY DESIGN Multicenter, parallel group, open-label, randomized controlled trial of women with twin pregnancies and asymptomatic cervical dilation of 1 to 5 cm between 16 weeks 0/7 days of gestation and 23 weeks 6/7 days of gestation were enrolled from July 2015 to July 2019 in 8 centers. Eligible women were randomized in a 1:1 ratio into either cerclage or no cerclage groups. We excluded women with monochorionic-monoamniotic twin pregnancy, selective fetal growth restriction, twin-twin transfusion syndrome, major fetal malformation, known genetic anomaly, placenta previa, signs of labor, or clinical chorioamnionitis. The primary outcome was the incidence of preterm birth at <34 weeks of gestation. Secondary outcomes were preterm births at <32, <28, and <24 weeks of gestation, interval from diagnosis to delivery, and perinatal mortality. Data were analyzed by intention-to-treat methods. RESULTS After an interim analysis was performed, the Data and Safety Monitoring Board recommended stopping the trial because of a significant decrease in perinatal mortality in the cerclage group. We randomized 34 women, with 4 women being excluded because of expired informed consent. A total of 17 women were randomized to physical examination-indicated cerclage and 13 women to no cerclage. Whereas 4 women randomized to cerclage did not receive the surgical procedure, no women in the no cerclage group received cerclage. Maternal demographics were not significantly different. All women in the cerclage group also received indomethacin and antibiotics. When comparing the cerclage group vs the no cerclage group, the incidence of preterm birth was significantly decreased as follows: preterm birth at <34 weeks of gestation, 12 of 17 women (70%) vs 13 of 13 women (100%) (risk ratio, 0.71; 95% confidence interval, 0.52-0.96); preterm birth at <32 weeks of gestation, 11 of 17 women (64.7%) vs 13 of 13 women (100%) (risk ratio, 0.65; 95% confidence interval, 0.46-0.92); preterm birth at <28 weeks of gestation, 7 of 17 women (41%) vs 11 of 13 women (84%) (risk ratio, 0.49; 95% confidence interval, 0.26-0.89); and preterm birth at <24 weeks of gestation, 5 of 17 women (30%) vs 11 of 13 women (84%) (risk ratio, 0.35; 95% confidence interval, 0.16-0.75). The mean gestational age at delivery was 29.05±1.7 vs 22.5±3.9 weeks (P<.01), respectively; the mean interval from diagnosis of cervical dilation to delivery was 8.3±5.8 vs 2.9±3.0 weeks (P=.02), respectively. Perinatal mortality was also significantly reduced in the cerclage group compared with the no cerclage group as follows: 6 of 34 women (17.6%) vs 20 of 26 women (77%) (risk ratio, 0.22; 95% confidence interval, 0.1-0.5), respectively. CONCLUSION In women with twin pregnancies and asymptomatic cervical dilation before 24 weeks of gestation, a combination of physical examination-indicated cerclage, indomethacin, and antibiotics significantly decreased preterm birth at all evaluated gestational ages. Most importantly, cerclage in this population was associated with a 50% decrease in early preterm birth at <28 weeks of gestation and with a 78% decrease in perinatal mortality.
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Affiliation(s)
- Amanda Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.
| | - Noelia Zork
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University, New York, NY
| | - Sina Haeri
- Division of Maternal-Fetal Medicine, Obstetrics and Gynecology Department, St David's Women's Center of Texas, Austin, TX
| | - Corina N Schoen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Sarah Colihan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Albany Medical Center, Albany, NY
| | - Craig Zelig
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Albany Medical Center, Albany, NY
| | - Alexis C Gimovsky
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, the George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Neil S Seligman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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18
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Eisenberg MJ, Hébert-Losier A, Windle SB, Greenspoon T, Brandys T, Fülöp T, Nguyen T, Elkouri S, Montigny M, Wilderman I, Bertrand OF, Bostwick JA, Abrahamson J, Lacasse Y, Pakhale S, Cabaussel J, Filion KB. Effect of e-Cigarettes Plus Counseling vs Counseling Alone on Smoking Cessation: A Randomized Clinical Trial. JAMA 2020; 324:1844-1854. [PMID: 33170240 PMCID: PMC7656286 DOI: 10.1001/jama.2020.18889] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [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: 12/15/2022]
Abstract
IMPORTANCE Electronic cigarettes (e-cigarettes) for smoking cessation remain controversial. OBJECTIVE To evaluate e-cigarettes with individual counseling for smoking cessation. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial enrolled adults motivated to quit smoking from November 2016 to September 2019 at 17 Canadian sites (801 individuals screened; 274 ineligible and 151 declined). Manufacturing delays resulted in early termination (376/486 participants, 77% of target). Outcomes through 24 weeks (March 2020) are reported. INTERVENTIONS Randomization to nicotine e-cigarettes (n = 128), nonnicotine e-cigarettes (n = 127), or no e-cigarettes (n = 121) for 12 weeks. All groups received individual counseling. MAIN OUTCOMES AND MEASURES The primary end point was point prevalence abstinence (7-day recall, biochemically validated using expired carbon monoxide) at 12 weeks, changed from 52 weeks following early termination. Participants missing data were assumed to be smoking. The 7 secondary end points, examined at multiple follow-ups, were point prevalence abstinence at other follow-ups, continuous abstinence, daily cigarette consumption change, serious adverse events, adverse events, dropouts due to adverse effects, and treatment adherence. RESULTS Among 376 randomized participants (mean age, 52 years; 178 women [47%]), 299 (80%) and 278 (74%) self-reported smoking status at 12 and 24 weeks, respectively. Point prevalence abstinence was significantly greater for nicotine e-cigarettes plus counseling vs counseling alone at 12 weeks (21.9% vs 9.1%; risk difference [RD], 12.8 [95% CI, 4.0 to 21.6]) but not 24 weeks (17.2% vs 9.9%; RD, 7.3 [95% CI, -1.2 to 15.7]). Point prevalence abstinence for nonnicotine e-cigarettes plus counseling was not significantly different from counseling alone at 12 weeks (17.3% vs 9.1%; RD, 8.2 [95% CI, -0.1 to 16.6]), but was significantly greater at 24 weeks (20.5% vs 9.9%; RD, 10.6 [95% CI, 1.8 to 19.4]). Adverse events were common (nicotine e-cigarette with counseling: 120 [94%]; nonnicotine e-cigarette with counseling: 118 [93%]; counseling only: 88 [73%]), with the most common being cough (64%) and dry mouth (53%). CONCLUSIONS AND RELEVANCE Among adults motivated to quit smoking, nicotine e-cigarettes plus counseling vs counseling alone significantly increased point prevalence abstinence at 12 weeks. However, the difference was no longer significant at 24 weeks, and trial interpretation is limited by early termination and inconsistent findings for nicotine and nonnicotine e-cigarettes, suggesting further research is needed. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02417467.
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Affiliation(s)
- Mark J. Eisenberg
- Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada
- Departments of Medicine and Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada
- Division of Cardiology, Jewish General Hospital, Montréal, Québec, Canada
| | | | - Sarah B. Windle
- Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada
| | - Todd Greenspoon
- Hamilton Community Health Centre, Family Health Organization, Hamilton, Ontario, Canada
| | | | - Tamàs Fülöp
- Centre de recherche sur le vieillissement, Sherbrooke, Québec, Canada
| | - Thang Nguyen
- St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Stéphane Elkouri
- Division of Vascular Surgery, Centre hospitalier de l’Université de Montréal, Montréal, Québec, Canada
| | - Martine Montigny
- Centre intégré de santé et de services sociaux de Laval, Hôpital Cité-de-la-Santé, Laval, Québec, Canada
| | - Igor Wilderman
- Wilderman Medical Clinic/Canadian Centre for Clinical Trials, Thornhill, Ontario, Canada
| | - Olivier F. Bertrand
- Institut de Cardiologie et de Pneumologie de Québec (IUCPQ), Québec City, Québec, Canada
| | | | | | - Yves Lacasse
- Institut de Cardiologie et de Pneumologie de Québec (IUCPQ), Québec City, Québec, Canada
| | - Smita Pakhale
- The Ottawa Hospital Research Institute/The Bridge Engagement Centre, Ottawa, Ontario, Canada
| | | | - Kristian B. Filion
- Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada
- Departments of Medicine and Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, Québec, Canada
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Zarbock A, Küllmar M, Kindgen-Milles D, Wempe C, Gerss J, Brandenburger T, Dimski T, Tyczynski B, Jahn M, Mülling N, Mehrländer M, Rosenberger P, Marx G, Simon TP, Jaschinski U, Deetjen P, Putensen C, Schewe JC, Kluge S, Jarczak D, Slowinski T, Bodenstein M, Meybohm P, Wirtz S, Moerer O, Kortgen A, Simon P, Bagshaw SM, Kellum JA, Meersch M. Effect of Regional Citrate Anticoagulation vs Systemic Heparin Anticoagulation During Continuous Kidney Replacement Therapy on Dialysis Filter Life Span and Mortality Among Critically Ill Patients With Acute Kidney Injury: A Randomized Clinical Trial. JAMA 2020; 324:1629-1639. [PMID: 33095849 PMCID: PMC7585036 DOI: 10.1001/jama.2020.18618] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [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] [Indexed: 01/10/2023]
Abstract
IMPORTANCE Although current guidelines suggest the use of regional citrate anticoagulation (which involves the addition of a citrate solution to the blood before the filter of the extracorporeal dialysis circuit) as first-line treatment for continuous kidney replacement therapy in critically ill patients, the evidence for this recommendation is based on few clinical trials and meta-analyses. OBJECTIVE To determine the effect of regional citrate anticoagulation, compared with systemic heparin anticoagulation, on filter life span and mortality. DESIGN, SETTING, AND PARTICIPANTS A parallel-group, randomized multicenter clinical trial in 26 centers across Germany was conducted between March 2016 and December 2018 (final date of follow-up, January 21, 2020). The trial was terminated early after 596 critically ill patients with severe acute kidney injury or clinical indications for initiation of kidney replacement therapy had been enrolled. INTERVENTIONS Patients were randomized to receive either regional citrate anticoagulation (n = 300), which consisted of a target ionized calcium level of 1.0 to 1.40 mg/dL, or systemic heparin anticoagulation (n = 296), which consisted of a target activated partial thromboplastin time of 45 to 60 seconds, for continuous kidney replacement therapy. MAIN OUTCOMES AND MEASURES Coprimary outcomes were filter life span and 90-day mortality. Secondary end points included bleeding complications and new infections. RESULTS Among 638 patients randomized, 596 (93.4%) (mean age, 67.5 years; 183 [30.7%] women) completed the trial. In the regional citrate group vs systemic heparin group, median filter life span was 47 hours (interquartile range [IQR], 19-70 hours) vs 26 hours (IQR, 12-51 hours) (difference, 15 hours [95% CI, 11 to 20 hours]; P < .001). Ninety-day all-cause mortality occurred in 150 of 300 patients vs 156 of 296 patients (Kaplan-Meier estimator percentages, 51.2% vs 53.6%; unadjusted difference, -2.4% [95% CI, -10.5% to 5.8%]; unadjusted hazard ratio, 0.91 [95% CI, 0.72 to 1.13]; unadjusted P = .38; adjusted difference, -6.1% [95% CI, -12.6% to 0.4%]; primary adjusted hazard ratio, 0.79 [95% CI, 0.63 to 1.004]; primary adjusted P = .054). Of 38 prespecified secondary end points, 34 showed no significant difference. Compared with the systemic heparin group, the regional citrate group had significantly fewer bleeding complications (15/300 [5.1%] vs 49/296 [16.9%]; difference, -11.8% [95% CI, -16.8% to -6.8%]; P < .001) and significantly more new infections (204/300 [68.0%] vs 164/296 [55.4%]; difference, 12.6% [95% CI, 4.9% to 20.3%]; P = .002). CONCLUSIONS AND RELEVANCE Among critically ill patients with acute kidney injury receiving continuous kidney replacement therapy, anticoagulation with regional citrate, compared with systemic heparin anticoagulation, resulted in significantly longer filter life span. The trial was terminated early and was therefore underpowered to reach conclusions about the effect of anticoagulation strategy on mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02669589.
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Affiliation(s)
- Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Mira Küllmar
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology and Critical Care Medicine, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | - Carola Wempe
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Timo Brandenburger
- Department of Anesthesiology and Critical Care Medicine, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | - Thomas Dimski
- Department of Anesthesiology and Critical Care Medicine, Heinrich-Heine University of Düsseldorf, Düsseldorf, Germany
| | | | - Michael Jahn
- Department of Nephrology, University Hospital Essen, Essen, Germany
| | - Nils Mülling
- Department of Nephrology, University Hospital Essen, Essen, Germany
| | - Martin Mehrländer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine, University of Aachen, Aachen, Germany
| | - Tim Philipp Simon
- Department of Intensive Care Medicine, University of Aachen, Aachen, Germany
| | - Ulrich Jaschinski
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Philipp Deetjen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Christian Putensen
- University Hospital Bonn, Department of Anesthesiology and Intensive Care Medicine, Bonn, Germany
| | - Jens-Christian Schewe
- University Hospital Bonn, Department of Anesthesiology and Intensive Care Medicine, Bonn, Germany
| | - Stefan Kluge
- University Medical Center Hamburg-Eppendorf, Department of Intensive Care, Hamburg, Germany
| | - Dominik Jarczak
- University Medical Center Hamburg-Eppendorf, Department of Intensive Care, Hamburg, Germany
| | - Torsten Slowinski
- Department of Nephrology and Medical Intensive Care, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Marc Bodenstein
- Universitätsmedizin Mainz, Department of Anesthesiology, Mainz, Germany
| | - Patrick Meybohm
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Frankfurt, Frankfurt, Germany
- Department of Anesthesiology, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Wirtz
- Department of Anesthesiology, Intensive Care and Pain Medicine, Helios Klinikum Bad Saarow, Bad Saarow, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Andreas Kortgen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, Jena, Germany
| | - Philipp Simon
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - John A. Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
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Angus DC, Derde L, Al-Beidh F, Annane D, Arabi Y, Beane A, van Bentum-Puijk W, Berry L, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Buzgau A, Cheng AC, de Jong M, Detry M, Estcourt L, Fitzgerald M, Goossens H, Green C, Haniffa R, Higgins AM, Horvat C, Hullegie SJ, Kruger P, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, Marshall J, McAuley D, McGlothin A, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Parker J, Rowan K, Sanil A, Santos M, Saunders C, Seymour C, Turner A, van de Veerdonk F, Venkatesh B, Zarychanski R, Berry S, Lewis RJ, McArthur C, Webb SA, Gordon AC, Al-Beidh F, Angus D, Annane D, Arabi Y, van Bentum-Puijk W, Berry S, Beane A, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Cheng A, De Jong M, Derde L, Estcourt L, Goossens H, Gordon A, Green C, Haniffa R, Lamontagne F, Lawler P, Litton E, Marshall J, McArthur C, McAuley D, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Rowan K, Seymour C, Turner A, van de Veerdonk F, Webb S, Zarychanski R, Campbell L, Forbes A, Gattas D, Heritier S, Higgins L, Kruger P, Peake S, Presneill J, Seppelt I, Trapani T, Young P, Bagshaw S, Daneman N, Ferguson N, Misak C, Santos M, Hullegie S, Pletz M, Rohde G, Rowan K, Alexander B, Basile K, Girard T, Horvat C, Huang D, Linstrum K, Vates J, Beasley R, Fowler R, McGloughlin S, Morpeth S, Paterson D, Venkatesh B, Uyeki T, Baillie K, Duffy E, Fowler R, Hills T, Orr K, Patanwala A, Tong S, Netea M, Bihari S, Carrier M, Fergusson D, Goligher E, Haidar G, Hunt B, Kumar A, Laffan M, Lawless P, Lother S, McCallum P, Middeldopr S, McQuilten Z, Neal M, Pasi J, Schutgens R, Stanworth S, Turgeon A, Weissman A, Adhikari N, Anstey M, Brant E, de Man A, Lamonagne F, Masse MH, Udy A, Arnold D, Begin P, Charlewood R, Chasse M, Coyne M, Cooper J, Daly J, Gosbell I, Harvala-Simmonds H, Hills T, MacLennan S, Menon D, McDyer J, Pridee N, Roberts D, Shankar-Hari M, Thomas H, Tinmouth A, Triulzi D, Walsh T, Wood E, Calfee C, O’Kane C, Shyamsundar M, Sinha P, Thompson T, Young I, Bihari S, Hodgson C, Laffey J, McAuley D, Orford N, Neto A, Detry M, Fitzgerald M, Lewis R, McGlothlin A, Sanil A, Saunders C, Berry L, Lorenzi E, Miller E, Singh V, Zammit C, van Bentum Puijk W, Bouwman W, Mangindaan Y, Parker L, Peters S, Rietveld I, Raymakers K, Ganpat R, Brillinger N, Markgraf R, Ainscough K, Brickell K, Anjum A, Lane JB, Richards-Belle A, Saull M, Wiley D, Bion J, Connor J, Gates S, Manax V, van der Poll T, Reynolds J, van Beurden M, Effelaar E, Schotsman J, Boyd C, Harland C, Shearer A, Wren J, Clermont G, Garrard W, Kalchthaler K, King A, Ricketts D, Malakoutis S, Marroquin O, Music E, Quinn K, Cate H, Pearson K, Collins J, Hanson J, Williams P, Jackson S, Asghar A, Dyas S, Sutu M, Murphy S, Williamson D, Mguni N, Potter A, Porter D, Goodwin J, Rook C, Harrison S, Williams H, Campbell H, Lomme K, Williamson J, Sheffield J, van’t Hoff W, McCracken P, Young M, Board J, Mart E, Knott C, Smith J, Boschert C, Affleck J, Ramanan M, D’Souza R, Pateman K, Shakih A, Cheung W, Kol M, Wong H, Shah A, Wagh A, Simpson J, Duke G, Chan P, Cartner B, Hunter S, Laver R, Shrestha T, Regli A, Pellicano A, McCullough J, Tallott M, Kumar N, Panwar R, Brinkerhoff G, Koppen C, Cazzola F, Brain M, Mineall S, Fischer R, Biradar V, Soar N, White H, Estensen K, Morrison L, Smith J, Cooper M, Health M, Shehabi Y, Al-Bassam W, Hulley A, Whitehead C, Lowrey J, Gresha R, Walsham J, Meyer J, Harward M, Venz E, Williams P, Kurenda C, Smith K, Smith M, Garcia R, Barge D, Byrne D, Byrne K, Driscoll A, Fortune L, Janin P, Yarad E, Hammond N, Bass F, Ashelford A, Waterson S, Wedd S, McNamara R, Buhr H, Coles J, Schweikert S, Wibrow B, Rauniyar R, Myers E, Fysh E, Dawda A, Mevavala B, Litton E, Ferrier J, Nair P, Buscher H, Reynolds C, Santamaria J, Barbazza L, Homes J, Smith R, Murray L, Brailsford J, Forbes L, Maguire T, Mariappa V, Smith J, Simpson S, Maiden M, Bone A, Horton M, Salerno T, Sterba M, Geng W, Depuydt P, De Waele J, De Bus L, Fierens J, Bracke S, Reeve B, Dechert W, Chassé M, Carrier FM, Boumahni D, Benettaib F, Ghamraoui A, Bellemare D, Cloutier È, Francoeur C, Lamontagne F, D’Aragon F, Carbonneau E, Leblond J, Vazquez-Grande G, Marten N, Wilson M, Albert M, Serri K, Cavayas A, Duplaix M, Williams V, Rochwerg B, Karachi T, Oczkowski S, Centofanti J, Millen T, Duan E, Tsang J, Patterson L, English S, Watpool I, Porteous R, Miezitis S, McIntyre L, Brochard L, Burns K, Sandhu G, Khalid I, Binnie A, Powell E, McMillan A, Luk T, Aref N, Andric Z, Cviljevic S, Đimoti R, Zapalac M, Mirković G, Baršić B, Kutleša M, Kotarski V, Vujaklija Brajković A, Babel J, Sever H, Dragija L, Kušan I, Vaara S, Pettilä L, Heinonen J, Kuitunen A, Karlsson S, Vahtera A, Kiiski H, Ristimäki S, Azaiz A, Charron C, Godement M, Geri G, Vieillard-Baron A, Pourcine F, Monchi M, Luis D, Mercier R, Sagnier A, Verrier N, Caplin C, Siami S, Aparicio C, Vautier S, Jeblaoui A, Fartoukh M, Courtin L, Labbe V, Leparco C, Muller G, Nay MA, Kamel T, Benzekri D, Jacquier S, Mercier E, Chartier D, Salmon C, Dequin P, Schneider F, Morel G, L’Hotellier S, Badie J, Berdaguer FD, Malfroy S, Mezher C, Bourgoin C, Megarbane B, Voicu S, Deye N, Malissin I, Sutterlin L, Guitton C, Darreau C, Landais M, Chudeau N, Robert A, Moine P, Heming N, Maxime V, Bossard I, Nicholier TB, Colin G, Zinzoni V, Maquigneau N, Finn A, Kreß G, Hoff U, Friedrich Hinrichs C, Nee J, Pletz M, Hagel S, Ankert J, Kolanos S, Bloos F, Petros S, Pasieka B, Kunz K, Appelt P, Schütze B, Kluge S, Nierhaus A, Jarczak D, Roedl K, Weismann D, Frey A, Klinikum Neukölln V, Reill L, Distler M, Maselli A, Bélteczki J, Magyar I, Fazekas Á, Kovács S, Szőke V, Szigligeti G, Leszkoven J, Collins D, Breen P, Frohlich S, Whelan R, McNicholas B, Scully M, Casey S, Kernan M, Doran P, O’Dywer M, Smyth M, Hayes L, Hoiting O, Peters M, Rengers E, Evers M, Prinssen A, Bosch Ziekenhuis J, Simons K, Rozendaal W, Polderman F, de Jager P, Moviat M, Paling A, Salet A, Rademaker E, Peters AL, de Jonge E, Wigbers J, Guilder E, Butler M, Cowdrey KA, Newby L, Chen Y, Simmonds C, McConnochie R, Ritzema Carter J, Henderson S, Van Der Heyden K, Mehrtens J, Williams T, Kazemi A, Song R, Lai V, Girijadevi D, Everitt R, Russell R, Hacking D, Buehner U, Williams E, Browne T, Grimwade K, Goodson J, Keet O, Callender O, Martynoga R, Trask K, Butler A, Schischka L, Young C, Lesona E, Olatunji S, Robertson Y, José N, Amaro dos Santos Catorze T, de Lima Pereira TNA, Neves Pessoa LM, Castro Ferreira RM, Pereira Sousa Bastos JM, Aysel Florescu S, Stanciu D, Zaharia MF, Kosa AG, Codreanu D, Marabi Y, Al Qasim E, Moneer Hagazy M, Al Swaidan L, Arishi H, Muñoz-Bermúdez R, Marin-Corral J, Salazar Degracia A, Parrilla Gómez F, Mateo López MI, Rodriguez Fernandez J, Cárcel Fernández S, Carmona Flores R, León López R, de la Fuente Martos C, Allan A, Polgarova P, Farahi N, McWilliam S, Hawcutt D, Rad L, O’Malley L, Whitbread J, Kelsall O, Wild L, Thrush J, Wood H, Austin K, Donnelly A, Kelly M, O’Kane S, McClintock D, Warnock M, Johnston P, Gallagher LJ, Mc Goldrick C, Mc Master M, Strzelecka A, Jha R, Kalogirou M, Ellis C, Krishnamurthy V, Deelchand V, Silversides J, McGuigan P, Ward K, O’Neill A, Finn S, Phillips B, Mullan D, Oritz-Ruiz de Gordoa L, Thomas M, Sweet K, Grimmer L, Johnson R, Pinnell J, Robinson M, Gledhill L, Wood T, Morgan M, Cole J, Hill H, Davies M, Antcliffe D, Templeton M, Rojo R, Coghlan P, Smee J, Mackay E, Cort J, Whileman A, Spencer T, Spittle N, Kasipandian V, Patel A, Allibone S, Genetu RM, Ramali M, Ghosh A, Bamford P, London E, Cawley K, Faulkner M, Jeffrey H, Smith T, Brewer C, Gregory J, Limb J, Cowton A, O’Brien J, Nikitas N, Wells C, Lankester L, Pulletz M, Williams P, Birch J, Wiseman S, Horton S, Alegria A, Turki S, Elsefi T, Crisp N, Allen L, McCullagh I, Robinson P, Hays C, Babio-Galan M, Stevenson H, Khare D, Pinder M, Selvamoni S, Gopinath A, Pugh R, Menzies D, Mackay C, Allan E, Davies G, Puxty K, McCue C, Cathcart S, Hickey N, Ireland J, Yusuff H, Isgro G, Brightling C, Bourne M, Craner M, Watters M, Prout R, Davies L, Pegler S, Kyeremeh L, Arbane G, Wilson K, Gomm L, Francia F, Brett S, Sousa Arias S, Elin Hall R, Budd J, Small C, Birch J, Collins E, Henning J, Bonner S, Hugill K, Cirstea E, Wilkinson D, Karlikowski M, Sutherland H, Wilhelmsen E, Woods J, North J, Sundaran D, Hollos L, Coburn S, Walsh J, Turns M, Hopkins P, Smith J, Noble H, Depante MT, Clarey E, Laha S, Verlander M, Williams A, Huckle A, Hall A, Cooke J, Gardiner-Hill C, Maloney C, Qureshi H, Flint N, Nicholson S, Southin S, Nicholson A, Borgatta B, Turner-Bone I, Reddy A, Wilding L, Chamara Warnapura L, Agno Sathianathan R, Golden D, Hart C, Jones J, Bannard-Smith J, Henry J, Birchall K, Pomeroy F, Quayle R, Makowski A, Misztal B, Ahmed I, KyereDiabour T, Naiker K, Stewart R, Mwaura E, Mew L, Wren L, Willams F, Innes R, Doble P, Hutter J, Shovelton C, Plumb B, Szakmany T, Hamlyn V, Hawkins N, Lewis S, Dell A, Gopal S, Ganguly S, Smallwood A, Harris N, Metherell S, Lazaro JM, Newman T, Fletcher S, Nortje J, Fottrell-Gould D, Randell G, Zaman M, Elmahi E, Jones A, Hall K, Mills G, Ryalls K, Bowler H, Sall J, Bourne R, Borrill Z, Duncan T, Lamb T, Shaw J, Fox C, Moreno Cuesta J, Xavier K, Purohit D, Elhassan M, Bakthavatsalam D, Rowland M, Hutton P, Bashyal A, Davidson N, Hird C, Chhablani M, Phalod G, Kirkby A, Archer S, Netherton K, Reschreiter H, Camsooksai J, Patch S, Jenkins S, Pogson D, Rose S, Daly Z, Brimfield L, Claridge H, Parekh D, Bergin C, Bates M, Dasgin J, McGhee C, Sim M, Hay SK, Henderson S, Phull MK, Zaidi A, Pogreban T, Rosaroso LP, Harvey D, Lowe B, Meredith M, Ryan L, Hormis A, Walker R, Collier D, Kimpton S, Oakley S, Rooney K, Rodden N, Hughes E, Thomson N, McGlynn D, Walden A, Jacques N, Coles H, Tilney E, Vowell E, Schuster-Bruce M, Pitts S, Miln R, Purandare L, Vamplew L, Spivey M, Bean S, Burt K, Moore L, Day C, Gibson C, Gordon E, Zitter L, Keenan S, Baker E, Cherian S, Cutler S, Roynon-Reed A, Harrington K, Raithatha A, Bauchmuller K, Ahmad N, Grecu I, Trodd D, Martin J, Wrey Brown C, Arias AM, Craven T, Hope D, Singleton J, Clark S, Rae N, Welters I, Hamilton DO, Williams K, Waugh V, Shaw D, Puthucheary Z, Martin T, Santos F, Uddin R, Somerville A, Tatham KC, Jhanji S, Black E, Dela Rosa A, Howle R, Tully R, Drummond A, Dearden J, Philbin J, Munt S, Vuylsteke A, Chan C, Victor S, Matsa R, Gellamucho M, Creagh-Brown B, Tooley J, Montague L, De Beaux F, Bullman L, Kersiake I, Demetriou C, Mitchard S, Ramos L, White K, Donnison P, Johns M, Casey R, Mattocks L, Salisbury S, Dark P, Claxton A, McLachlan D, Slevin K, Lee S, Hulme J, Joseph S, Kinney F, Senya HJ, Oborska A, Kayani A, Hadebe B, Orath Prabakaran R, Nichols L, Thomas M, Worner R, Faulkner B, Gendall E, Hayes K, Hamilton-Davies C, Chan C, Mfuko C, Abbass H, Mandadapu V, Leaver S, Forton D, Patel K, Paramasivam E, Powell M, Gould R, Wilby E, Howcroft C, Banach D, Fernández de Pinedo Artaraz Z, Cabreros L, White I, Croft M, Holland N, Pereira R, Zaki A, Johnson D, Jackson M, Garrard H, Juhaz V, Roy A, Rostron A, Woods L, Cornell S, Pillai S, Harford R, Rees T, Ivatt H, Sundara Raman A, Davey M, Lee K, Barber R, Chablani M, Brohi F, Jagannathan V, Clark M, Purvis S, Wetherill B, Dushianthan A, Cusack R, de Courcy-Golder K, Smith S, Jackson S, Attwood B, Parsons P, Page V, Zhao XB, Oza D, Rhodes J, Anderson T, Morris S, Xia Le Tai C, Thomas A, Keen A, Digby S, Cowley N, Wild L, Southern D, Reddy H, Campbell A, Watkins C, Smuts S, Touma O, Barnes N, Alexander P, Felton T, Ferguson S, Sellers K, Bradley-Potts J, Yates D, Birkinshaw I, Kell K, Marshall N, Carr-Knott L, Summers C. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA 2020. [PMID: 32876697 DOI: 10.1001/jama.2020.1702221] [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] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. OBJECTIVE To determine whether hydrocortisone improves outcome for patients with severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. INTERVENTIONS The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). MAIN OUTCOMES AND MEASURES The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). RESULTS After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Derek C Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Charlotte Bradbury
- Bristol Royal Informatory, Bristol, United Kingdom
- University of Bristol, Bristol, United Kingdom
| | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care (CSCC), Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Adrian Buzgau
- Helix, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Menno de Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | | | - Lise Estcourt
- NHS Blood and Transplant, Bristol, United Kingdom
- Transfusion Medicine, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher Horvat
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Sebastiaan J Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | | | - John Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Bryan McVerry
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie Montgomery
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Marlene Santos
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher Seymour
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Balasubramanian Venkatesh
- Southside Clinical Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Steven A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
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Angus DC, Derde L, Al-Beidh F, Annane D, Arabi Y, Beane A, van Bentum-Puijk W, Berry L, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Buzgau A, Cheng AC, de Jong M, Detry M, Estcourt L, Fitzgerald M, Goossens H, Green C, Haniffa R, Higgins AM, Horvat C, Hullegie SJ, Kruger P, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, Marshall J, McAuley D, McGlothin A, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Parker J, Rowan K, Sanil A, Santos M, Saunders C, Seymour C, Turner A, van de Veerdonk F, Venkatesh B, Zarychanski R, Berry S, Lewis RJ, McArthur C, Webb SA, Gordon AC, Al-Beidh F, Angus D, Annane D, Arabi Y, van Bentum-Puijk W, Berry S, Beane A, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Cheng A, De Jong M, Derde L, Estcourt L, Goossens H, Gordon A, Green C, Haniffa R, Lamontagne F, Lawler P, Litton E, Marshall J, McArthur C, McAuley D, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Rowan K, Seymour C, Turner A, van de Veerdonk F, Webb S, Zarychanski R, Campbell L, Forbes A, Gattas D, Heritier S, Higgins L, Kruger P, Peake S, Presneill J, Seppelt I, Trapani T, Young P, Bagshaw S, Daneman N, Ferguson N, Misak C, Santos M, Hullegie S, Pletz M, Rohde G, Rowan K, Alexander B, Basile K, Girard T, Horvat C, Huang D, Linstrum K, Vates J, Beasley R, Fowler R, McGloughlin S, Morpeth S, Paterson D, Venkatesh B, Uyeki T, Baillie K, Duffy E, Fowler R, Hills T, Orr K, Patanwala A, Tong S, Netea M, Bihari S, Carrier M, Fergusson D, Goligher E, Haidar G, Hunt B, Kumar A, Laffan M, Lawless P, Lother S, McCallum P, Middeldopr S, McQuilten Z, Neal M, Pasi J, Schutgens R, Stanworth S, Turgeon A, Weissman A, Adhikari N, Anstey M, Brant E, de Man A, Lamonagne F, Masse MH, Udy A, Arnold D, Begin P, Charlewood R, Chasse M, Coyne M, Cooper J, Daly J, Gosbell I, Harvala-Simmonds H, Hills T, MacLennan S, Menon D, McDyer J, Pridee N, Roberts D, Shankar-Hari M, Thomas H, Tinmouth A, Triulzi D, Walsh T, Wood E, Calfee C, O’Kane C, Shyamsundar M, Sinha P, Thompson T, Young I, Bihari S, Hodgson C, Laffey J, McAuley D, Orford N, Neto A, Detry M, Fitzgerald M, Lewis R, McGlothlin A, Sanil A, Saunders C, Berry L, Lorenzi E, Miller E, Singh V, Zammit C, van Bentum Puijk W, Bouwman W, Mangindaan Y, Parker L, Peters S, Rietveld I, Raymakers K, Ganpat R, Brillinger N, Markgraf R, Ainscough K, Brickell K, Anjum A, Lane JB, Richards-Belle A, Saull M, Wiley D, Bion J, Connor J, Gates S, Manax V, van der Poll T, Reynolds J, van Beurden M, Effelaar E, Schotsman J, Boyd C, Harland C, Shearer A, Wren J, Clermont G, Garrard W, Kalchthaler K, King A, Ricketts D, Malakoutis S, Marroquin O, Music E, Quinn K, Cate H, Pearson K, Collins J, Hanson J, Williams P, Jackson S, Asghar A, Dyas S, Sutu M, Murphy S, Williamson D, Mguni N, Potter A, Porter D, Goodwin J, Rook C, Harrison S, Williams H, Campbell H, Lomme K, Williamson J, Sheffield J, van’t Hoff W, McCracken P, Young M, Board J, Mart E, Knott C, Smith J, Boschert C, Affleck J, Ramanan M, D’Souza R, Pateman K, Shakih A, Cheung W, Kol M, Wong H, Shah A, Wagh A, Simpson J, Duke G, Chan P, Cartner B, Hunter S, Laver R, Shrestha T, Regli A, Pellicano A, McCullough J, Tallott M, Kumar N, Panwar R, Brinkerhoff G, Koppen C, Cazzola F, Brain M, Mineall S, Fischer R, Biradar V, Soar N, White H, Estensen K, Morrison L, Smith J, Cooper M, Health M, Shehabi Y, Al-Bassam W, Hulley A, Whitehead C, Lowrey J, Gresha R, Walsham J, Meyer J, Harward M, Venz E, Williams P, Kurenda C, Smith K, Smith M, Garcia R, Barge D, Byrne D, Byrne K, Driscoll A, Fortune L, Janin P, Yarad E, Hammond N, Bass F, Ashelford A, Waterson S, Wedd S, McNamara R, Buhr H, Coles J, Schweikert S, Wibrow B, Rauniyar R, Myers E, Fysh E, Dawda A, Mevavala B, Litton E, Ferrier J, Nair P, Buscher H, Reynolds C, Santamaria J, Barbazza L, Homes J, Smith R, Murray L, Brailsford J, Forbes L, Maguire T, Mariappa V, Smith J, Simpson S, Maiden M, Bone A, Horton M, Salerno T, Sterba M, Geng W, Depuydt P, De Waele J, De Bus L, Fierens J, Bracke S, Reeve B, Dechert W, Chassé M, Carrier FM, Boumahni D, Benettaib F, Ghamraoui A, Bellemare D, Cloutier È, Francoeur C, Lamontagne F, D’Aragon F, Carbonneau E, Leblond J, Vazquez-Grande G, Marten N, Wilson M, Albert M, Serri K, Cavayas A, Duplaix M, Williams V, Rochwerg B, Karachi T, Oczkowski S, Centofanti J, Millen T, Duan E, Tsang J, Patterson L, English S, Watpool I, Porteous R, Miezitis S, McIntyre L, Brochard L, Burns K, Sandhu G, Khalid I, Binnie A, Powell E, McMillan A, Luk T, Aref N, Andric Z, Cviljevic S, Đimoti R, Zapalac M, Mirković G, Baršić B, Kutleša M, Kotarski V, Vujaklija Brajković A, Babel J, Sever H, Dragija L, Kušan I, Vaara S, Pettilä L, Heinonen J, Kuitunen A, Karlsson S, Vahtera A, Kiiski H, Ristimäki S, Azaiz A, Charron C, Godement M, Geri G, Vieillard-Baron A, Pourcine F, Monchi M, Luis D, Mercier R, Sagnier A, Verrier N, Caplin C, Siami S, Aparicio C, Vautier S, Jeblaoui A, Fartoukh M, Courtin L, Labbe V, Leparco C, Muller G, Nay MA, Kamel T, Benzekri D, Jacquier S, Mercier E, Chartier D, Salmon C, Dequin P, Schneider F, Morel G, L’Hotellier S, Badie J, Berdaguer FD, Malfroy S, Mezher C, Bourgoin C, Megarbane B, Voicu S, Deye N, Malissin I, Sutterlin L, Guitton C, Darreau C, Landais M, Chudeau N, Robert A, Moine P, Heming N, Maxime V, Bossard I, Nicholier TB, Colin G, Zinzoni V, Maquigneau N, Finn A, Kreß G, Hoff U, Friedrich Hinrichs C, Nee J, Pletz M, Hagel S, Ankert J, Kolanos S, Bloos F, Petros S, Pasieka B, Kunz K, Appelt P, Schütze B, Kluge S, Nierhaus A, Jarczak D, Roedl K, Weismann D, Frey A, Klinikum Neukölln V, Reill L, Distler M, Maselli A, Bélteczki J, Magyar I, Fazekas Á, Kovács S, Szőke V, Szigligeti G, Leszkoven J, Collins D, Breen P, Frohlich S, Whelan R, McNicholas B, Scully M, Casey S, Kernan M, Doran P, O’Dywer M, Smyth M, Hayes L, Hoiting O, Peters M, Rengers E, Evers M, Prinssen A, Bosch Ziekenhuis J, Simons K, Rozendaal W, Polderman F, de Jager P, Moviat M, Paling A, Salet A, Rademaker E, Peters AL, de Jonge E, Wigbers J, Guilder E, Butler M, Cowdrey KA, Newby L, Chen Y, Simmonds C, McConnochie R, Ritzema Carter J, Henderson S, Van Der Heyden K, Mehrtens J, Williams T, Kazemi A, Song R, Lai V, Girijadevi D, Everitt R, Russell R, Hacking D, Buehner U, Williams E, Browne T, Grimwade K, Goodson J, Keet O, Callender O, Martynoga R, Trask K, Butler A, Schischka L, Young C, Lesona E, Olatunji S, Robertson Y, José N, Amaro dos Santos Catorze T, de Lima Pereira TNA, Neves Pessoa LM, Castro Ferreira RM, Pereira Sousa Bastos JM, Aysel Florescu S, Stanciu D, Zaharia MF, Kosa AG, Codreanu D, Marabi Y, Al Qasim E, Moneer Hagazy M, Al Swaidan L, Arishi H, Muñoz-Bermúdez R, Marin-Corral J, Salazar Degracia A, Parrilla Gómez F, Mateo López MI, Rodriguez Fernandez J, Cárcel Fernández S, Carmona Flores R, León López R, de la Fuente Martos C, Allan A, Polgarova P, Farahi N, McWilliam S, Hawcutt D, Rad L, O’Malley L, Whitbread J, Kelsall O, Wild L, Thrush J, Wood H, Austin K, Donnelly A, Kelly M, O’Kane S, McClintock D, Warnock M, Johnston P, Gallagher LJ, Mc Goldrick C, Mc Master M, Strzelecka A, Jha R, Kalogirou M, Ellis C, Krishnamurthy V, Deelchand V, Silversides J, McGuigan P, Ward K, O’Neill A, Finn S, Phillips B, Mullan D, Oritz-Ruiz de Gordoa L, Thomas M, Sweet K, Grimmer L, Johnson R, Pinnell J, Robinson M, Gledhill L, Wood T, Morgan M, Cole J, Hill H, Davies M, Antcliffe D, Templeton M, Rojo R, Coghlan P, Smee J, Mackay E, Cort J, Whileman A, Spencer T, Spittle N, Kasipandian V, Patel A, Allibone S, Genetu RM, Ramali M, Ghosh A, Bamford P, London E, Cawley K, Faulkner M, Jeffrey H, Smith T, Brewer C, Gregory J, Limb J, Cowton A, O’Brien J, Nikitas N, Wells C, Lankester L, Pulletz M, Williams P, Birch J, Wiseman S, Horton S, Alegria A, Turki S, Elsefi T, Crisp N, Allen L, McCullagh I, Robinson P, Hays C, Babio-Galan M, Stevenson H, Khare D, Pinder M, Selvamoni S, Gopinath A, Pugh R, Menzies D, Mackay C, Allan E, Davies G, Puxty K, McCue C, Cathcart S, Hickey N, Ireland J, Yusuff H, Isgro G, Brightling C, Bourne M, Craner M, Watters M, Prout R, Davies L, Pegler S, Kyeremeh L, Arbane G, Wilson K, Gomm L, Francia F, Brett S, Sousa Arias S, Elin Hall R, Budd J, Small C, Birch J, Collins E, Henning J, Bonner S, Hugill K, Cirstea E, Wilkinson D, Karlikowski M, Sutherland H, Wilhelmsen E, Woods J, North J, Sundaran D, Hollos L, Coburn S, Walsh J, Turns M, Hopkins P, Smith J, Noble H, Depante MT, Clarey E, Laha S, Verlander M, Williams A, Huckle A, Hall A, Cooke J, Gardiner-Hill C, Maloney C, Qureshi H, Flint N, Nicholson S, Southin S, Nicholson A, Borgatta B, Turner-Bone I, Reddy A, Wilding L, Chamara Warnapura L, Agno Sathianathan R, Golden D, Hart C, Jones J, Bannard-Smith J, Henry J, Birchall K, Pomeroy F, Quayle R, Makowski A, Misztal B, Ahmed I, KyereDiabour T, Naiker K, Stewart R, Mwaura E, Mew L, Wren L, Willams F, Innes R, Doble P, Hutter J, Shovelton C, Plumb B, Szakmany T, Hamlyn V, Hawkins N, Lewis S, Dell A, Gopal S, Ganguly S, Smallwood A, Harris N, Metherell S, Lazaro JM, Newman T, Fletcher S, Nortje J, Fottrell-Gould D, Randell G, Zaman M, Elmahi E, Jones A, Hall K, Mills G, Ryalls K, Bowler H, Sall J, Bourne R, Borrill Z, Duncan T, Lamb T, Shaw J, Fox C, Moreno Cuesta J, Xavier K, Purohit D, Elhassan M, Bakthavatsalam D, Rowland M, Hutton P, Bashyal A, Davidson N, Hird C, Chhablani M, Phalod G, Kirkby A, Archer S, Netherton K, Reschreiter H, Camsooksai J, Patch S, Jenkins S, Pogson D, Rose S, Daly Z, Brimfield L, Claridge H, Parekh D, Bergin C, Bates M, Dasgin J, McGhee C, Sim M, Hay SK, Henderson S, Phull MK, Zaidi A, Pogreban T, Rosaroso LP, Harvey D, Lowe B, Meredith M, Ryan L, Hormis A, Walker R, Collier D, Kimpton S, Oakley S, Rooney K, Rodden N, Hughes E, Thomson N, McGlynn D, Walden A, Jacques N, Coles H, Tilney E, Vowell E, Schuster-Bruce M, Pitts S, Miln R, Purandare L, Vamplew L, Spivey M, Bean S, Burt K, Moore L, Day C, Gibson C, Gordon E, Zitter L, Keenan S, Baker E, Cherian S, Cutler S, Roynon-Reed A, Harrington K, Raithatha A, Bauchmuller K, Ahmad N, Grecu I, Trodd D, Martin J, Wrey Brown C, Arias AM, Craven T, Hope D, Singleton J, Clark S, Rae N, Welters I, Hamilton DO, Williams K, Waugh V, Shaw D, Puthucheary Z, Martin T, Santos F, Uddin R, Somerville A, Tatham KC, Jhanji S, Black E, Dela Rosa A, Howle R, Tully R, Drummond A, Dearden J, Philbin J, Munt S, Vuylsteke A, Chan C, Victor S, Matsa R, Gellamucho M, Creagh-Brown B, Tooley J, Montague L, De Beaux F, Bullman L, Kersiake I, Demetriou C, Mitchard S, Ramos L, White K, Donnison P, Johns M, Casey R, Mattocks L, Salisbury S, Dark P, Claxton A, McLachlan D, Slevin K, Lee S, Hulme J, Joseph S, Kinney F, Senya HJ, Oborska A, Kayani A, Hadebe B, Orath Prabakaran R, Nichols L, Thomas M, Worner R, Faulkner B, Gendall E, Hayes K, Hamilton-Davies C, Chan C, Mfuko C, Abbass H, Mandadapu V, Leaver S, Forton D, Patel K, Paramasivam E, Powell M, Gould R, Wilby E, Howcroft C, Banach D, Fernández de Pinedo Artaraz Z, Cabreros L, White I, Croft M, Holland N, Pereira R, Zaki A, Johnson D, Jackson M, Garrard H, Juhaz V, Roy A, Rostron A, Woods L, Cornell S, Pillai S, Harford R, Rees T, Ivatt H, Sundara Raman A, Davey M, Lee K, Barber R, Chablani M, Brohi F, Jagannathan V, Clark M, Purvis S, Wetherill B, Dushianthan A, Cusack R, de Courcy-Golder K, Smith S, Jackson S, Attwood B, Parsons P, Page V, Zhao XB, Oza D, Rhodes J, Anderson T, Morris S, Xia Le Tai C, Thomas A, Keen A, Digby S, Cowley N, Wild L, Southern D, Reddy H, Campbell A, Watkins C, Smuts S, Touma O, Barnes N, Alexander P, Felton T, Ferguson S, Sellers K, Bradley-Potts J, Yates D, Birkinshaw I, Kell K, Marshall N, Carr-Knott L, Summers C. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA 2020; 324:1317-1329. [PMID: 32876697 PMCID: PMC7489418 DOI: 10.1001/jama.2020.17022] [Citation(s) in RCA: 542] [Impact Index Per Article: 135.5] [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: 01/27/2023]
Abstract
IMPORTANCE Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. OBJECTIVE To determine whether hydrocortisone improves outcome for patients with severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. INTERVENTIONS The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). MAIN OUTCOMES AND MEASURES The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). RESULTS After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Derek C Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Charlotte Bradbury
- Bristol Royal Informatory, Bristol, United Kingdom
- University of Bristol, Bristol, United Kingdom
| | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care (CSCC), Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Adrian Buzgau
- Helix, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Menno de Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | | | - Lise Estcourt
- NHS Blood and Transplant, Bristol, United Kingdom
- Transfusion Medicine, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher Horvat
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Sebastiaan J Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | | | - John Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Bryan McVerry
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie Montgomery
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Marlene Santos
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher Seymour
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Balasubramanian Venkatesh
- Southside Clinical Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Steven A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
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Dequin PF, Heming N, Meziani F, Plantefève G, Voiriot G, Badié J, François B, Aubron C, Ricard JD, Ehrmann S, Jouan Y, Guillon A, Leclerc M, Coffre C, Bourgoin H, Lengellé C, Caille-Fénérol C, Tavernier E, Zohar S, Giraudeau B, Annane D, Le Gouge A. Effect of Hydrocortisone on 21-Day Mortality or Respiratory Support Among Critically Ill Patients With COVID-19: A Randomized Clinical Trial. JAMA 2020; 324:1298-1306. [PMID: 32876689 PMCID: PMC7489432 DOI: 10.1001/jama.2020.16761] [Citation(s) in RCA: 322] [Impact Index Per Article: 80.5] [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: 07/23/2020] [Accepted: 08/18/2020] [Indexed: 12/15/2022]
Abstract
Importance Coronavirus disease 2019 (COVID-19) is associated with severe lung damage. Corticosteroids are a possible therapeutic option. Objective To determine the effect of hydrocortisone on treatment failure on day 21 in critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and acute respiratory failure. Design, Setting, and Participants Multicenter randomized double-blind sequential trial conducted in France, with interim analyses planned every 50 patients. Patients admitted to the intensive care unit (ICU) for COVID-19-related acute respiratory failure were enrolled from March 7 to June 1, 2020, with last follow-up on June 29, 2020. The study intended to enroll 290 patients but was stopped early following the recommendation of the data and safety monitoring board. Interventions Patients were randomized to receive low-dose hydrocortisone (n = 76) or placebo (n = 73). Main Outcomes and Measures The primary outcome, treatment failure on day 21, was defined as death or persistent dependency on mechanical ventilation or high-flow oxygen therapy. Prespecified secondary outcomes included the need for tracheal intubation (among patients not intubated at baseline); cumulative incidences (until day 21) of prone position sessions, extracorporeal membrane oxygenation, and inhaled nitric oxide; Pao2:Fio2 ratio measured daily from day 1 to day 7, then on days 14 and 21; and the proportion of patients with secondary infections during their ICU stay. Results The study was stopped after 149 patients (mean age, 62.2 years; 30.2% women; 81.2% mechanically ventilated) were enrolled. One hundred forty-eight patients (99.3%) completed the study, and there were 69 treatment failure events, including 11 deaths in the hydrocortisone group and 20 deaths in the placebo group. The primary outcome, treatment failure on day 21, occurred in 32 of 76 patients (42.1%) in the hydrocortisone group compared with 37 of 73 (50.7%) in the placebo group (difference of proportions, -8.6% [95.48% CI, -24.9% to 7.7%]; P = .29). Of the 4 prespecified secondary outcomes, none showed a significant difference. No serious adverse events were related to the study treatment. Conclusions and Relevance In this study of critically ill patients with COVID-19 and acute respiratory failure, low-dose hydrocortisone, compared with placebo, did not significantly reduce treatment failure (defined as death or persistent respiratory support) at day 21. However, the study was stopped early and likely was underpowered to find a statistically and clinically important difference in the primary outcome. Trial Registration ClinicalTrials.gov Identifier: NCT02517489.
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Affiliation(s)
- Pierre-François Dequin
- Médecine Intensive-Réanimation, CHU de Tours, Tours, France
- INSERM U1100, Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
- INSERM CIC1415, CHU de Tours, Tours, France
| | - Nicholas Heming
- Médecine Intensive Réanimation, Hôpital Raymond Poincaré (GHU APHP Université Paris Saclay), Garches, France, and RHU RECORDS and FHU SEPSIS
- INSERM U1173, Université de Versailles SQY-Université Paris Saclay, Garches, France
| | - Ferhat Meziani
- Médecine Intensive Réanimation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- INSERM UMR 1260, Université de Strasbourg, Strasbourg, France
| | | | - Guillaume Voiriot
- Médecine Intensive Réanimation, Hôpital Tenon (Assistance Publique–Hôpitaux de Paris), Paris, France
- Sorbonne Université, Paris, France
| | - Julio Badié
- Réanimation Polyvalente, Hôpital Nord Franche-Comté, Trevenans, France
| | - Bruno François
- Réanimation Polyvalente, CHU de Limoges, Limoges, France
- INSERM UMR 1092, Université de Limoges, Limoges, France
- INSERM CIC 1435, CHU de Limoges, Limoges, France
| | - Cécile Aubron
- Médecine Intensive Réanimation, CHRU de Brest, Brest, France
- Université de Bretagne Occidentale, Brest, France
| | - Jean-Damien Ricard
- Université de Paris, IAME U1137, Médecine Intensive Réanimation, DMU ESPRIT, Hôpital Louis Mourier, Assistance Publique–Hôpitaux de Paris, Colombe, France
| | - Stephan Ehrmann
- Médecine Intensive-Réanimation, CHU de Tours, Tours, France
- INSERM U1100, Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
- INSERM CIC1415, CHU de Tours, Tours, France
| | - Youenn Jouan
- Médecine Intensive-Réanimation, CHU de Tours, Tours, France
- INSERM U1100, Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
- INSERM CIC1415, CHU de Tours, Tours, France
| | - Antoine Guillon
- Médecine Intensive-Réanimation, CHU de Tours, Tours, France
- INSERM U1100, Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
- INSERM CIC1415, CHU de Tours, Tours, France
| | - Marie Leclerc
- Délégation à la Recherche Clinique et à l’Innovation, CHU de Tours, Tours, France
| | - Carine Coffre
- Délégation à la Recherche Clinique et à l’Innovation, CHU de Tours, Tours, France
| | | | - Céline Lengellé
- Centre régional de pharmacovigilance et d'information sur le médicament, service de pharmacosurveillance, CHU de Tours, Tours, France
| | | | | | - Sarah Zohar
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| | - Bruno Giraudeau
- INSERM CIC1415, CHU de Tours, Tours, France
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France
| | - Djillali Annane
- Médecine Intensive Réanimation, Hôpital Raymond Poincaré (GHU APHP Université Paris Saclay), Garches, France, and RHU RECORDS and FHU SEPSIS
- INSERM U1173, Université de Versailles SQY-Université Paris Saclay, Garches, France
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Tomazini BM, Maia IS, Cavalcanti AB, Berwanger O, Rosa RG, Veiga VC, Avezum A, Lopes RD, Bueno FR, Silva MVAO, Baldassare FP, Costa ELV, Moura RAB, Honorato MO, Costa AN, Damiani LP, Lisboa T, Kawano-Dourado L, Zampieri FG, Olivato GB, Righy C, Amendola CP, Roepke RML, Freitas DHM, Forte DN, Freitas FGR, Fernandes CCF, Melro LMG, Junior GFS, Morais DC, Zung S, Machado FR, Azevedo LCP. Effect of Dexamethasone on Days Alive and Ventilator-Free in Patients With Moderate or Severe Acute Respiratory Distress Syndrome and COVID-19: The CoDEX Randomized Clinical Trial. JAMA 2020; 324:1307-1316. [PMID: 32876695 PMCID: PMC7489411 DOI: 10.1001/jama.2020.17021] [Citation(s) in RCA: 826] [Impact Index Per Article: 206.5] [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: 08/04/2020] [Accepted: 08/20/2020] [Indexed: 12/16/2022]
Abstract
Importance Acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) is associated with substantial mortality and use of health care resources. Dexamethasone use might attenuate lung injury in these patients. Objective To determine whether intravenous dexamethasone increases the number of ventilator-free days among patients with COVID-19-associated ARDS. Design, Setting, and Participants Multicenter, randomized, open-label, clinical trial conducted in 41 intensive care units (ICUs) in Brazil. Patients with COVID-19 and moderate to severe ARDS, according to the Berlin definition, were enrolled from April 17 to June 23, 2020. Final follow-up was completed on July 21, 2020. The trial was stopped early following publication of a related study before reaching the planned sample size of 350 patients. Interventions Twenty mg of dexamethasone intravenously daily for 5 days, 10 mg of dexamethasone daily for 5 days or until ICU discharge, plus standard care (n =151) or standard care alone (n = 148). Main Outcomes and Measures The primary outcome was ventilator-free days during the first 28 days, defined as being alive and free from mechanical ventilation. Secondary outcomes were all-cause mortality at 28 days, clinical status of patients at day 15 using a 6-point ordinal scale (ranging from 1, not hospitalized to 6, death), ICU-free days during the first 28 days, mechanical ventilation duration at 28 days, and Sequential Organ Failure Assessment (SOFA) scores (range, 0-24, with higher scores indicating greater organ dysfunction) at 48 hours, 72 hours, and 7 days. Results A total of 299 patients (mean [SD] age, 61 [14] years; 37% women) were enrolled and all completed follow-up. Patients randomized to the dexamethasone group had a mean 6.6 ventilator-free days (95% CI, 5.0-8.2) during the first 28 days vs 4.0 ventilator-free days (95% CI, 2.9-5.4) in the standard care group (difference, 2.26; 95% CI, 0.2-4.38; P = .04). At 7 days, patients in the dexamethasone group had a mean SOFA score of 6.1 (95% CI, 5.5-6.7) vs 7.5 (95% CI, 6.9-8.1) in the standard care group (difference, -1.16; 95% CI, -1.94 to -0.38; P = .004). There was no significant difference in the prespecified secondary outcomes of all-cause mortality at 28 days, ICU-free days during the first 28 days, mechanical ventilation duration at 28 days, or the 6-point ordinal scale at 15 days. Thirty-three patients (21.9%) in the dexamethasone group vs 43 (29.1%) in the standard care group experienced secondary infections, 47 (31.1%) vs 42 (28.3%) needed insulin for glucose control, and 5 (3.3%) vs 9 (6.1%) experienced other serious adverse events. Conclusions and Relevance Among patients with COVID-19 and moderate or severe ARDS, use of intravenous dexamethasone plus standard care compared with standard care alone resulted in a statistically significant increase in the number of ventilator-free days (days alive and free of mechanical ventilation) over 28 days. Trial Registration ClinicalTrials.gov Identifier: NCT04327401.
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Affiliation(s)
- Bruno M. Tomazini
- Hospital Sírio-Libanês, São Paulo, Brazil
- Departamento de Cirurgia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Israel S. Maia
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
| | - Alexandre B. Cavalcanti
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Regis G. Rosa
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Viviane C. Veiga
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- BP–A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Renato D. Lopes
- Brazilian Clinical Research Institute, São Paulo, Brazil
- Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | - Eduardo L. V. Costa
- Hospital Sírio-Libanês, São Paulo, Brazil
- UTI Respiratória, Instituto do Coração (Incor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Andre N. Costa
- Hospital Sírio-Libanês, São Paulo, Brazil
- Departamento de Cardiopneumologia, Instituto do Coração (Incor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Thiago Lisboa
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Hospital de Clinicas de Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Fernando G. Zampieri
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
| | - Guilherme B. Olivato
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Hospital Vila Santa Catarina, São Paulo, Brazil
| | - Cassia Righy
- Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Laboratorio de Medicina Intensiva, Instituto Nacional de Infectologia, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - Roberta M. L. Roepke
- Departamento de Cirurgia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil
| | - Daniela H. M. Freitas
- UTI Respiratória, Instituto do Coração (Incor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Daniel N. Forte
- Hospital Sírio-Libanês, São Paulo, Brazil
- UTI 09DN, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Flávio G. R. Freitas
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Anesthesiology, Pain, and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Stevin Zung
- Aché Laboratórios Farmacêuticos, São Paulo, Brazil
| | - Flávia R. Machado
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Anesthesiology, Pain, and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil
| | - Luciano C. P. Azevedo
- Hospital Sírio-Libanês, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- Disciplina de Emergências Clínicas, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Mann DL, Greene SJ, Givertz MM, Vader JM, Starling RC, Ambrosy AP, Shah P, McNulty SE, Mahr C, Gupta D, Redfield MM, Lala A, Lewis GD, Mohammed SF, Gilotra NA, DeVore AD, Gorodeski EZ, Desvigne-Nickens P, Hernandez AF, Braunwald E. Sacubitril/Valsartan in Advanced Heart Failure With Reduced Ejection Fraction: Rationale and Design of the LIFE Trial. JACC Heart Fail 2020; 8:789-799. [PMID: 32641226 PMCID: PMC7286640 DOI: 10.1016/j.jchf.2020.05.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 12/11/2022]
Abstract
The PARADIGM-HF (Prospective Comparison of Angiotensin II Receptor Blocker Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial reported that sacubitril/valsartan (S/V), an angiotensin receptor-neprilysin inhibitor, significantly reduced mortality and heart failure (HF) hospitalization in HF patients with a reduced ejection fraction (HFrEF). However, fewer than 1% of patients in the PARADIGM-HF study had New York Heart Association (NYHA) functional class IV symptoms. Accordingly, data that informed the use of S/V among patients with advanced HF were limited. The LIFE (LCZ696 in Hospitalized Advanced Heart Failure) study was a 24-week prospective, multicenter, double-blinded, double-dummy, active comparator trial that compared the safety, efficacy, and tolerability of S/V with those of valsartan in patients with advanced HFrEF. The trial planned to randomize 400 patients ≥18 years of age with advanced HF, defined as an EF ≤35%, New York Heart Association functional class IV symptoms, elevated natriuretic peptide concentration (B-type natriuretic peptide [BNP] ≥250 pg/ml or N-terminal pro-B-type natriuretic peptide [NT-proBNP] ≥800 pg/ml), and ≥1 objective finding of advanced HF. Following a 3- to 7-day open label run-in period with S/V (24 mg/26 mg twice daily), patients were randomized 1:1 to S/V titrated to 97 mg/103 mg twice daily versus 160 mg of V twice daily. The primary endpoint was the proportional change from baseline in the area under the curve for NT-proBNP levels measured through week 24. Secondary and tertiary endpoints included clinical outcomes and safety and tolerability. Because of the COVID-19 pandemic, enrollment in the LIFE trial was stopped prematurely to ensure patient safety and data integrity. The primary analysis consists of the first 335 randomized patients whose clinical follow-up examination results were not severely impacted by COVID-19. (Entresto [LCZ696] in Advanced Heart Failure [LIFE STUDY] [HFN-LIFE]; NCT02816736).
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Affiliation(s)
- Douglas L Mann
- Department of Medicine, Washington University, St. Louis, Missouri.
| | - Stephen J Greene
- Department of Medicine, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Michael M Givertz
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Justin M Vader
- Department of Medicine, Washington University, St. Louis, Missouri
| | - Randall C Starling
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Andrew P Ambrosy
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Steven E McNulty
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Claudius Mahr
- Department of Medicine, University of Washington, Seattle, Washington
| | - Divya Gupta
- Department of Medicine, Emory University, Atlanta, Georgia
| | | | - Anuradha Lala
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gregory D Lewis
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Nisha A Gilotra
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam D DeVore
- Department of Medicine, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Eiran Z Gorodeski
- Department of Medicine, Harrington Heart and Vascular Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Baltimore, Maryland
| | - Adrian F Hernandez
- Department of Medicine, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Eugene Braunwald
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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25
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Mislang A, Mollard R, Tapia Rico G, Fairlie WD, Lee EF, Harris TJ, Aston R, Brown MP. A preliminary assessment of oral monepantel's tolerability and pharmacokinetics in individuals with treatment-refractory solid tumors. Cancer Chemother Pharmacol 2020; 86:589-594. [PMID: 32960289 DOI: 10.1007/s00280-020-04146-5] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 09/08/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Monepantel is an approved veterinary anthelmintic with a strong safety profile. Preclinical evidence suggests novel mTOR pathway-associated anticancer activity. An open-label Phase I trial assessed tolerability, pharmacokinetics, pharmacodynamics and PET-CT imaging following oral Zolvix® monepantel administration to adults with treatment refractory, progressing and unresectable solid tumors. METHODS Subjects were scheduled to daily home-based monepantel administration for 28 days in a 3 + 3 dose escalation study (5.0, 25.0 and 62.5 mg/kg bw). RESULTS Of 41 reported drug-related AEs, 68% were Grade 1 and 24% were Grade 2; 35 AEs related to gastrointestinal effects including very poor palatability. DLT and MTD could not be determined due to early termination. Myelosuppression was not observed at the lowest level tested. Three of four Cohort 1 subjects had reduced mTOR pathway marker p-RPS6KB1 levels in PBMCs and achieved RECISTv1.1 SD by CT; one had progressive bony metastases by FDG-PET. One subject recorded PD on day 28, correlating with no detectable plasma monepantel from day 7. Monepantel sulfone dominated monepantel in pharmacokinetics. Both Cohort 2 subjects withdrew early due to AEs and the trial was terminated. CONCLUSIONS Short-term 5 mg/kg bw monepantel administration provides a combined steady-state trough plasma monepantel and monepantel sulfone concentration of 0.5 μM. Gastrointestinal AEs including very poor palatability are concerning and suggested to be resolved by future drug product reformulation. RECISTv1.1, p-RPS6KB1 and plasma tumor marker outcomes provide preliminary evidence of anticancer activity.
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Affiliation(s)
- Anna Mislang
- Cancer Clinical Trials Unit, Royal Adelaide Hospital, Adelaide, 5000, Australia
| | - Richard Mollard
- PharmAust Ltd, Claremont, 6010, Australia
- Department of Veterinary and Agricultural Science, University of Melbourne, Parkville, 3052, Australia
| | - Gonzalo Tapia Rico
- Cancer Clinical Trials Unit, Royal Adelaide Hospital, Adelaide, 5000, Australia
- School of Medicine, University of Adelaide, Adelaide, 5000, Australia
| | - W Douglas Fairlie
- Olivia Newton-John Cancer Research Institute, Heidelberg, 3084, Australia
- School of Cancer Medicine, La Trobe University, Heidelberg, 3084, Australia
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Sciences, La Trobe University, Bundoora, VIC, 3086, Australia
| | - Erinna F Lee
- Olivia Newton-John Cancer Research Institute, Heidelberg, 3084, Australia
- School of Cancer Medicine, La Trobe University, Heidelberg, 3084, Australia
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Sciences, La Trobe University, Bundoora, VIC, 3086, Australia
| | - Tiffany J Harris
- Olivia Newton-John Cancer Research Institute, Heidelberg, 3084, Australia
| | | | - Michael P Brown
- Cancer Clinical Trials Unit, Royal Adelaide Hospital, Adelaide, 5000, Australia.
- Centre for Cancer Biology, SA Pathology and University of South Australia, Adelaide, 5000, Australia.
- School of Medicine, University of Adelaide, Adelaide, 5000, Australia.
- Cancer Clinical Trials Unit, Department of Medical Oncology, 6E351, Royal Adelaide Hospital, Adelaide, 5000, Australia.
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26
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Abstract
BACKGROUND Sickle cell disease is one of the commonest severe monogenic disorders in the world, due to the inheritance of two abnormal haemoglobin (beta globin) genes. Sickle cell disease can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Stroke affects around 10% of children with sickle cell anaemia (HbSS). Chronic blood transfusions may reduce the risk of vaso-occlusion and stroke by diluting the proportion of sickled cells in the circulation. This is an update of a Cochrane Review first published in 2002, and last updated in 2017. OBJECTIVES To assess risks and benefits of chronic blood transfusion regimens in people with sickle cell disease for primary and secondary stroke prevention (excluding silent cerebral infarcts). SEARCH METHODS We searched for relevant trials in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1980), and ongoing trial databases; all searches current to 8 October 2019. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register: 19 September 2019. SELECTION CRITERIA Randomised controlled trials comparing red blood cell transfusions as prophylaxis for stroke in people with sickle cell disease to alternative or standard treatment. There were no restrictions by outcomes examined, language or publication status. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility and the risk of bias and extracted data. MAIN RESULTS We included five trials (660 participants) published between 1998 and 2016. Four of these trials were terminated early. The vast majority of participants had the haemoglobin (Hb)SS form of sickle cell disease. Three trials compared regular red cell transfusions to standard care in primary prevention of stroke: two in children with no previous long-term transfusions; and one in children and adolescents on long-term transfusion. Two trials compared the drug hydroxyurea (hydroxycarbamide) and phlebotomy to long-term transfusions and iron chelation therapy: one in primary prevention (children); and one in secondary prevention (children and adolescents). The quality of the evidence was very low to moderate across different outcomes according to GRADE methodology. This was due to the trials being at a high risk of bias due to lack of blinding, indirectness and imprecise outcome estimates. Red cell transfusions versus standard care Children with no previous long-term transfusions Long-term transfusions probably reduce the incidence of clinical stroke in children with a higher risk of stroke (abnormal transcranial doppler velocities or previous history of silent cerebral infarct), risk ratio 0.12 (95% confidence interval 0.03 to 0.49) (two trials, 326 participants), moderate quality evidence. Long-term transfusions may: reduce the incidence of other sickle cell disease-related complications (acute chest syndrome, risk ratio 0.24 (95% confidence interval 0.12 to 0.48)) (two trials, 326 participants); increase quality of life (difference estimate -0.54, 95% confidence interval -0.92 to -0.17) (one trial, 166 participants); but make little or no difference to IQ scores (least square mean: 1.7, standard error 95% confidence interval -1.1 to 4.4) (one trial, 166 participants), low quality evidence. We are very uncertain whether long-term transfusions: reduce the risk of transient ischaemic attacks, Peto odds ratio 0.13 (95% confidence interval 0.01 to 2.11) (two trials, 323 participants); have any effect on all-cause mortality, no deaths reported (two trials, 326 participants); or increase the risk of alloimmunisation, risk ratio 3.16 (95% confidence interval 0.18 to 57.17) (one trial, 121 participants), very low quality evidence. Children and adolescents with previous long-term transfusions (one trial, 79 participants) We are very uncertain whether continuing long-term transfusions reduces the incidence of: stroke, risk ratio 0.22 (95% confidence interval 0.01 to 4.35); or all-cause mortality, Peto odds ratio 8.00 (95% confidence interval 0.16 to 404.12), very low quality evidence. Several review outcomes were only reported in one trial arm (sickle cell disease-related complications, alloimmunisation, transient ischaemic attacks). The trial did not report neurological impairment, or quality of life. Hydroxyurea and phlebotomy versus red cell transfusions and chelation Neither trial reported on neurological impairment, alloimmunisation, or quality of life. Primary prevention, children (one trial, 121 participants) Switching to hydroxyurea and phlebotomy may have little or no effect on liver iron concentrations, mean difference -1.80 mg Fe/g dry-weight liver (95% confidence interval -5.16 to 1.56), low quality evidence. We are very uncertain whether switching to hydroxyurea and phlebotomy has any effect on: risk of stroke (no strokes); all-cause mortality (no deaths); transient ischaemic attacks, risk ratio 1.02 (95% confidence interval 0.21 to 4.84); or other sickle cell disease-related complications (acute chest syndrome, risk ratio 2.03 (95% confidence interval 0.39 to 10.69)), very low quality evidence. Secondary prevention, children and adolescents (one trial, 133 participants) Switching to hydroxyurea and phlebotomy may: increase the risk of sickle cell disease-related serious adverse events, risk ratio 3.10 (95% confidence interval 1.42 to 6.75); but have little or no effect on median liver iron concentrations (hydroxyurea, 17.3 mg Fe/g dry-weight liver (interquartile range 10.0 to 30.6)); transfusion 17.3 mg Fe/g dry-weight liver (interquartile range 8.8 to 30.7), low quality evidence. We are very uncertain whether switching to hydroxyurea and phlebotomy: increases the risk of stroke, risk ratio 14.78 (95% confidence interval 0.86 to 253.66); or has any effect on all-cause mortality, Peto odds ratio 0.98 (95% confidence interval 0.06 to 15.92); or transient ischaemic attacks, risk ratio 0.66 (95% confidence interval 0.25 to 1.74), very low quality evidence. AUTHORS' CONCLUSIONS There is no evidence for managing adults, or children who do not have HbSS sickle cell disease. In children who are at higher risk of stroke and have not had previous long-term transfusions, there is moderate quality evidence that long-term red cell transfusions reduce the risk of stroke, and low quality evidence they also reduce the risk of other sickle cell disease-related complications. In primary and secondary prevention of stroke there is low quality evidence that switching to hydroxyurea with phlebotomy has little or no effect on the liver iron concentration. In secondary prevention of stroke there is low-quality evidence that switching to hydroxyurea with phlebotomy increases the risk of sickle cell disease-related events. All other evidence in this review is of very low quality.
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Affiliation(s)
- Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Ruchika Kohli
- Haematology, Wolfson Institute of Preventive Medicine, London, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | | | - Winfred C Wang
- Department of Hematology, St Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
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Camara C. Early termination of clinical trials in paediatrics. Br J Nurs 2020; 29:814-815. [PMID: 32697647 DOI: 10.12968/bjon.2020.29.14.814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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Piechotta V, Chai KL, Valk SJ, Doree C, Monsef I, Wood EM, Lamikanra A, Kimber C, McQuilten Z, So-Osman C, Estcourt LJ, Skoetz N. Convalescent plasma or hyperimmune immunoglobulin for people with COVID-19: a living systematic review. Cochrane Database Syst Rev 2020; 7:CD013600. [PMID: 32648959 PMCID: PMC7389743 DOI: 10.1002/14651858.cd013600.pub2] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [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] [Indexed: 12/17/2022]
Abstract
BACKGROUND Convalescent plasma and hyperimmune immunoglobulin may reduce mortality in patients with viral respiratory diseases, and are currently being investigated in trials as potential therapy for coronavirus disease 2019 (COVID-19). A thorough understanding of the current body of evidence regarding the benefits and risks is required. OBJECTIVES: To continually assess, as more evidence becomes available, whether convalescent plasma or hyperimmune immunoglobulin transfusion is effective and safe in treatment of people with COVID-19. SEARCH METHODS We searched the World Health Organization (WHO) COVID-19 Global Research Database, MEDLINE, Embase, Cochrane COVID-19 Study Register, Centers for Disease Control and Prevention COVID-19 Research Article Database and trial registries to identify completed and ongoing studies on 4 June 2020. SELECTION CRITERIA We followed standard Cochrane methodology. We included studies evaluating convalescent plasma or hyperimmune immunoglobulin for people with COVID-19, irrespective of study design, disease severity, age, gender or ethnicity. We excluded studies including populations with other coronavirus diseases (severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS)) and studies evaluating standard immunoglobulin. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane 'Risk of bias' tool for randomised controlled trials (RCTs), the Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) tool for controlled non-randomised studies of interventions (NRSIs), and the assessment criteria for observational studies, provided by Cochrane Childhood Cancer for non-controlled NRSIs. MAIN RESULTS: This is the first living update of our review. We included 20 studies (1 RCT, 3 controlled NRSIs, 16 non-controlled NRSIs) with 5443 participants, of whom 5211 received convalescent plasma, and identified a further 98 ongoing studies evaluating convalescent plasma or hyperimmune immunoglobulin, of which 50 are randomised. We did not identify any completed studies evaluating hyperimmune immunoglobulin. Overall risk of bias of included studies was high, due to study design, type of participants, and other previous or concurrent treatments. Effectiveness of convalescent plasma for people with COVID-19 We included results from four controlled studies (1 RCT (stopped early) with 103 participants, of whom 52 received convalescent plasma; and 3 controlled NRSIs with 236 participants, of whom 55 received convalescent plasma) to assess effectiveness of convalescent plasma. Control groups received standard care at time of treatment without convalescent plasma. All-cause mortality at hospital discharge (1 controlled NRSI, 21 participants) We are very uncertain whether convalescent plasma has any effect on all-cause mortality at hospital discharge (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.61 to 1.31; very low-certainty evidence). Time to death (1 RCT, 103 participants; 1 controlled NRSI, 195 participants) We are very uncertain whether convalescent plasma prolongs time to death (RCT: hazard ratio (HR) 0.74, 95% CI 0.30 to 1.82; controlled NRSI: HR 0.46, 95% CI 0.22 to 0.96; very low-certainty evidence). Improvement of clinical symptoms, assessed by need for respiratory support (1 RCT, 103 participants; 1 controlled NRSI, 195 participants) We are very uncertain whether convalescent plasma has any effect on improvement of clinical symptoms at seven days (RCT: RR 0.98, 95% CI 0.30 to 3.19), 14 days (RCT: RR 1.85, 95% CI 0.91 to 3.77; controlled NRSI: RR 1.08, 95% CI 0.91 to 1.29), and 28 days (RCT: RR 1.20, 95% CI 0.80 to 1.81; very low-certainty evidence). Quality of life No studies reported this outcome. Safety of convalescent plasma for people with COVID-19 We included results from 1 RCT, 3 controlled NRSIs and 10 non-controlled NRSIs assessing safety of convalescent plasma. Reporting of adverse events and serious adverse events was variable. The controlled studies reported on adverse events and serious adverse events only in participants receiving convalescent plasma. The duration of follow-up varied. Some, but not all, studies included death as a serious adverse event. Grade 3 or 4 adverse events (13 studies, 201 participants) The studies did not report the grade of adverse events. Thirteen studies (201 participants) reported on adverse events of possible grade 3 or 4 severity. The majority of these adverse events were allergic or respiratory events. We are very uncertain whether or not convalescent plasma therapy affects the risk of moderate to severe adverse events (very low-certainty evidence). Serious adverse events (14 studies, 5201 participants) Fourteen studies (5201 participants) reported on serious adverse events. The majority of participants were from one non-controlled NRSI (5000 participants), which reported only on serious adverse events limited to the first four hours after convalescent plasma transfusion. This study included death as a serious adverse event; they reported 15 deaths, four of which they classified as potentially, probably or definitely related to transfusion. Other serious adverse events reported in all studies were predominantly allergic or respiratory in nature, including anaphylaxis, transfusion-associated dyspnoea, and transfusion-related acute lung injury (TRALI). We are very uncertain whether or not convalescent plasma affects the number of serious adverse events. AUTHORS' CONCLUSIONS We are very uncertain whether convalescent plasma is beneficial for people admitted to hospital with COVID-19. For safety outcomes we also included non-controlled NRSIs. There was limited information regarding adverse events. Of the controlled studies, none reported on this outcome in the control group. There is only very low-certainty evidence for safety of convalescent plasma for COVID-19. While major efforts to conduct research on COVID-19 are being made, problems with recruiting the anticipated number of participants into these studies are conceivable. The early termination of the first RCT investigating convalescent plasma, and the multitude of studies registered in the past months illustrate this. It is therefore necessary to critically assess the design of these registered studies, and well-designed studies should be prioritised. Other considerations for these studies are the need to report outcomes for all study arms in the same way, and the importance of maintaining comparability in terms of co-interventions administered in all study arms. There are 98 ongoing studies evaluating convalescent plasma and hyperimmune immunoglobulin, of which 50 are RCTs. This is the first living update of the review, and we will continue to update this review periodically. These updates may show different results to those reported here.
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Affiliation(s)
- Vanessa Piechotta
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Khai Li Chai
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sarah J Valk
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/Leiden University Medical Center, Leiden, Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Abigail Lamikanra
- Clinical, Research and Development, NHS Blood and Transplant, Oxford, UK
| | - Catherine Kimber
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Zoe McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Cynthia So-Osman
- Sanquin Blood Bank, Amsterdam, Netherlands
- Erasmus Medical Centre, Rotterdam, Netherlands
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Shimura M, Nomura S, Wakabayashi M, Maruo K, Gosho M. Assessment of Hazard Ratios in Oncology Clinical Trials Terminated Early for Superiority: A Systematic Review. JAMA Netw Open 2020; 3:e208633. [PMID: 32573709 PMCID: PMC7312398 DOI: 10.1001/jamanetworkopen.2020.8633] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Group sequential designs allow potential early trial termination at the interim analysis, before study completion. Traditional maximum likelihood estimate is commonly used to quantify the treatment effect in group sequential design trials; however, in published clinical trials, a bias-adjusted estimator has rarely been reported. OBJECTIVE To emphasize the need for considering overestimation of treatment effect by applying 2 bias-adjusted estimators to previously published, early-terminated oncology clinical trials. EVIDENCE REVIEW Trials published from 2013 to 2017 were identified by searching MEDLINE and Embase on February 23, 2018. This review was restricted to oncology clinical trials using group sequential designs with a single preplanned interim analysis as well as 2-arm randomized clinical trials that were subsequently stopped for efficacy reasons. Each article was independently reviewed by 3 biostatisticians during text screening, and differences in opinion were resolved by discussion. This report presents the unadjusted hazard ratio (HR) of an experimental arm to a reference arm and 2 bias-adjusted HRs calculated by using the conditional mean-adjusted estimator (CMAE) and weighted CMAE (WCMAE). FINDINGS In total, 198 abstracts were screened for eligibility, of which, 19 eligible clinical trials were identified as applicable to the bias-adjusted estimators. Unadjusted HRs ranged from 0.203 (95% CI, 0.150-0.276) to 0.71 (95% CI, 0.60-0.84), number of events at the interim analysis from 58 to 540, and information time from 48% to 82%. In each study, the HRs adjusted by CMAE and WCMAE were higher than the unadjusted HR. Bias-adjusted estimates in large trials (243 and 414 events at the interim analysis) were similar to the unadjusted HR. However, in small trials (eg, with 58 events at the interim analysis), bias-adjusted estimates were highly disparate from the unadjusted HR. In trials with large treatment effects (eg, HRs of 0.20 and 0.22), the difference between unadjusted and bias-adjusted HRs was small even though the number of events at the interim analysis was small; larger differences were observed when the unadjusted HR was greater than 0.5. CONCLUSIONS AND RELEVANCE In this systematic review of oncology clinical trials that were stopped for efficacy at the interim analysis, relatively large differences were noted between the unadjusted and adjusted HRs when the number of events at the interim analysis was small or when the unadjusted HR was close to the boundaries. These findings suggest presenting the 2 bias-adjusted HRs along with the unadjusted HR in the data monitoring committee meeting.
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Affiliation(s)
- Masashi Shimura
- Data Science Department, Taiho Pharmaceutical Co, Ltd, Tokyo, Japan
| | - Shogo Nomura
- Center for Research and Administration and Support, Biostatistics Division, National Cancer Center, Chiba, Japan
| | - Masashi Wakabayashi
- Center for Research and Administration and Support, Biostatistics Division, National Cancer Center, Chiba, Japan
| | - Kazushi Maruo
- Department of Biostatistics, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masahiko Gosho
- Department of Biostatistics, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Pels A, Derks J, Elvan-Taspinar A, van Drongelen J, de Boer M, Duvekot H, van Laar J, van Eyck J, Al-Nasiry S, Sueters M, Post M, Onland W, van Wassenaer-Leemhuis A, Naaktgeboren C, Jakobsen JC, Gluud C, Duijnhoven RG, Lely T, Gordijn S, Ganzevoort W. Maternal Sildenafil vs Placebo in Pregnant Women With Severe Early-Onset Fetal Growth Restriction: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e205323. [PMID: 32585017 PMCID: PMC7301225 DOI: 10.1001/jamanetworkopen.2020.5323] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE Severe early onset fetal growth restriction caused by placental dysfunction leads to high rates of perinatal mortality and neonatal morbidity. The phosphodiesterase 5 inhibitor, sildenafil, inhibits cyclic guanosine monophosphate hydrolysis, thereby activating the effects of nitric oxide, and might improve uteroplacental function and subsequent perinatal outcomes. OBJECTIVE To determine whether sildenafil reduces perinatal mortality or major morbidity. DESIGN, SETTING, AND PARTICIPANTS This placebo-controlled randomized clinical trial was conducted at 10 tertiary referral centers and 1 general hospital in the Netherlands from January 20, 2015, to July 16, 2018. Participants included pregnant women between 20 and 30 weeks of gestation with severe fetal growth restriction, defined as fetal abdominal circumference below the third percentile or estimated fetal weight below the fifth percentile combined with Dopplers measurements outside reference ranges or a maternal hypertensive disorder. The trial was stopped early owing to safety concerns on July 19, 2018, whereas benefit on the primary outcome was unlikely. Data were analyzed from January 20, 2015, to January 18, 2019. The prespecified primary analysis was an intention-to-treat analysis including all randomized participants. INTERVENTIONS Participants were randomized to sildenafil, 25 mg, 3 times a day vs placebo. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of perinatal mortality or major neonatal morbidity until hospital discharge. RESULTS Out of 360 planned participants, a total of 216 pregnant women were included, with 108 women randomized to sildenafil (median gestational age at randomization, 24 weeks 5 days [interquartile range, 23 weeks 3 days to 25 weeks 5 days]; mean [SD] estimated fetal weight, 458 [160] g) and 108 women randomized to placebo (median gestational age, 25 weeks 0 days [interquartile range, 22 weeks 5 days to 26 weeks 3 days]; mean [SD] estimated fetal weight, 464 [186] g). In July 2018, the trial was halted owing to concerns that sildenafil may cause neonatal pulmonary hypertension, whereas benefit on the primary outcome was unlikely. The primary outcome, perinatal mortality or major neonatal morbidity, occurred in the offspring of 65 participants (60.2%) allocated to sildenafil vs 58 participants (54.2%) allocated to placebo (relative risk, 1.11; 95% CI, 0.88-1.40; P = .38). Pulmonary hypertension, a predefined outcome important for monitoring safety, occurred in 16 neonates (18.8%) in the sildenafil group vs 4 neonates (5.1%) in the placebo group (relative risk, 3.67; 95% CI, 1.28-10.51; P = .008). CONCLUSIONS AND RELEVANCE These findings suggest that antenatal maternal sildenafil administration for severe early onset fetal growth restriction did not reduce the risk of perinatal mortality or major neonatal morbidity. The results suggest that sildenafil may increase the risk of neonatal pulmonary hypertension. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02277132.
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Affiliation(s)
- Anouk Pels
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan Derks
- Wilhelmina Children’s Hospital, Department of Obstetrics, University Medical Center Utrecht, Gynecology and Neonatology, Utrecht, the Netherlands
| | - Ayten Elvan-Taspinar
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, the Netherlands
| | - Joris van Drongelen
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marjon de Boer
- Department of Obstetrics and Gynecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Hans Duvekot
- Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Judith van Laar
- Department of Obstetrics and Gynecology, Maxima Medical Center, Veldhoven, the Netherlands
| | - Jim van Eyck
- Department of Obstetrics and Gynecology, Isala Hospital, Zwolle, the Netherlands
| | - Salwan Al-Nasiry
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Marieke Sueters
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marinka Post
- Department of Obstetrics and Gynecology, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Wes Onland
- Emma Children’s Hospital, Amsterdam UMC, Department of Neonatology, University of Amsterdam, Amsterdam, the Netherlands
| | - Aleid van Wassenaer-Leemhuis
- Emma Children’s Hospital, Amsterdam UMC, Department of Neonatology, University of Amsterdam, Amsterdam, the Netherlands
| | - Christiana Naaktgeboren
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Janus C. Jakobsen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ruben G. Duijnhoven
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Titia Lely
- Wilhelmina Children’s Hospital, Department of Obstetrics, University Medical Center Utrecht, Gynecology and Neonatology, Utrecht, the Netherlands
| | - Sanne Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, the Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Marlow LL, Lee AH, Hedley E, Grocott MP, Steiner MC, Young JD, Rahman NM, Snowden CP, Pattinson KT. Findings of a feasibility study of pre-operative pulmonary rehabilitation to reduce post-operative pulmonary complications in people with chronic obstructive pulmonary disease scheduled for major abdominal surgery. F1000Res 2020; 9:172. [PMID: 33299545 PMCID: PMC7702168 DOI: 10.12688/f1000research.22040.1] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2020] [Indexed: 11/20/2022] Open
Abstract
Background: Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of complications and death following surgery. Pulmonary complications are particularly prominent. Pulmonary rehabilitation is a course of physical exercise and education that helps people with COPD manage their condition. Although proven to improve health outcomes in patients with stable COPD, it has never been formally tested as a pre-surgical intervention in patients scheduled for non-cardiothoracic surgery. If a beneficial effect were to be demonstrated, pulmonary rehabilitation for pre-surgical patients with COPD might be rapidly implemented across the National Health Service, as pulmonary rehabilitation courses are already well established across much of the United Kingdom (UK). Methods: We performed a feasibility study to test study procedures and barriers to identification and recruitment to a randomised controlled trial testing whether pulmonary rehabilitation, delivered before major abdominal surgery in a population of people with COPD, would reduce the incidence of post-operative pulmonary complications. This study was run in two UK centres (Oxford and Newcastle upon Tyne). Results: We determined that a full randomised controlled trial would not be feasible, due to failure to identify and recruit participants. We identified an unmet need to identify more effectively patients with COPD earlier in the surgical pathway. Service evaluations suggested that barriers to identification and recruitment would likely be the same across other UK hospitals. Conclusions: Although pulmonary rehabilitation is a potentially beneficial intervention to prevent post-operative pulmonary complications, a randomised controlled trial is unlikely to recruit sufficient participants to answer our study question conclusively at the present time, when spirometry is not automatically conducted in all patients planned for surgery. As pulmonary rehabilitation is a recommended treatment for all people with COPD, alternative study methods combined with earlier identification of candidate patients in the surgical pathway should be considered. Trial registration: ISRCTN29696295, 31/08/2017.
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Affiliation(s)
- Lucy L. Marlow
- Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Warwick Medical School, The University of Warwick, Coventry, UK
| | - Angeline H.Y. Lee
- Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Emma Hedley
- Division of Experimental Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Michael P. Grocott
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Anaesthesia Perioperative and Critical Care Research Group, Southampton National Institute of Health Research (NIHR) Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Michael C. Steiner
- Leicester Respiratory Biomedical Research Centre, Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - J. Duncan Young
- Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Najib M. Rahman
- Division of Experimental Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Christopher P. Snowden
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle University, Newcastle upon Tyne, UK
| | - Kyle T.S. Pattinson
- Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Vincenzi B, Trower M, Duggal A, Guglielmini P, Harris P, Jackson D, Lacouture ME, Ratti E, Tonini G, Wood A, Ständer S. Neurokinin-1 antagonist orvepitant for EGFRI-induced pruritus in patients with cancer: a randomised, placebo-controlled phase II trial. BMJ Open 2020; 10:e030114. [PMID: 32034016 PMCID: PMC7045265 DOI: 10.1136/bmjopen-2019-030114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of orvepitant (10 or 30 mg given once daily, orally for 4 weeks), a neurokinin-1 receptor antagonist, compared with placebo in reducing the intensity of epidermal growth factor receptor inhibitor (EGFRI)-induced intense pruritus. DESIGN Randomised, double-blind, placebo-controlled clinical trial. SETTING 15 hospitals in Italy and five hospitals in the UK. PARTICIPANTS 44 patients aged ≥18 years receiving an EGFRI for a histologically confirmed malignant solid tumour and experiencing moderate or intense pruritus after EGFRI treatment. INTERVENTION 30 or 10 mg orvepitant or placebo tablets once daily for 4 weeks (randomised 1:1:1). PRIMARY AND SECONDARY OUTCOME MEASURES The primary endpoint was change from baseline in mean patient-recorded numerical rating scale (NRS) score (over the last three recordings) at week 4. Secondary outcome measures were NRS score, verbal rating scale score, Skindex-16 and Leeds Sleep Evaluation Questionnaire at each study visit (baseline, weeks 1, 4, 8); rescue medication use; EGFRI dose reduction; and study withdrawal because of intense uncontrolled pruritus. RESULTS The trial was terminated early because of recruitment challenges; only 44 of the planned 90 patients were randomised. All patients were analysed for efficacy and safety. Mean NRS score change from baseline to week 4 was -2.78 (SD: 2.64) points in the 30 mg group, -3.04 (SD: 3.06) points in the 10 mg group and -3.21 (SD: 1.77) points in the placebo group; the difference between orvepitant and placebo was not statistically significant. No safety signal was detected. Adverse events related to orvepitant (asthenia, dizziness, dry mouth, hyperhidrosis) were all of mild or moderate severity. CONCLUSIONS Orvepitant was safe and well tolerated. No difference in NRS score between the orvepitant and placebo groups was observed at the week 4 primary endpoint. A number of explanations for this outcome are possible. TRIAL REGISTRATION NUMBER EudraCT2013-002763-25.
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Affiliation(s)
- Bruno Vincenzi
- Medical Oncology, Universita Campus Bio-Medico di Roma Facolta di Medicina e Chirurgia, Roma, Italy
| | | | - Ajay Duggal
- Adnovate Clinical Development Strategies, East Sussex, UK
| | | | | | | | - Mario E Lacouture
- Department of Dermatology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Giuseppe Tonini
- Medical Oncology, Universita Campus Bio-Medico di Roma Facolta di Medicina e Chirurgia, Roma, Italy
| | | | - Sonja Ständer
- Center for Chronic Pruritus, University Hospital Münster, Münster, Germany
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Kelly KM, Sanga P, Zaki N, Wang S, Haeussler J, Louie J, Thipphawong J. Safety and efficacy of fulranumab in osteoarthritis of the hip and knee: results from four early terminated phase III randomized studies. Curr Med Res Opin 2019; 35:2117-2127. [PMID: 31387410 DOI: 10.1080/03007995.2019.1653068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objective: To evaluate the safety and efficacy of fulranumab as adjunct or monotherapy in patients with knee or hip pain related to moderate-to-severe osteoarthritis.Methods: Osteoarthritic patients (aged ≥18 years) from four phase 3 randomized, double-blind (DB), placebo-controlled studies were randomized to receive placebo, fulranumab 1 mg every 4 weeks (Q4wk), or 3 mg Q4wk in 16-week DB phase, followed by a 52-week post-treatment follow-up phase. Safety assessments included treatment-emergent adverse events (TEAEs), and neurological, sympathetic, and joint-related events of interest. Efficacy assessments included pain and physical function sub-scales of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores.Results: Of 245 patients from the ITT set (median age = 64 years; 62% women), 84 (34%) completed the DB phase; the majority of discontinuations (57%) were due to early study termination. In the DB phase, the incidence of TEAEs in fulranumab 3 mg (57.8%) and 1 mg (56.8%) was similar to placebo (56.8%). Two events adjudicated as joint-related events of interest include rapidly progressive osteoarthritis and fracture of unknown etiology. There were no new neurological TEAEs. Fulranumab showed evidence of efficacy in improving pain and physical function based on WOMAC sub-scale scores. Due to premature study termination, the number of patients enrolled were too small to make any definitive efficacy claims.Conclusions: Treatment with fulranumab was generally tolerated with no new safety signals. Within the limited sample analyzed, fulranumab showed evidence of improvement of pain and function in patients with moderate-to-severe osteoarthritis who had failed prior therapy and were candidates for joint replacement surgery.Clinical trial registration numbers: NCT02336685; NCT02336698; NCT02289716; NCT02301234KEY POINTSFulranumab as adjuvant or monotherapy was well tolerated with no new safety signalsFulranumab demonstrated evidence suggestive of efficacy in osteoarthritic pain of hip and kneeFulranumab demonstrated evidence suggestive of improvement of pain and physical function in osteoarthritis.
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MESH Headings
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Arthralgia/diagnosis
- Arthralgia/drug therapy
- Arthralgia/etiology
- Double-Blind Method
- Early Termination of Clinical Trials
- Female
- Humans
- Male
- Middle Aged
- Osteoarthritis, Hip/diagnosis
- Osteoarthritis, Hip/drug therapy
- Osteoarthritis, Hip/physiopathology
- Osteoarthritis, Knee/diagnosis
- Osteoarthritis, Knee/drug therapy
- Osteoarthritis, Knee/physiopathology
- Pain Measurement/methods
- Physical Functional Performance
- Severity of Illness Index
- Treatment Outcome
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Affiliation(s)
| | - Panna Sanga
- Janssen Research and Development, LLC, Titusville, NJ, USA
| | - Naim Zaki
- Janssen Research and Development, LLC, Titusville, NJ, USA
| | - Steven Wang
- Janssen Research and Development, LLC, Titusville, NJ, USA
| | | | - John Louie
- Janssen Research and Development, LLC, Fremont, CA, USA
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Katheria A, Reister F, Essers J, Mendler M, Hummler H, Subramaniam A, Carlo W, Tita A, Truong G, Davis-Nelson S, Schmölzer G, Chari R, Kaempf J, Tomlinson M, Yanowitz T, Beck S, Simhan H, Dempsey E, O’Donoghue K, Bhat S, Hoffman M, Faksh A, Arnell K, Rich W, Finer N, Vaucher Y, Khanna P, Meyers M, Varner M, Allman P, Szychowski J, Cutter G. Association of Umbilical Cord Milking vs Delayed Umbilical Cord Clamping With Death or Severe Intraventricular Hemorrhage Among Preterm Infants. JAMA 2019; 322:1877-1886. [PMID: 31742630 PMCID: PMC6865839 DOI: 10.1001/jama.2019.16004] [Citation(s) in RCA: 149] [Impact Index Per Article: 29.8] [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: 12/19/2022]
Abstract
IMPORTANCE Umbilical cord milking as an alternative to delayed umbilical cord clamping may provide equivalent benefits to preterm infants, but without delaying resuscitation. OBJECTIVE To determine whether the rates of death or severe intraventricular hemorrhage differ among preterm infants receiving placental transfusion with umbilical cord milking vs delayed umbilical cord clamping. DESIGN, SETTING, AND PARTICIPANTS Noninferiority randomized clinical trial of preterm infants (born at 23-31 weeks' gestation) from 9 university and private medical centers in 4 countries were recruited and enrolled between June 2017 and September 2018. Planned enrollment was 750 per group. However, a safety signal comprising an imbalance in the number of severe intraventricular hemorrhage events by study group was observed at the first interim analysis; enrollment was stopped based on recommendations from the data and safety monitoring board. The planned noninferiority analysis could not be conducted and a post hoc comparison was performed instead. Final date of follow-up was December 2018. INTERVENTIONS Participants were randomized to umbilical cord milking (n = 236) or delayed umbilical cord clamping (n = 238). MAIN OUTCOMES AND MEASURES The primary outcome was a composite of death or severe intraventricular hemorrhage to determine noninferiority of umbilical cord milking with a 1% noninferiority margin. RESULTS Among 540 infants randomized, 474 (88%) were enrolled and completed the trial (mean gestational age of 28 weeks; 46% female). Twelve percent (29/236) of the umbilical cord milking group died or developed severe intraventricular hemorrhage compared with 8% (20/238) of the delayed umbilical cord clamping group (risk difference, 4% [95% CI, -2% to 9%]; P = .16). Although there was no statistically significant difference in death, severe intraventricular hemorrhage was statistically significantly higher in the umbilical cord milking group than in the delayed umbilical cord clamping group (8% [20/236] vs 3% [8/238], respectively; risk difference, 5% [95% CI, 1% to 9%]; P = .02). The test for interaction between gestational age strata and treatment group was significant for severe intraventricular hemorrhage only (P = .003); among infants born at 23 to 27 weeks' gestation, severe intraventricular hemorrhage was statistically significantly higher with umbilical cord milking than with delayed umbilical cord clamping (22% [20/93] vs 6% [5/89], respectively; risk difference, 16% [95% CI, 6% to 26%]; P = .002). CONCLUSIONS AND RELEVANCE In this post hoc analysis of a prematurely terminated randomized clinical trial of umbilical cord milking vs delayed umbilical cord clamping among preterm infants born at less than 32 weeks' gestation, there was no statistically significant difference in the rate of a composite outcome of death or severe intraventricular hemorrhage, but there was a statistically significantly higher rate of severe intraventricular hemorrhage in the umbilical cord milking group. The early study termination and resulting post hoc nature of the analyses preclude definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03019367.
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Affiliation(s)
- Anup Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Frank Reister
- Department of Obstetrics, University of Ulm, Ulm, Germany
| | - Jochen Essers
- Department of Pediatrics, University of Ulm, Ulm, Germany
| | - Marc Mendler
- Department of Pediatrics, University of Ulm, Ulm, Germany
| | - Helmut Hummler
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
| | | | - Waldemar Carlo
- Department of Pediatrics, University of Alabama at Birmingham
| | - Alan Tita
- Department of Obstetrics, University of Alabama at Birmingham
| | - Giang Truong
- Department of Pediatrics, Loma Linda University, Loma Linda, California
| | | | - Georg Schmölzer
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Radha Chari
- Department of Obstetrics, University of Alberta, Edmonton, Canada
| | - Joseph Kaempf
- Women and Children’s Services, Providence St Vincent Medical Center, Portland, Oregon
| | - Mark Tomlinson
- Women and Children’s Services, Providence St Vincent Medical Center, Portland, Oregon
| | - Toby Yanowitz
- Department of Pediatrics, Magee Women’s Hospital of UPMC, Pittsburgh, Pennsylvania
| | - Stacy Beck
- Department of Obstetrics, Magee Women’s Hospital of UPMC, Pittsburgh, Pennsylvania
| | - Hyagriv Simhan
- Department of Obstetrics, Magee Women’s Hospital of UPMC, Pittsburgh, Pennsylvania
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
- INFANT Research Centre, University College Cork, Cork, Ireland
| | | | - Shazia Bhat
- Department of Pediatrics, Christiana Care Health System, Newark, Delaware
| | - Matthew Hoffman
- Department of Obstetrics, Christiana Care Health System, Newark, Delaware
| | - Arij Faksh
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Kathy Arnell
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Wade Rich
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Neil Finer
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Yvonne Vaucher
- Department of Radiology, Children’s Hospital Colorado, University of Colorado School of Medicine, Denver
| | - Paritosh Khanna
- Department of Radiology, Rady Children’s Hospital, San Diego, California
| | - Mariana Meyers
- Department of Radiology, Children’s Hospital Colorado, University of Colorado School of Medicine, Denver
| | - Michael Varner
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City
| | - Phillip Allman
- Department of Biostatistics, University of Alabama at Birmingham
| | - Jeff Szychowski
- Department of Biostatistics, University of Alabama at Birmingham
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham
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Fisher BT, Zaoutis T, Dvorak CC, Nieder M, Zerr D, Wingard JR, Callahan C, Villaluna D, Chen L, Dang H, Esbenshade AJ, Alexander S, Wiley JM, Sung L. Effect of Caspofungin vs Fluconazole Prophylaxis on Invasive Fungal Disease Among Children and Young Adults With Acute Myeloid Leukemia: A Randomized Clinical Trial. JAMA 2019; 322:1673-1681. [PMID: 31688884 PMCID: PMC6865545 DOI: 10.1001/jama.2019.15702] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [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: 12/29/2022]
Abstract
IMPORTANCE Children, adolescents, and young adults with acute myeloid leukemia are at high risk of life-threatening invasive fungal disease with both yeasts and molds. OBJECTIVE To compare the efficacy of caspofungin vs fluconazole prophylaxis against proven or probable invasive fungal disease and invasive aspergillosis during neutropenia following acute myeloid leukemia chemotherapy. DESIGN, SETTING, AND PARTICIPANTS This multicenter, randomized, open-label, clinical trial enrolled patients aged 3 months to 30 years with newly diagnosed de novo, relapsed, or secondary acute myeloid leukemia being treated at 115 US and Canadian institutions (April 2011-November 2016; last follow-up June 30, 2018). INTERVENTIONS Participants were randomly assigned during the first chemotherapy cycle to prophylaxis with caspofungin (n = 257) or fluconazole (n = 260). Prophylaxis was administered during the neutropenic period following each chemotherapy cycle. MAIN OUTCOMES AND MEASURES The primary outcome was proven or probable invasive fungal disease as adjudicated by blinded central review. Secondary outcomes were invasive aspergillosis, empirical antifungal therapy, and overall survival. RESULTS The second interim efficacy analysis and an unplanned futility analysis based on 394 patients appeared to have suggested futility, so the study was closed to accrual. Among the 517 participants who were randomized (median age, 9 years [range, 0-26 years]; 44% female), 508 (98%) completed the trial. The 23 proven or probable invasive fungal disease events (6 caspofungin vs 17 fluconazole) included 14 molds, 7 yeasts, and 2 fungi not further categorized. The 5-month cumulative incidence of proven or probable invasive fungal disease was 3.1% (95% CI, 1.3%-7.0%) in the caspofungin group vs 7.2% (95% CI, 4.4%-11.8%) in the fluconazole group (overall P = .03 by log-rank test) and for cumulative incidence of proven or probable invasive aspergillosis was 0.5% (95% CI, 0.1%-3.5%) with caspofungin vs 3.1% (95% CI, 1.4%-6.9%) with fluconazole (overall P = .046 by log-rank test). No statistically significant differences in empirical antifungal therapy (71.9% caspofungin vs 69.5% fluconazole, overall P = .78 by log-rank test) or 2-year overall survival (68.8% caspofungin vs 70.8% fluconazole, overall P = .66 by log-rank test) were observed. The most common toxicities were hypokalemia (22 caspofungin vs 13 fluconazole), respiratory failure (6 caspofungin vs 9 fluconazole), and elevated alanine transaminase (4 caspofungin vs 8 fluconazole). CONCLUSIONS AND RELEVANCE Among children, adolescents, and young adults with acute myeloid leukemia, prophylaxis with caspofungin compared with fluconazole resulted in significantly lower incidence of invasive fungal disease. The findings suggest that caspofungin may be considered for prophylaxis against invasive fungal disease, although study interpretation is limited by early termination due to an unplanned interim analysis that appeared to have suggested futility. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01307579.
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Affiliation(s)
- Brian T. Fisher
- Division of Pediatrics Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Theoklis Zaoutis
- Division of Pediatrics Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher C. Dvorak
- Division of Pediatric Allergy, Immunology and Bone Marrow Transplant, University of California San Francisco
| | - Michael Nieder
- Division of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida
| | - Danielle Zerr
- Division of Pediatric Infectious Diseases, Seattle Children’s Hospital, Seattle, Washington
| | | | - Colleen Callahan
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Lu Chen
- Division of Biostatistics, City of Hope, Duarte, California
| | - Ha Dang
- Department of Preventive Medicine, University of Southern California, Los Angeles
| | - Adam J. Esbenshade
- Division of Pediatric Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah Alexander
- Division of Haematology Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joseph M. Wiley
- Division of Pediatric Hematology and Oncology, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Lillian Sung
- Division of Haematology Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Savonitto S, De Servi S, Maggioni AP, Cesana BM. [Early interruption of a clinical trial: rationale and interpretation]. G Ital Cardiol (Rome) 2019; 20:619-626. [PMID: 31697268 DOI: 10.1714/3254.32222] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Early interruption of a clinical trial is not a rare case, and it may be due to several reasons that are summarized in the present article. It is important for the clinician, the primary user of the information derived from clinical trials, to be able to assess whether the eventual interruption of the trial had been planned in the study protocol, whether the study organization was such as to correctly monitor the accrual of efficacy and safety data, who took the decision to interrupt the trial, whether the study patients have been exposed to excessive risks and, finally, whether the conclusions of the study report are valid. In most cases, these issues are carefully assessed during the review process of the study publication (and, of course, by the regulatory authorities) but, particularly for the studies interrupted for "overwhelming evidence of benefit", wisdom and prudence are mandatory, and the results must be considered within the context of all available evidence.
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Affiliation(s)
| | - Stefano De Servi
- Dipartimento Cardiovascolare, IRCCS Multimedica, Sesto San Giovanni (MI)
| | | | - Bruno M Cesana
- Dipartimento di Scienze Cliniche e di Comunità, Unità di Statistica Medica, Biometria e Bioinformatica "Giulio A. Maccacaro", Facoltà di Medicina e Chirurgia, Università degli Studi, Milano
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Celentano S, Capolongo G, Pollastro RM. [Bardoxolone: a new potential therapeutic agent in the treatment of autosomal dominant polycystic kidney disease?]. G Ital Nefrol 2019; 36:36-5-2019-5. [PMID: 31580543] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic cause of chronic renal failure. The natural history of ADPKD is characterized by development of multiple bilateral renal cysts that progressively destroy the architecture of the parenchyma and lead to an enlargement in the total kidney volume (TKV) and to the decline of the renal function. Cyst growth activates the immune system response causing interstitial inflammation and fibrosis that contribute to disease progression. In recent years, the therapeutic toolkit available to the nephrologist in the treatment of ADPKD has been enriched with new tools, and in this context bardoxolone is classified as a potential therapeutic agent. It is a semisynthetic derivative of triterpenoids, a family of compounds widely used in traditional Asian medicine for their multiple effects. Bardoxolone exerts antioxidant activity by promoting the activation of Nrf2 (Nuclear factor erythroid2-derivative - 2) and the downregulation of the proinflammatory NF-kB (Nuclear factor kappa-light-chain-enhancer of activated B cells) signaling. Several pieces of evidence support the use of bardoxolone in the treatment of chronic kidney disease (CKD) documenting an effect on the increase of glomerular filtration rate (GFR). However, its use is limited to patients at risk of heart failure. The FALCON study will clarify the efficacy and safety of bardoxolone in the treatment of ADPKD.
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Affiliation(s)
- Sonia Celentano
- Università degli studi della Campania "Luigi Vanvitelli", U.O.C. di Nefrologia e Dialisi, Napoli, Italia
| | - Giovanna Capolongo
- Università degli studi della Campania "Luigi Vanvitelli", U.O.C. di Nefrologia e Dialisi, Napoli, Italia
| | - Rosa Maria Pollastro
- Università degli studi della Campania "Luigi Vanvitelli", U.O.C. di Nefrologia e Dialisi, Napoli, Italia
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Russell L, Pascoe MC, Seymour JF, Aranda S, Butow P, Gough K, Schofield P. The trials and tribulations of conducting an m-health pilot randomized controlled trial to improve oral cancer therapy adherence: recommendations for future multisite, non-drug clinical trials. BMC Res Notes 2019; 12:226. [PMID: 30987685 PMCID: PMC6466650 DOI: 10.1186/s13104-019-4264-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/06/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Integrating mobile phone-based health (m-health) interventions into healthcare systems is one solution to improve access to services for the growing number of patients with chronic illness. Practical challenges such as poor recruitment and inadequate resource allocation can hamper the assessment of such interventions with clinical trial methodology. This paper highlights the challenges encountered during a pilot randomized controlled trial of an m-health medication adherence intervention and offers recommendations for future multi-site, non-drug clinical trials. RESULTS Eighteen patients were recruited to the study; eight were randomly allocated to the intervention arm. Intervention participants responded to their daily medication-reminder text messages, indicating that medication had been taken or not, and nurses were able to organize their calls around their workload. The trial closed prematurely primarily due to inadequate numbers of eligible patients; however, other potentially resolvable feasibility issues were identified. These included lack of infrastructure at study sites, poor screening data acquisition and management processes, and inexperience in conducting supportive care trials at participating sites. M-health intervention trials are designed to inform implementation of best supportive care practice. Adequate skills and infrastructure are research prerequisites that require careful consideration and sufficient investment for the successful execution of multi-site supportive care trials. Trial registration Australian and New Zealand Clinical Trials Register: ACTRN12612000635864.
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Affiliation(s)
- Lahiru Russell
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Geelong, VIC Australia
| | - Michaela C. Pascoe
- Institute of Sport, Exercise and Active Living, Victoria University, Footscray, VIC Australia
| | - John F. Seymour
- Peter MacCallum Cancer Centre, Parkville, Melbourne, VIC Australia
- Royal Melbourne Hospital, Parkville, Melbourne, VIC Australia
- University of Melbourne, Melbourne, VIC Australia
| | - Sanchia Aranda
- University of Melbourne, Melbourne, VIC Australia
- Cancer Council Australia, Sydney, Australia
| | - Phyllis Butow
- Department of Psychology, University of Sydney, Sydney, Australia
| | - Karla Gough
- Peter MacCallum Cancer Centre, Parkville, Melbourne, VIC Australia
- University of Melbourne, Melbourne, VIC Australia
| | - Penelope Schofield
- Peter MacCallum Cancer Centre, Parkville, Melbourne, VIC Australia
- University of Melbourne, Melbourne, VIC Australia
- Swinburne University of Technology, Hawthorn, VIC Australia
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Abstract
BACKGROUND Sickle cell disease is an inherited disorder of hemoglobin, resulting in abnormal red blood cells. These are rigid and may block blood vessels leading to acute painful crises and other complications. Recent research has focused on therapies to rehydrate the sickled cells by reducing the loss of water and ions from them. Little is known about the effectiveness and safety of such drugs. This is an updated version of a previously published review. OBJECTIVES To assess the relative risks and benefits of drugs to rehydrate sickled red blood cells. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register. We also searched online trials registries for any ongoing trials (01 July 2018).Last search of the Group's Haemoglobinopathies Trials Register: 08 October 2018. SELECTION CRITERIA Randomized or quasi-randomized controlled trials of drugs to rehydrate sickled red blood cells compared to placebo or an alternative treatment. DATA COLLECTION AND ANALYSIS Both authors independently selected studies for inclusion, assessed study quality and extracted data. MAIN RESULTS Of the 51 studies identified, three met the inclusion criteria, including 524 people with sickle cell disease aged between 12 and 65 years of age. One study tested the effectiveness of zinc sulphate as compared to placebo and the remaining two assessed senicapoc versus placebo. No deaths were seen in any of the studies (low-quality evidence). The zinc sulphate study showed a significant reduction in painful crises (in a total of 145 participants) over one and a half years, mean difference -2.83 (95% confidence interval -3.51 to -2.15) (moderate-quality evidence). However, analysis was restricted due to limited statistical data. Changes to red blood cell parameters and blood counts were inconsistent (very low-quality evidence). No serious adverse events were noted in the study. The Phase II dose-finding study of senicapoc (a Gardos channel blocker) compared to placebo showed that the high dose senicapoc showed significant improvement in change in hemoglobin level, the number and proportion of dense red blood cells, red blood cell count and indices and hematocrit value (very low-quality evidence). The results with low-dose senicapoc were similar to the high-dose senicapoc group but of lesser magnitude. There was no difference in the frequency of painful crises between the three groups (low-quality evidence). A subsequent Phase III study of senicapoc was terminated early since there was no difference observed between the treatment and control groups in the primary end point of painful crises. AUTHORS' CONCLUSIONS While the results of zinc for reducing sickle-related crises are encouraging, larger and longer-term multicenter studies are needed to evaluate the effectiveness of this therapy for people with sickle cell disease.While the Phase II and the prematurely terminated phase III studies of senicapoc showed that the drug improved red blood cell survival (depending on dose), this did not lead to fewer painful crises.Given this is no longer an active area of research, this review will no longer be regularly updated.
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Affiliation(s)
- Srikanth Nagalla
- Division of Hematology and Oncology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Texas, USA, 75390
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Groom KM, Ganzevoort W, Alfirevic Z, Lim K, Papageorghiou AT. Clinicians should stop prescribing sildenafil for fetal growth restriction (FGR): comment from the STRIDER Consortium. Ultrasound Obstet Gynecol 2018; 52:295-296. [PMID: 30079989 DOI: 10.1002/uog.19186] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- K M Groom
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Academisch Medisch Centrum, Amsterdam, The Netherlands
| | - Z Alfirevic
- Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - K Lim
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - A T Papageorghiou
- Fetal Medicine Unit, St George's, University of London, London, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
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Abstract
BACKGROUND Endometrial cancer is the sixth most common cancer in women worldwide and most commonly occurs after the menopause (75%) (globocan.iarc.fr). About 319,000 new cases were diagnosed worldwide in 2012. Endometrial cancer is commonly considered as a potentially 'curable cancer,' as approximately 75% of cases are diagnosed before disease has spread outside the uterus (FIGO (International Federation of Gynecology and Obstetrics) stage I). The overall five-year survival for all stages is about 86%, and, if the cancer is confined to the uterus, the five-year survival rate may increase to 97%. The majority of women diagnosed with endometrial cancer have early-stage disease, leading to a good prognosis after hysterectomy and removal of the ovaries (oophorectomy), with or without radiotherapy. However, women may have early physiological and psychological postmenopausal changes, either pre-existing or as a result of oophorectomy, depending on age and menopausal status at the time of diagnosis. Lack of oestrogen can cause hot flushes, night sweats, genital tract atrophy and longer-term adverse effects, such as osteoporosis and cardiovascular disease. These changes may be temporarily managed by using oestrogens, in the form of hormone replacement therapy (HRT). However, there is a theoretical risk of promoting residual tumour cell growth and increasing cancer recurrence. Therefore, this is a potential survival disadvantage in a woman who has a potentially curable cancer. In premenopausal women with endometrial cancer, treatment induces early menopause and this may adversely affect overall survival. Additionally, most women with early-stage disease will be cured of their cancer, making longer-term quality of life (QoL) issues more pertinent. Following bilateral oophorectomy, premenopausal women may develop significant and debilitating menopausal symptoms, so there is a need for information about the risk and benefits of taking HRT, enabling women to make an informed decision, weighing the advantages and disadvantages of using HRT for their individual circumstances. OBJECTIVES To assess the risks and benefits of HRT (oestrogen alone or oestrogen with progestogen) for women previously treated for endometrial cancer. SEARCH METHODS We searched the Cochrane Register of Controlled Trials (CENTRAL 2017, Issue 5), MEDLINE (1946 to April, week 4, 2017) and Embase (1980 to 2017, week 18). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles. SELECTION CRITERIA We included randomised controlled trials (RCTs), in all languages, that examined the efficacy of symptom relief and the safety of using HRT in women treated for endometrial cancer, where safety in this situation was considered as not increasing the risk of recurrence of endometrial cancer above that of women not taking HRT. DATA COLLECTION AND ANALYSIS Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified 2190 unique records, evaluated the full text of seven studies and included one study with 1236 participants. This study reported tumour recurrence in 2.3% of women in the oestrogen arm versus 1.9% of women receiving placebo (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.54 to 2.50; very low-certainty evidence). The study reported one woman in the HRT arm (0.16%) and three women in the placebo arm (0.49%) who developed breast cancer (new malignancy) during follow-up (RR 0.80, 95% CI 0.32 to 2.01; 1236 participants, 1 study; very low-certainty evidence). The study did not report on symptom relief, overall survival or progression-free survival for HRT versus placebo. However, they did report the percentage of women alive with no evidence of disease (94.3% in the HRT group and 95.6% in the placebo group) and the percentage of women alive irrespective of disease progression (95.8% in the HRT group and 96.9% in the placebo group) at the end of the 36 months' follow-up. The study did not report time to recurrence and it was underpowered due to closing early. The authors closed it as a result of the publication of the Women's Health Initiative (WHI) study, which, at that time, suggested that risks of exogenous hormone therapy outweighed benefits and had an impact on study recruitment. No assessment of efficacy was reported. AUTHORS' CONCLUSIONS Currently, there is insufficient high-quality evidence to inform women considering HRT after treatment for endometrial cancer. The available evidence (both the single RCT and non-randomised evidence) does not suggest significant harm, if HRT is used after surgical treatment for early-stage endometrial cancer. There is no information available regarding use of HRT in higher-stage endometrial cancer (FIGO stage II and above). The use of HRT after endometrial cancer treatment should be individualised, taking account of the woman's symptoms and preferences, and the uncertainty of evidence for and against HRT use.
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Affiliation(s)
| | - Stuart Rundle
- Northern Gynaecological Oncology CentreGynaecological OncologyQueen Elizabeth HospitalSheriff HillGatesheadUKNE9 6SX
| | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
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Abstract
BACKGROUND Cystic fibrosis is an autosomal recessive multisystem disorder with an approximate prevalence of 1 in 3500 live births. Allergic bronchopulmonary aspergillosis is a lung disease caused by aspergillus-induced hypersensitivity with a prevalence of 2% to 15% in people with cystic fibrosis. The mainstay of treatment includes corticosteroids and itraconazole. The treatment with corticosteroids for prolonged periods of time, or repeatedly for exacerbations of allergic bronchopulmonary aspergillosis, may lead to many adverse effects. The monoclonal anti-IgE antibody, omalizumab, has improved asthma control in severely allergic asthmatics. The drug is given as a subcutaneous injection every two to four weeks. Since allergic bronchopulmonary aspergillosis is also a condition resulting from hypersensitivity to specific allergens, as in asthma, it may be a candidate for therapy using anti-IgE antibodies. Therefore, anti-IgE therapy, using agents like omalizumab, may be a potential therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. This is an updated version of the review. OBJECTIVES To evaluate the efficacy and adverse effects of anti-IgE therapy for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews. Last search: 29 September 2017.We searched two ongoing trial registries (Clinicaltrials.gov and the WHO trials platform). Date of latest search: 24 January 2018. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing anti-IgE therapy to placebo or other therapies for allergic bronchopulmonary aspergillosis in people with cystic fibrosis. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias in the included study. They planned to perform data analysis using Review Manager. MAIN RESULTS Only one study enrolling 14 participants was eligible for inclusion in the review. The double-blind study compared a daily dose of 600 mg omalizumab or placebo along with twice daily itraconazole and oral corticosteroids, with a maximum daily dose of 400 mg. Treatment lasted six months but the study was terminated prematurely and complete data were not available. We contacted the study investigator and were told that the study was terminated due to the inability to recruit participants into the study despite all reasonable attempts. One or more serious side effects were encountered in six out of nine (66.67%) and one out of five (20%) participants in omalizumab group and placebo group respectively. AUTHORS' CONCLUSIONS There is lack of evidence for the efficacy and safety of anti-IgE (omalizumab) therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis. There is a need for large prospective randomized controlled studies of anti-IgE therapy in people with cystic fibrosis and allergic bronchopulmonary aspergillosis with both clinical and laboratory outcome measures such as steroid requirement, allergic bronchopulmonary aspergillosis exacerbations and lung function.
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Affiliation(s)
- Kana R Jat
- All India Institute of Medical Sciences (AIIMS)Department of PediatricsAnsari NagarNew DelhiDelhiIndia110029
| | - Dinesh K Walia
- Govt. Medical College and Hospital (GMCH)Department of Community MedicineSector‐32ChandigarhChandigarh UTIndia160030
| | - Anju Khairwa
- Postgraduate Institute of Medical Education and Research (PGIMER)Department of PathologySector‐12ChandigarhChandigarh UTIndia160012
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Dungan K, Craven TE, Soe K, Wright JT, Basile J, Haley WE, Kressin NR, Rani U, Tamariz L, Whittle J, Wiggers A, Osei K. Influence of metabolic syndrome and race on the relationship between intensive blood pressure control and cardiovascular outcomes in the SPRINT cohort. Diabetes Obes Metab 2018; 20:629-637. [PMID: 29024310 PMCID: PMC5812782 DOI: 10.1111/dom.13127] [Citation(s) in RCA: 4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 09/22/2017] [Accepted: 10/09/2017] [Indexed: 01/06/2023]
Abstract
AIMS To determine whether baseline metabolic syndrome (MetS) modifies the effect of intensive blood pressure control on cardiovascular (CV) outcomes, and whether the effects varied by race/ethnicity. METHODS We performed post hoc analyses among non-Hispanic black, non-hispanic white and Hispanic participants, with and without MetS, in the Systolic Blood Pressure Intervention Trial (SPRINT), who were randomized to a systolic blood pressure (SBP) target of <120 mm Hg (intensive group, N = 4544) or an SBP target of <140 mm Hg (standard group, N = 4553). The median follow-up was 3.26 years. The primary outcome was the composite of the first occurrence of myocardial infarction, stroke, heart failure, non-myocardial infarction acute coronary syndrome or CV death. RESULTS Overall, 3521/9097 participants (38.7%) met the criteria for MetS at baseline. Baseline characteristics were similar in the two SBP target groups within each MetS subgroup, except body mass index was slightly higher in the standard arm of the MetS subgroup (33.3 ± 5.6 vs 33.0 ± 5.3 kg/m2 ; P < .01), but were similar across treatment arms in the non-MetS subgroup. The hazard ratio for the primary outcome was similarly reduced in participants with or without baseline MetS: 0.75 (95% confidence interval [CI] 0.57, 0.96) and 0.71 (95% CI 0.57, 0.87), respectively (adjusted P value for treatment by subgroup interaction = .98). Similarly, there was no evidence of treatment × MetS subgroup interaction for all-cause mortality (adjusted interaction P value = .98). The findings were also similar across race/ethnic subgroups. CONCLUSIONS In this analysis the CV benefit of intensive SBP control did not differ among participants by baseline MetS status, regardless of race/ethnicity.
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Affiliation(s)
- Kathleen Dungan
- Division of Endocrinology, Diabetes and Metabolism, Ohio State University, Columbus, Ohio
| | - Timothy E Craven
- Department of Biostatistics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kyaw Soe
- Division of Endocrinology, UT Southwestern Medical Center, Dallas, Texas
- Division of Population Health and Computational Medicine, University of Miami and Geriatric Research and Education Clinical Center, Miami
| | - Jackson T Wright
- Division of Nephrology and Hypertension, Clinical Hypertension Program, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Jan Basile
- Division of General Internal Medicine, Seinsheimer Cardiovascular Health Program, Medical University of South Carolina, Charleston, South Carolina
| | - William E Haley
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Nancy R Kressin
- VA Boston Healthcare System; Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Uzma Rani
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Leonardo Tamariz
- Division of Population Health and Computational Medicine, University of Miami and Geriatric Research and Education Clinical Center, Miami, Florida
| | - Jeff Whittle
- Division of Primary Care, Clement J Zablocki VA Medical Center, Milwaukee, Wisconsin
| | - Alan Wiggers
- Department of Primary Care, Ohio University Heritage College of Osteopathic Medicine, Cleveland campus, Cleveland, Ohio
| | - Kwame Osei
- Division of Endocrinology, Diabetes and Metabolism, Ohio State University, Columbus, Ohio
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McCleary NJ, Hubbard J, Mahoney MR, Meyerhardt JA, Sargent D, Venook A, Grothey A. Challenges of conducting a prospective clinical trial for older patients: Lessons learned from NCCTG N0949 (alliance). J Geriatr Oncol 2018; 9:24-31. [PMID: 28917648 PMCID: PMC5757827 DOI: 10.1016/j.jgo.2017.08.005] [Citation(s) in RCA: 8] [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] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/14/2017] [Accepted: 08/14/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVES While the risk of developing colorectal cancer increases with age, there are limited prospective data regarding best treatment in the older adult population. We launched a phase III trial to evaluate difference in treatment outcome for older adults (aged ≥70years) with advanced colorectal cancer. Here we review the challenges faced and reasons for poor accrual to N0949. MATERIALS AND METHODS We describe the conceptualization, development and limited results of N0949, a randomized phase III study of fluoropyrimidine/bevacizumab with or without oxaliplatin (mFOLFOX7 or XELOX) as first line chemotherapy for metastatic colorectal cancer. Fluoropyrimidine was physician choice (e.g., 5-FU/LV or capecitabine). RESULTS Of the projected 380 patients, only 32 patients were enrolled between the study activation in January 2011 until its closure in September 2012. Reasons for poor accrual included eligibility criteria that were too stringent, discomfort with randomizing older patients to regimens of varying intensity without considering their physical fitness, and discomfort with the use of bevacizumab in the older patient population. Several efforts were mounted to design a rationale and age-appropriate study, consider toxicities and varying study practices, and be responsive to stakeholder feedback. CONCLUSIONS Challenges were experienced in conducting the first prospective phase III study evaluating progression-free survival of older adults with advanced colorectal cancer receiving palliative chemotherapy with fluoropyrimidine/bevacizumab with or without oxaliplatin in the USA. Future efforts to evaluate treatment outcomes in the older adult population should reflect on lessons learned in this large national effort.
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Affiliation(s)
- Nadine J McCleary
- Department of Medical Oncology, Dana-Farber/Partners Cancer Care, Boston, MA, United States.
| | - Joleen Hubbard
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States
| | - Michelle R Mahoney
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, United States
| | - Jeffrey A Meyerhardt
- Department of Medical Oncology, Dana-Farber/Partners Cancer Care, Boston, MA, United States
| | - Daniel Sargent
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN, United States
| | - Alan Venook
- Department of Medical Oncology, University of San Francisco, CA, United States
| | - Axel Grothey
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, United States
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Bouman-Wammes EW, van den Berg HP, de Munck L, Beeker A, Smorenburg CH, Vervenne WL, Coenen JLLM, Verheul HMW, Gerritsen WR, Van den Eertwegh AJM. A randomised phase II trial of docetaxel versus docetaxel plus carboplatin in patients with castration-resistant prostate cancer who have progressed after response to prior docetaxel chemotherapy: The RECARDO trial. Eur J Cancer 2017; 90:1-9. [PMID: 29268139 DOI: 10.1016/j.ejca.2017.11.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 07/14/2017] [Revised: 11/09/2017] [Accepted: 11/20/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Docetaxel is standard first-line chemotherapy for patients with metastatic castration-resistant prostate carcinoma (mCRPC). Docetaxel re-challenge has never been tested in a prospective randomised controlled study. As some studies support the addition of carboplatin to docetaxel, we performed a phase II trial investigating the combination of docetaxel plus carboplatin versus docetaxel re-treatment in docetaxel pre-treated mCRPC patients. METHODS Patients with mCRPC with a progression-free interval of ≥3 months after initial docetaxel treatment were randomised between docetaxel 75 mg/m2 or docetaxel 60 mg/m2 plus carboplatin AUC4. The primary end-point was progression-free survival (PFS; PSA/RECIST). RESULTS Owing to insufficient recruitment, the study was discontinued early after inclusion of 75 patients (targeted 150) PFS and overall survival (OS) were comparable between both groups (median PFS 12.7 months (95% CI 9.9-17.5 months) with docetaxel monotherapy and 11.7 months (95% CI 8.5-21.0 months) with combination therapy (p = 0.98); OS 18.5 months (95% CI 11.8-24.5 months) versus 18.9 months (95% CI 16.0-23.7 months) (p = 0.79). An interim analysis (SEQTEST) showed that the null hypothesis could already be excepted, and no significant difference between both study arms was expected if inclusion would be completed. The incidence of grade 3-4 infections and gastrointestinal side-effects was numerical higher in the carboplatin arm (p = 0.056). CONCLUSION This early terminated study suggests no benefit from the addition of carboplatin to docetaxel re-treatment in patients with mCRPC, whereas the combination resulted in more toxicity. Re-treatment with docetaxel monotherapy appears to be feasible, save and effective for patients with mCRPC and an initial good response to docetaxel. TRIAL REGISTRATION NTR3070.
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Affiliation(s)
- Esther W Bouman-Wammes
- Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands.
| | | | - Linda de Munck
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - Aart Beeker
- Department of Medical Oncology, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | | | - Walter L Vervenne
- Department of Medical Oncology, Deventer ziekenhuis, Deventer, The Netherlands
| | | | - Henk M W Verheul
- Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands
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Tanaka I, Kawada K, Morise M, Hase T, Hayashi H, Sokai A, Fukatsu A, Kondo M, Nomura F, Hasegawa Y. A phase II trial of Ifosfamide combination with recommended supportive therapy for recurrent SCLC in second-line and heavily treated setting. Cancer Chemother Pharmacol 2017; 81:339-345. [PMID: 29234921 DOI: 10.1007/s00280-017-3497-0] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/05/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE The response rate of ifosfamide (IFM) monotherapy for small-cell lung cancer (SCLC) is reported as 42.4% in Japanese package insert. However, these efficacy data are based on clinical studies conducted in 1970s. This phase II study evaluated the efficacy and safety of IFM combination with recommended current supportive therapy for recurrent SCLC in second-line and heavily treated setting. METHODS Recurrent SCLC patients pretreated with one to three prior regimens received IFM monotherapy (1.5 g/m2 for 3 days every 3 weeks). Treatment was continued until disease progression or unacceptable toxicity. The primary end point was objective response rate. RESULTS Twelve patients were enrolled in the study from June 2009 to January 2013. The study was early terminated at interim analysis due to futility stop. Patient characteristics were as follows: median age was 65 years, 11 were males (91.7%) and eight (66.7%) and four (33.3%) were Performance Status 0 and 1, respectively. Four patients (33.3%) enrolled in second-line setting were all refractory relapse SCLC and 8 (66.7%) were heavily treated patients. No patient showed objective response. Stable disease was observed in 3 patients. Median progression-free survival and overall survival were 0.9 months (95% CI, 0.3-1.5) and 4.8 months (95% CI, 1.6-9.9), respectively. Although one grade 4 amylase increase possibly related to IFM was observed, toxicity profile was totally favorable. CONCLUSIONS IFM monotherapy should not be used for refractory relapse or heavily treated SCLC, and no further investigation is required in these populations.
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Affiliation(s)
- Ichidai Tanaka
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Kenji Kawada
- Departments of Medical Oncology, Fujita Health University Graduate School of Medicine, Toyoake, Japan
| | - Masahiro Morise
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tetsunari Hase
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hiroaki Hayashi
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Japan
| | - Akihiko Sokai
- Department of Respiratory Medicine, Takatsuki Red Cross Hospital, Takatsuki, Japan
| | - Asuki Fukatsu
- Department of Respiratory Medicine, Anjyo Kosei Hospital, Anjyo, Japan
| | - Masashi Kondo
- Departments of Respiratory Medicine, Fujita Health University Graduate School of Medicine, Toyoake, Japan
| | - Fumio Nomura
- Department of Respiratory Medicine, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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McCandless SE, Yanovski JA, Miller J, Fu C, Bird LM, Salehi P, Chan CL, Stafford D, Abuzzahab MJ, Viskochil D, Barlow SE, Angulo M, Myers SE, Whitman BY, Styne D, Roof E, Dykens EM, Scheimann AO, Malloy J, Zhuang D, Taylor K, Hughes TE, Kim DD, Butler MG. Effects of MetAP2 inhibition on hyperphagia and body weight in Prader-Willi syndrome: A randomized, double-blind, placebo-controlled trial. Diabetes Obes Metab 2017; 19:1751-1761. [PMID: 28556449 PMCID: PMC5673540 DOI: 10.1111/dom.13021] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [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: 01/13/2017] [Revised: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 01/01/2023]
Abstract
AIMS There are no treatments for the extreme hyperphagia and obesity in Prader-Willi syndrome (PWS). The bestPWS clinical trial assessed the efficacy, safety and tolerability of the methionine aminopeptidase 2 (MetAP2) inhibitor, beloranib. MATERIALS AND METHODS Participants with PWS (12-65 years old) were randomly assigned (1:1:1) to biweekly placebo, 1.8 mg beloranib or 2.4 mg beloranib injection for 26 weeks at 15 US sites. Co-primary endpoints were the changes in hyperphagia [measured by Hyperphagia Questionnaire for Clinical Trials (HQ-CT); possible score 0-36] and weight by intention-to-treat. ClinicalTrials.gov registration: NCT02179151. RESULTS One-hundred and seven participants were included in the intention-to-treat analysis: placebo (n = 34); 1.8 mg beloranib (n = 36); or 2.4 mg beloranib (n = 37). Improvement (reduction) in HQ-CT total score was greater in the 1.8 mg (mean difference -6.3, 95% CI -9.6 to -3.0; P = .0003) and 2.4 mg beloranib groups (-7.0, 95% CI -10.5 to -3.6; P = .0001) vs placebo. Compared with placebo, weight change was greater with 1.8 mg (mean difference - 8.2%, 95% CI -10.8 to -5.6; P < .0001) and 2.4 mg beloranib (-9.5%, 95% CI -12.1 to -6.8; P < .0001). Injection site bruising was the most frequent adverse event with beloranib. Dosing was stopped early due to an imbalance in venous thrombotic events in beloranib-treated participants (2 fatal events of pulmonary embolism and 2 events of deep vein thrombosis) compared with placebo. CONCLUSIONS MetAP2 inhibition with beloranib produced statistically significant and clinically meaningful improvements in hyperphagia-related behaviours and weight loss in participants with PWS. Although investigation of beloranib has ceased, inhibition of MetAP2 is a novel mechanism for treating hyperphagia and obesity.
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Affiliation(s)
- Shawn E McCandless
- UH Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Jack A Yanovski
- Section on Growth and Obesity, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | | | - Cary Fu
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lynne M Bird
- UCSD Rady Children's Hospital, San Diego, California
| | - Parisa Salehi
- Division of Endocrinology & Diabetes, Seattle Children's Hospital, Seattle, Washington
| | | | | | | | | | | | | | - Susan E Myers
- Saint Louis University School of Medicine, Saint Louis, Missouri
| | | | - Dennis Styne
- UC Davis Children's Hospital, UC Davis Medical Center, Davis, California
| | - Elizabeth Roof
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Ann O Scheimann
- Baylor College of Medicine and Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | - Merlin G Butler
- Departments of Psychiatry, Behavioral Sciences and Pediatrics, University of Kansas Medical Center, Kansas City, Kansas
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Loibl S, de la Pena L, Nekljudova V, Zardavas D, Michiels S, Denkert C, Rezai M, Bermejo B, Untch M, Lee SC, Turri S, Urban P, Kümmel S, Steger G, Gombos A, Lux M, Piccart MJ, Von Minckwitz G, Baselga J, Loi S. Neoadjuvant buparlisib plus trastuzumab and paclitaxel for women with HER2+ primary breast cancer: A randomised, double-blind, placebo-controlled phase II trial (NeoPHOEBE). Eur J Cancer 2017; 85:133-145. [PMID: 28923573 PMCID: PMC5640494 DOI: 10.1016/j.ejca.2017.08.020] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [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: 04/07/2017] [Revised: 08/18/2017] [Accepted: 08/18/2017] [Indexed: 12/25/2022]
Abstract
AIM The Neoadjuvant PI3K inhibition in HER2 OverExpressing Breast cancEr (NeoPHOEBE) trial evaluated the efficacy and safety of buparlisib, a pan-phosphatidylinositol 3-kinase (PI3K) inhibitor, plus trastuzumab and paclitaxel as neoadjuvant treatment for human epidermal growth factor receptor-2 positive (HER2+) breast cancer. METHODS NeoPHOEBE was a neoadjuvant, phase II, randomised, double-blind study. Women with HER2+ breast cancer were randomised within two independent cohorts by PIK3CA mutation status and, in each cohort stratified by oestrogen receptor (ER) status to receive buparlisib or placebo plus trastuzumab (first 6 weeks) followed by buparlisib or placebo with trastuzumab and paclitaxel. Primary end-point was pathological complete response (pCR) rate; key secondary end-point was objective response rate (ORR) at 6 weeks. Exploratory end-points were evaluation of Ki67 levels and change in tumour infiltrating lymphocytes (TILs) in intermediate biopsies at day 15. RESULTS Recruitment was suspended mainly due to liver toxicity after enrolment of 50 of the planned 256 patients. In each arm (buparlisib n = 25; placebo n = 25) 21 patients (84%) had wild type PIK3CA and 4 patients (16%) had mutant PIK3CA. Overall, pCR rate was similar between buparlisib and placebo arms (32.0% versus 40%; one-sided P = 0.811). A trend towards higher ORR (68.8% versus 33.3%; P = 0.053) and a significant decrease in Ki67 (75% versus 26.7%; P = 0.021) was observed in buparlisib versus placebo arm in the ER+ subgroup (Pinteraction = 0.03). CONCLUSIONS Addition of the pan-PI3K inhibitor buparlisib to taxane-trastuzumab-based therapy in HER2+ early breast cancer was not feasible. However, the higher ORR and Ki67 reduction in the ER+, HER2+ subgroup indicates a potential role for PI3K-targeted therapy in this setting and may warrant further investigation with better-tolerated second-generation PI3K inhibitors. TRIAL REGISTRATION IDENTIFIER NCT01816594.
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Affiliation(s)
- Sibylle Loibl
- German Breast Group, Neu-Isenburg, Germany; Sana-Klinikum Offenbach, Germany.
| | | | | | | | - Stefan Michiels
- Gustave Roussy, Service de Biostatistique et d'Epidémiologie, Villejuif, France; CESP, Inserm U1018, Univ. Paris Sud, Univ. Paris-Saclay, Villejuif, France
| | - Carsten Denkert
- Institute of Pathology, Charité University Hospital, Berlin, Germany
| | | | | | - Michael Untch
- Helios Klinikum Berlin-Buch, Department of Obstetrics and Gynaecology, Berlin, Germany
| | - Soo Chin Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | | | | | | | - Guenther Steger
- Department of Internal Medicine I, Division of Oncology, Medical University of Vienna, Austria; Comprehensive Cancer Center Vienna, Austria
| | - Andrea Gombos
- Université Libre de Bruxelles, Institut Jules Rue Héger-Bordet 1, Medical Oncology Clinic, Belgium
| | - Michael Lux
- University Breast Centre of Franconia, OBGYN Department, University Hospital Erlangen, CCC Erlangen-EMN, Germany
| | - Martine J Piccart
- Breast International Group, Brussels, Belgium; Université Libre de Bruxelles, Institut Jules Rue Héger-Bordet 1, Medical Oncology Clinic, Belgium
| | | | - José Baselga
- SOLTI Breast Cancer Research Group, Barcelona, Spain; Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Sherene Loi
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Australian New Zealand Breast Cancer Trials Group (ANZBCTG), Newcastle, Australia.
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Guasch-Ferré M, Salas-Salvadó J, Ros E, Estruch R, Corella D, Fitó M, Martínez-González MA. The PREDIMED trial, Mediterranean diet and health outcomes: How strong is the evidence? Nutr Metab Cardiovasc Dis 2017; 27:624-632. [PMID: 28684083 DOI: 10.1016/j.numecd.2017.05.004] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 04/20/2017] [Accepted: 05/08/2017] [Indexed: 12/14/2022]
Abstract
AIMS To address potential controversies on the health benefits of the Mediterranean diet (MedDiet) after PREDIMED, a randomized trial of MedDiet for primary cardiovascular prevention. We have focused on: a) the PREDIMED study design, b) analysis of PREDIMED data and c) interpretation of its results. DATA SYNTHESIS Regarding the design of the trial, its early termination and between-group differences in the intensity of the intervention are potential causes of concern. The planned duration was 6 years but the trial was prematurely stopped when an interim analysis at 4.8-year provided sufficient evidence of benefit for the two MedDiets. In the MedDiet groups supplemented with extra-virgin olive oil or mixed-nuts, the primary composite endpoint (myocardial infarction, stroke, or cardiovascular death) was reduced by 30% and 28% respectively, as compared with the control group. Final results did not change after taking into account the different intensity of educational efforts during the trial. Other potential doubts related to data analysis (e.g., intention to treat versus a per-protocol approach, and consequences of dropouts) should not be causes of concern. Finally, we addressed alternative interpretations of the effect on all-cause mortality. The protocol-defined primary endpoint was a composite cardiovascular endpoint, not all-cause mortality. To analyze total mortality, we would have needed a much larger sample size and longer follow-up. Therefore, the PREDIMED results cannot be used to draw firm conclusions on MedDiets and all-cause mortality. CONCLUSIONS The PREDIMED study was designed to overcome three major problems of previous nutritional research: a) residual confounding, addressed by using a randomized design; b) single-nutrient approaches, by randomizing an overall dietary pattern; and c) the limitations of assessing only intermediate risk markers, by using hard clinical end-points.
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Affiliation(s)
- M Guasch-Ferré
- Human Nutrition Unit, University Hospital of Sant Joan de Reus, Department of Biochemistry and Biotechnology, Faculty of Medicine and Health Sciences, IISPV, Rovira i Virgili University, Reus, Spain; Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA; CIBER Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - J Salas-Salvadó
- Human Nutrition Unit, University Hospital of Sant Joan de Reus, Department of Biochemistry and Biotechnology, Faculty of Medicine and Health Sciences, IISPV, Rovira i Virgili University, Reus, Spain; CIBER Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - E Ros
- CIBER Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain; Lipid Clinic, Endocrinology and Nutrition Service, Institut d'Investigacions Biomèdiques August Pi Sunyer (DIBAPS), Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - R Estruch
- CIBER Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain; Department of Internal Medicine, IDIBAPS, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - D Corella
- CIBER Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain; Department of Preventive Medicine and Public Health, University of Valencia, Valencia, Spain
| | - M Fitó
- CIBER Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain; Cardiovascular Risk and Nutrition (Regicor Study Group), Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - M A Martínez-González
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA; CIBER Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain; University of Navarra, Department of Preventive Medicine and Public Health, Pamplona, Spain.
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