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- Assessment of a New Method of Warfarin Management vs the New Oral Anticoagulants and Conventional Warfarin Management in Atrial Fibrillation. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):532A.
Quality & Clinical Improvement Posters ISESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PMPURPOSE: To assess the impact of International Normalized Ratio (INR) self testing and online remote monitoring and management (STORM2) on clinical events and costs vs. traditional warfarin management and the new oral anticoagulants (NOACs) in atrial fibrillation (AF).METHODS: The mean INR time in the target range (TTR) was 77.2% in 7 STORM2 trials. Thromboembolism (TE) and major bleeding (MB) rates at 30%, 45%, 55%, 65%, and 75% TTR were calculated using linear regression equations from a systematic review of 38 AF studies (approx. 34,000 patients). MB = 10.104 - 0.120x[TTR], (p = 0.004) and TE = 8.313 - 0.098x[TTR], (p = 0.03). MB and TE rates were sub-divided based on the distribution in the NOAC trials. TTR-based mortality was calculated based on a 6%/yr rate multiplied by the adjusted relative risks from a data base analysis of approximately 38,000 AF patients. Projected event rates at 75% TTR, expressed as number per 1,000 patient-years, were compared to event rates at lower TTR ranges and to rates reported in the NOAC trials. Differences in the rates of ischemic stroke, myocardial infarction, intracranial hemorrhage, major gastrointestinal bleed, and death were used to calculate cost avoidance.RESULTS: Projected event rates with STORM2 (TTR of 75%) when compared to "conventional " TTR of 55% to 65% were 64% to 71% lower for MB, 47% to 64% lower for TE, and 47% to 57% lower for mortality. Compared to the NOAC study results, the projected rates were 48% to 70% lower for MB, 41% to 66% lower for TE, and 40% to 53% lower for mortality. Projected cost avoidance was $10.4 million vs. a TTR of < 30%, $2.2 million vs. a TTR of 65%; and from $1.4 to $3.1 million vs the NOACs. Costs of "other" MB and TE , drug costs, and monitoring costs were not included in the estimates. The regression equation projected relative risks of stroke at various TTR values were virtually identical to those reported from the UK data base analysis.CONCLUSIONS: STORM2 management of warfarin is projected to produce a 50% or greater reduction in major event rates with a cost avoidance of $1.4 to $10.4 million per 1,000 patients per year.CLINICAL IMPLICATIONS: STORM2 management may transform the safety and efficacy of anticoagulation for the millions of people with AF while substantially reducing costs. These findings warrant randomized, prospective trials in AF and other indications for anticoagulation.DISCLOSURE: Henry Bussey: Other: I am an unpaid consultant in the development of an online management system (ClotFree) which was developed and is owned by my daughter's company, Fiduciary position (of any organization, association, society, etc, other than ACCP: President and Senior Editor of ClotCare.org (a charitable 501(c)3 information service), Other: As the only , Fiduciary position (of any organization, association, society, etc, other than ACCP: Scientific Advisory Board of the North American Thrombosis Forum Edith Nutescu: Grant monies (from industry related sources): research support from Jansses Health Economics and Outcomes Research, Grant monies (from sources other than industry): research support from The Cranberry Institute, Fiduciary position (of any organization, association, society, etc, other than ACCP: Board of Regents for the American College of Clinical Pharmacy, Fiduciary position (of any organization, association, society, etc, other than ACCP: Board of Directors of the Anticoagulation Forum, Fiduciary position (of any organization, association, society, etc, other than ACCP: Medical and Scientific Advisory Board for the National Blood Clot Alliance, Consultant fee, speaker bureau, advisory committee, etc.: Consultant for Janssen Health Economics and Outcomes Research, Daichii Sankyo, and CSL BehringNo Product/Research Disclosure Information.
- Transcranial Laser Therapy in Acute Stroke Treatment: Results of Neurothera Effectiveness and Safety Trial 3, a Phase III Clinical End Point Device Trial. [JOURNAL ARTICLE]
- Stroke 2014 Oct 7.
On the basis of phase II trials, we considered that transcranial laser therapy could have neuroprotective effects in patients with acute ischemic stroke.We studied transcranial laser therapy in a double-blind, sham-controlled randomized clinical trial intended to enroll 1000 patients with acute ischemic stroke treated ≤24 hours after stroke onset and who did not undergo thrombolytic therapy. The primary efficacy measure was the 90-day functional outcome as assessed by the modified Rankin Scale, with hierarchical Bayesian analysis incorporating relevant previous data. Interim analyses were planned after 300 and 600 patients included.The study was terminated on recommendation by the Data Monitoring Committee after a futility analysis of 566 completed patients found no difference in the primary end point (transcranial laser therapy 140/282 [49.6%] versus sham 140/284 [49.3%] for good functional outcome; modified Rankin Scale, 0-2). The results remained stable after inclusion of all 630 randomized patients (adjusted odds ratio, 1.024; 95% confidence interval, 0.705-1.488).Once the results of the interim futility analysis became available, all study support was immediately withdrawn by the capital firms behind PhotoThera, and the company was dissolved. Proper termination of the trial was difficult but was finally achieved through special efforts by former employees of PhotoThera, the CRO Parexel and members of the steering and the safety committees. We conclude that transcranial laser therapy does not have a measurable neuroprotective effect in patients with acute ischemic stroke when applied within 24 hours after stroke onset.http://www.clinicaltrials.gov. Unique identifier: NCT01120301.
- The Esophageal Pressure-Guided Ventilation 2 (EPVent2) trial protocol: a multicentre, randomised clinical trial of mechanical ventilation guided by transpulmonary pressure. [Journal Article]
- BMJ Open 2014; 4(9):e006356.
Optimal ventilator management for patients with acute respiratory distress syndrome (ARDS) remains uncertain. Lower tidal volume ventilation appears to be beneficial, but optimal management of positive end-expiratory pressure (PEEP) remains unclear. The Esophageal Pressure-Guided Ventilation 2 Trial (EPVent2) aims to examine the impact of mechanical ventilation directed at maintaining a positive transpulmonary pressure (PTP) in patients with moderate-to-severe ARDS.EPVent2 is a multicentre, prospective, randomised, phase II clinical trial testing the hypothesis that the use of a PTP-guided ventilation strategy will lead to improvement in composite outcomes of mortality and time off the ventilator at 28 days as compared with a high-PEEP control. This study will enrol 200 study participants from 11 hospitals across North America. The trial will utilise a primary composite end point that incorporates death and days off the ventilator at 28 days to test the primary hypothesis that adjusting ventilator pressure to achieve positive PTP values will result in improved mortality and ventilator-free days.Safety oversight will be under the direction of an independent Data and Safety Monitoring Board (DSMB). Approval of the protocol was obtained from the DSMB prior to enrolling the first study participant. Approvals of the protocol as well as informed consent documents were also obtained from the Institutional Review Board of each participating institution prior to enrolling study participants at each respective site. The findings of this investigation, as well as associated ancillary studies, will be disseminated in the form of oral and abstract presentations at major national and international medical specialty meetings. The primary objective and other significant findings will also be presented in manuscript form. All final, published manuscripts resulting from this protocol will be submitted to PubMed Central in accordance with the National Institute of Health Public Access Policy.ClinicalTrials.gov under number NCT01681225.
- HyperOxic Therapy OR NormOxic Therapy after out-of-hospital cardiac arrest (HOT OR NOT): A randomised controlled feasibility trial. [JOURNAL ARTICLE]
- Resuscitation 2014 Sep 24.
To investigate the feasibility of delivering titrated oxygen therapy to adults with return of spontaneous circulation (ROSC) following out-of-hospital cardiac arrest (OHCA) caused by ventricular fibrillation (VF) or ventricular tachycardia (VT).We used a multicentre, randomised, single blind, parallel groups design to compare titrated and standard oxygen therapy in adults resuscitated from VF/VT OHCA. The intervention commenced in the community following ROSC and was maintained in the emergency department and the Intensive Care Unit. The primary end point was the median oxygen saturation by pulse oximetry (SpO2) in the pre-hospital period.159 OHCA patients were screened and 18 were randomised. 17 participants were analysed: nine in the standard care group and eight in the titrated oxygen group. In the pre-hospital period, SpO2 measurements were lower in the titrated oxygen therapy group than the standard care group (difference in medians 11.3%; 95% CI 1.0-20.5%). Low measured oxygen saturation (SpO2<88%) occurred in 7/8 of patients in the titrated oxygen group and 3/9 of patients in the standard care group (P=0.05). Following hospital admission, good separation of oxygen exposure between the groups was achieved without a significant increase in hypoxia events. The trial was terminated because accumulated data led the Data Safety Monitoring Board and Management Committee to conclude that safe delivery of titrated oxygen therapy in the pre-hospital period was not feasible.Titration of oxygen in the pre-hospital period following OHCA was not feasible; it may be feasible to titrate oxygen safely after arrival in hospital.
- Persistence and risk assessment of spiromesifen on tomato in India: a multilocational study. [JOURNAL ARTICLE]
- Environ Monit Assess 2014 Sep 14.
Supervised field trials were conducted at four different agro-climatic locations of India to evaluate the dissipation pattern and risk assessment of spiromesifen on tomato. Spiromesifen 240 SC was sprayed on tomato at 150 and 300 g a.i. ha(-1). Samples of tomato fruits were drawn at 0, 1, 3, 5, 7, 10 and 15 days after treatment and soil at 15 days after treatment. Quantification of residues was done on gas chromatograph-mass spectrophotometer in selective ion monitoring mode in the mass range of 271-274 (m/z). The limit of quantification of the method was found to be 0.05 mg kg(-1), while the limit of determination was 0.015 mg kg(-1). Residues were found below the LOQ of 0.05 mg kg(-1) in 10 days at both the doses of application at all the locations. Spiromesifen dissipated with a half-life of 0.93-1.38 days at the recommended rate of application and 1.04-1.34 days at the double the rate of application. Residues of spiromesifen in soil were detectable level (<0.05 mg kg(-1)) after 15 days of treatment. A preharvest interval (PHI) of 1 day has been recommended on tomato on the basis of data generated under All India Network Project on Pesticide Residues. Spiromesifen 240 SC has been registered for its use on tomato by Central Insecticide Board and Registration Committee, Ministry of Agriculture, Government of India. The maximum residue limit (MRL) of spiromesifen on tomato has been fixed by Food Safety Standard Authority of India, Ministry of Health and Family Welfare, Government of India as 0.3 μg/g after its risk assessment.
- Rationale and Design of the Vitamin D and Type 2 Diabetes (D2d) Study: A Diabetes Prevention Trial. [JOURNAL ARTICLE]
- Diabetes Care 2014 Sep 9.
Observational studies suggest that vitamin D may lower the risk of type 2 diabetes. However, data from long-term trials are lacking. The Vitamin D and Type 2 Diabetes (D2d) study is a randomized clinical trial designed to examine whether a causal relationship exists between vitamin D supplementation and the development of diabetes in people at high risk for type 2 diabetes.D2d was designed with support from a U34 planning grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The final protocol was approved by the D2d Research Group, the data and safety monitoring board, and NIDDK. Key eligibility criteria are age ≥30 years, BMI of 24 (22.5 for Asian Americans) to 42 kg/m(2), increased risk for diabetes (defined as meeting two of three glycemic criteria for prediabetes established by the American Diabetes Association [fasting glucose 100-125 mg/dL (5.5-6.9 mmol/L), 2-h postload glucose after 75-g glucose load 140-199 mg/dL (7.7-11.0 mmol/L), hemoglobin A1c 5.7-6.4% (39-46 mmol/mol)]), and no hyperparathyroidism, nephrolithiasis, or hypercalcemia. D2d participants are randomized to once-daily vitamin D3 (cholecalciferol 4,000 IU) or placebo and followed for an average of 3 years. The primary end point is time to incident diabetes as assessed by laboratory criteria during the study or by adjudication if diagnosed outside of D2d. Recruitment was initiated at the end of 2013.D2d will test whether vitamin D supplementation is safe and effective at lowering the risk of progression to diabetes in people at high risk for type 2 diabetes.
- Phase I/II Study of Azacitidine, Docetaxel, and Prednisone in Patients With Metastatic Castration-Resistant Prostate Cancer Previously Treated With Docetaxel-Based Therapy. [JOURNAL ARTICLE]
- Clin Genitourin Cancer 2014 Aug 1.
Methylation-mediated silencing of genes contributes to docetaxel resistance in prostate cancer. We propose that azacitidine, a demethylating agent, can reverse docetaxel resistance.Metastatic castration-resistant prostate cancer (mCRPC) patients, who progressed during or within 6 months of docetaxel chemotherapy, were eligible. Fifteen and 7 patients were treated in phase I and II, respectively. In phase I, azacitidine and docetaxel were alternately escalated in a standard 3 + 3 design. All patients received prednisone 5 mg twice daily continuously. Patients were evaluated for toxicity and efficacy. Growth arrest and DNA damage-inducible alpha (GADD45A) methylation was measured before and after azacitidine treatment in the first cycle in phase I patients.In phase I, no dose-limiting toxicity was observed. At the highest dose (azacitidine 150 mg/m(2) daily for 5 days followed by docetaxel 75 mg/m(2) on day 6), Grade 4 neutropenia was frequent, but infrequent with growth factor. Six patients in the phase II study received the highest dose including growth factor support. The sixth phase II patient died because of neutropenic sepsis. After data and safety monitoring board review, the phase II dose was reduced to azacitidine 75 mg/m(2) daily for 5 days followed by docetaxel 75 mg/m(2) on day 6 with growth factor support. Prostate-specific antigen response was seen in 10 of 19 evaluable patients and objective response was observed in 3 of 10 evaluable patients. Significant demethylation of GADD45A was observed with azacitidine treatment.The combination of azacitidine, docetaxel, and prednisone with growth factor support is active in mCRPC patients.
- Study design considerations for evaluating the efficacy and safety of pancreatic enzyme replacement therapy in patients with cystic fibrosis. [JOURNAL ARTICLE]
- Clin Investig (Lond) 2013 Aug; 3(8):731-741.
In 2006, the US FDA issued a 'Guidance for Industry' regarding submission of New Drug Applications for pancreatic enzyme replacement therapy (PERT) products. Five oral delayed-release PERT products have been approved by the FDA, and several others are under development and/ or evaluation for New Drug Application submission. We present in this paper recommendations of the Cystic Fibrosis Foundation's Cystic Fibrosis (CF) Therapeutics Development Network and Data Safety Monitoring Board regarding study design considerations for evaluating PERT products in patients with CF. Careful attention to study design and accuracy of the outcome measures has confirmed our understanding of the efficacy and safety of PERT for the treatment of exocrine pancreatic insufficiency of CF.
- A systematic review of clozapine induced cardiomyopathy. [REVIEW]
- Int J Cardiol 2014 Aug 1.
Clozapine is a unique anti-psychotic medication that is most effective in the treatment of refractory schizophrenia and reducing suicidality. Cardiomyopathy is among the side effects of this medication that limits its use. There are a number of case reports, case series and expert opinion papers discussing clozapine induced cardiomyopathy, but there is no evidence-based review of the subject to guide clinicians.We undertook a systematic review of the literature on cardiomyopathy associated with clozapine. The primary systemic search was in MEDLINE but EMBASE, PsycINFO, and Cochrane were searched and manufacturers of clozapine were contacted for cases. Articles were then individually reviewed to find additional reports.We identified 17 articles detailing 26 individual cases and 11 additional articles without individual case data. The mean age at time of diagnosis was 33.5years. The mean dose of clozapine on presentation was 360mg. Symptoms developed at an average of 14.4months after initiating clozapine. The clinical presentation was generally consistent with heart failure: including shortness of breath (60%) and palpitations (36%). Echocardiography at presentation showed dilated cardiomyopathy in 39% of cases and was not specified in other cases.There should be a low threshold in performing echocardiography in suspected cases of clozapine induced cardiomyopathy. Clozapine should be withheld in the setting of cardiomyopathy without other explanation. There is limited data on the safety of drug re-challenge in clozapine induced cardiomyopathy. Re-challenge may be considered in carefully selected cases but close monitoring and frequent echocardiography are required.
- Randomized controlled trial of the CGRP receptor antagonist telcagepant for migraine prevention. [JOURNAL ARTICLE]
- Neurology 2014 Aug 8.
To evaluate whether the calcitonin gene-related peptide (CGRP) receptor antagonist telcagepant might be effective for migraine prevention.In this randomized, double-blind, placebo-controlled, multicenter trial (ClinicalTrials.gov NCT00797667), patients experiencing 3-14 migraine days during a 4-week baseline were randomized to telcagepant 140 mg, telcagepant 280 mg, or placebo twice daily for 12 weeks. Efficacy was assessed by mean monthly headache days and migraine/probable migraine days (headache plus ≥1 associated symptom).The trial was terminated following a recommendation from the Safety Monitoring Board due to hepatotoxicity concerns. At termination, the planned 660 patients had been randomized, 656 had been treated with ≥1 dose of study medication, and 14 had completed the trial. The mean treatment duration was 48-50 days. Thirteen patients, all in the telcagepant groups, had an alanine aminotransferase (ALT) elevation ≥3× the upper limit of normal and 7 of these also had an aspartate aminotransferase elevation ≥3× the upper limit of normal. Two patients had very high symptomatic transaminase elevations that occurred within 2-6 weeks of treatment initiation and resolved after treatment discontinuation. The originally planned efficacy analysis over 12 weeks was not performed due to limited data at later time points, but there was evidence that telcagepant resulted in a larger reduction from baseline than placebo for mean monthly headache days (month 1: 140 mg = -2.9, 280 mg = -3.1, placebo = -1.7; p < 0.05) and migraine/probable migraine days (month 1: 140 mg = -2.7, 280 mg = -3.0, placebo = -1.6; p < 0.05).These data suggest a potential role for CGRP receptor antagonism in migraine prophylaxis. However, the observed aminotransferase elevations do not support the use of telcagepant for daily administration.This study provides Class II evidence that in patients with migraine, telcagepant taken daily reduces headache days by 1.4 days per month compared to placebo and causes 2.5% of patients to have elevations of serum ALT levels.