On the use of non-concurrent controls in platform trials: a scoping review.

BACKGROUND: Platform trials gained popularity during the last few years as they increase flexibility compared to multi-arm trials by allowing new experimental arms entering when the trial already started. Using a shared control group in platform trials increases the trial efficiency compared to separate trials. Because of the later entry of some of the experimental treatment arms, the shared control group includes concurrent and non-concurrent control data. For a given experimental arm, non-concurrent controls refer to patients allocated to the control arm before the arm enters the trial, while concurrent controls refer to control patients that are randomised concurrently to the experimental arm. Using non-concurrent controls can result in bias in the estimate in case of time trends if the appropriate methodology is not used and the assumptions are not met. METHODS: We conducted two reviews on the use of non-concurrent controls in platform trials: one on statistical methodology and one on regulatory guidance. We broadened our searches to the use of external and historical control data. We conducted our review on the statistical methodology in 43 articles identified through a systematic search in PubMed and performed a review on regulatory guidance on the use of non-concurrent controls in 37 guidelines published on the EMA and FDA websites. RESULTS: Only 7/43 of the methodological articles and 4/37 guidelines focused on platform trials. With respect to the statistical methodology, in 28/43 articles, a Bayesian approach was used to incorporate external/non-concurrent controls while 7/43 used a frequentist approach and 8/43 considered both. The majority of the articles considered a method that downweights the non-concurrent control in favour of concurrent control data (34/43), using for instance meta-analytic or propensity score approaches, and 11/43 considered a modelling-based approach, using regression models to incorporate non-concurrent control data. In regulatory guidelines, the use of non-concurrent control data was considered critical but was deemed acceptable for rare diseases in 12/37 guidelines or was accepted in specific indications (12/37). Non-comparability (30/37) and bias (16/37) were raised most often as the general concerns with non-concurrent controls. Indication specific guidelines were found to be most instructive. CONCLUSIONS: Statistical methods for incorporating non-concurrent controls are available in the literature, either by means of methods originally proposed for the incorporation of external controls or non-concurrent controls in platform trials. Methods mainly differ with respect to how the concurrent and non-concurrent data are combined and temporary changes handled. Regulatory guidance for non-concurrent controls in platform trials are currently still limited.

Bayesian Strategies in Rare Diseases.

Bayesian strategies for planning and analyzing clinical trials have become a viable choice, especially in rare diseases where drug development faces many challenges and stakeholders are interested in innovations that may help overcome them. Disease natural history and clinical outcomes occurrence and variability are often poorly understood. Standard trial designs are not optimized to obtain adequate safety and efficacy data from small numbers of patients. Bayesian methods are well-suited for adaptive trials, with an accelerated learning curve. Using Bayesian statistics can be advantageous in that design choices and their consequences are considered carefully, continuously monitored, and updated where necessary, which ultimately provides a natural and principled way of seamlessly combining prior clinical information with data, within a solid decision theoretical framework. In this article, we introduce the Bayesian option in the rare disease context to support clinical decision-makers in selecting the best choice for their drug development project. Many researchers in drug development show reluctance to using Bayesian statistics, and the top-two reported barriers are insufficient knowledge of Bayesian approaches and a lack of clarity or guidance from regulators. Here we introduce concepts of borrowing, extrapolation, adaptation, and modeling and illustrate them with examples that have been discussed or developed with regulatory bodies to show how Bayesian strategies can be applied to drug development in rare diseases.

On the role of data, statistics and decisions in a pandemic.

A pandemic poses particular challenges to decision-making because of the need to continuously adapt decisions to rapidly changing evidence and available data. For example, which countermeasures are appropriate at a particular stage of the pandemic? How can the severity of the pandemic be measured? What is the effect of vaccination in the population and which groups should be vaccinated first? The process of decision-making starts with data collection and modeling and continues to the dissemination of results and the subsequent decisions taken. The goal of this paper is to give an overview of this process and to provide recommendations for the different steps from a statistical perspective. In particular, we discuss a range of modeling techniques including mathematical, statistical and decision-analytic models along with their applications in the COVID-19 context. With this overview, we aim to foster the understanding of the goals of these modeling approaches and the specific data requirements that are essential for the interpretation of results and for successful interdisciplinary collaborations. A special focus is on the role played by data in these different models, and we incorporate into the discussion the importance of statistical literacy and of effective dissemination and communication of findings.

Quantification of Lipid Phase Order of In Vivo Human Skin Using Attenuated Total Reflection Fourier Transform Infrared (ATR FT-IR) Spectroscopy and Multivariate Curve Resolution Analysis.

A new analysis methodology utilizing multivariate curve resolution (MCR) has been successfully combined with Fourier transform infrared (FT-IR) measurement of in vivo human skin to resolve lipid phase constituents in the spectra relative to high and low chain ordering. A clinical study was performed to measure lipid order through different depths of stratum corneum of human subjects. Fourier transform IR spectra were collected through the top 10 layers of the skin on four sites on the left and right forearm of 12 individuals. Depth profiling was achieved by tape stripping to remove layers of skin with 10 successive tapes from each site. In vivo ATR FT-IR spectra were collected after removing each tape. Three isolated spectral regions were analyzed, centered around 2850 cm-1, 1460-1480 cm-1, and 730 cm-1, corresponding to stretching, scissoring, and rocking -CH2 vibrational modes, respectively. Both traditional lipid conformation analysis and MCR analysis were performed on the same spectral data. The lipid order ratio, expressed as the fraction of highly ordered orthorhombic (OR) lipids to the total lipids content (orthorhombic + hexagonal [HEX] + liquid crystal [LC]), was assessed as function of depth. Lipid order depth profiles (LODP) show an increase in order with the stratum corneum depth which can be adequately described by an exponential function for the data obtained in this study. The LODP derived from the three vibrational modes show very similar trends, although the absolute order ratios are somewhat different. The variance of the skin LODP across individuals is much greater than between sites within the same individual. The higher arm sites closer to the elbow on the left and right arm show no statistically significant difference and are recommended for use in comparative studies. The scissoring mode shows the highest sensitivity for determination of LODP value.

Intake of essential fatty acids in Indonesian children: secondary analysis of data from a nationally representative survey.

Essential fatty acids (EFA) such as α-linolenic acid (ALA) and linoleic acid (LA) are needed for healthy growth and development of children. Worldwide, reliable intake data of EFA are often lacking. The objective of this study was to investigate dietary intake of EFA in Indonesian children. Dietary intake data of 4-12-year-old children (n 45,821) from a nationally representative Indonesian survey were used to estimate median intake and distribution of population fatty acid intake. Missing data on individual fatty acids in the Indonesian food composition table were complemented through chemical analyses of national representative food samples and imputation of data from the US nutrient database. Nutrient adequacy ratios were calculated as a percentage of FAO/WHO intake recommendations. The medians of total fat intake of the children was 26·7 (10th-90th percentile 11·2-40·0) percentage of total daily energy (%E). Intakes of fatty acids were 4·05 (10th-90th percentile 1·83-7·22) %E for total PUFA, 3·36 (10th-90th percentile 1·14-6·29) %E for LA and 0·20 (10th-90th percentile 0·07-0·66) %E for ALA. Median intake of PUFA was 67 % and that of ALA 40 % of the minimum amounts recommended by FAO/WHO. These data indicate that a majority of Indonesian children has intakes of PUFA and specifically ALA that are lower than recommended intake levels. Total fat and LA intakes may be suboptimal for a smaller yet considerable proportion of children. Public health initiatives should provide practical guidelines to promote consumption of PUFA-rich foods.

The effect of a low-fat spread with added plant sterols on vascular function markers: results of the Investigating Vascular Function Effects of Plant Sterols (INVEST) study.

BACKGROUND: Plant sterols (PSs) lower LDL cholesterol, an established risk factor for coronary artery disease (CAD). No direct evidence is available supporting a reduced risk of CAD for foods with added PSs. Endothelial dysfunction is seen as an early indicator of atherosclerotic damage. OBJECTIVES: This study was primarily designed to investigate the effect of a low-fat spread with added PSs on brachial artery endothelial function as measured by flow-mediated dilation (FMD). Second, effects on arterial stiffness, blood pressure, serum lipids, and plasma PS concentrations were investigated. We hypothesized that PSs would not worsen FMD but would rather modestly improve FMD. DESIGN: This study had a double-blind, randomized, placebo-controlled, parallel design. After a 4-wk run-in period, 240 hypercholesterolemic but otherwise healthy men and women consumed 20 g/d of low-fat spread without (control) or with added PSs (3 g/d) during 12 wk. Pre- and postintervention, vascular function measurements and blood sampling were performed. RESULTS: In total, 232 participants completed the study period. For the primary endpoint FMD, 199 participants were included in the statistical analysis. PS intake did not affect FMD (+0.01 percentage points; 95% CI: -0.73, 0.75) compared with control. Measures of arterial stiffness (pulse wave velocity and augmentation index) and blood pressure were also not significantly changed compared with control. After PS intervention, LDL cholesterol significantly decreased on average by 0.26 mmol/L (95% CI: -0.40, -0.12) or 6.7% compared with control. Plasma sitosterol and campesterol concentrations significantly increased in the PS group up to on average 11.5 µmol/L and 13.9 µmol/L (expressed as geometric means), respectively. CONCLUSIONS: The intake of a low-fat spread with added PSs neither improved nor worsened FMD or other vascular function markers in hypercholesterolemic men and women. As expected, serum LDL cholesterol decreased, whereas plasma PSs increased after PS intake. This study was registered at clinicaltrials.gov as NCT01803178.

Metabolic response to decaffeinated green tea extract during rest and moderate-intensity exercise.

We previously reported that a 7 day ingestion of caffeinated green tea extract (cGTE) induced marked metabolic differences during rest and exercise. Here, we report the metabolic effects of 1, 7, and 28 day ingestions of decaffeinated GTE (dGTE). In this crossover placebo-controlled study, 19 healthy males ingested dGTE or placebo (PLA) for 28 days, separated by a 28 day wash-out period. On days 1, 7, and 28, participants completed a 30 min cycling exercise 2 h after the ingestion of dGTE or PLA. Blood samples were collected at rest (t = 0 and 120 min) and during exercise (t = 150 min). Plasma was analyzed using untargeted four-phase metabolite profiling and targeted profiling of catecholamines and catechins. dGTE abolished several metabolic effects when compared to our previous study with cGTE. However, following 7 and 28 day dGTE ingestions, increases in 3-hydroxybutyrate, a metabolic marker of fat oxidation, were observed at t = 0 min. dGTE ingestion did not induce significant acute or acute-on-chronic effects on endogenous metabolites just prior to and during exercise.

Assessment of inflammatory resilience in healthy subjects using dietary lipid and glucose challenges.

BACKGROUND: Resilience or the ability of our body to cope with daily-life challenges has been proposed as a new definition of health, with restoration of homeostasis as target resultant of various physiological stress responses. Challenge models may thus be a sensitive measure to study the body's health. The objective of this study was to select a dietary challenge model for the assessment of inflammatory resilience. Meals are a challenge to metabolic homeostasis and are suggested to affect inflammatory pathways, yet data in literature are limited and inconsistent. METHOD: The kinetic responses of three different dietary challenges and a water control challenge were assessed on various metabolic and inflammatory markers in 14 healthy males and females using a full cross-over study design. The dietary challenges included glucose (75 g glucose in 300 ml water), lipids (200 ml whipping cream) and a mix of glucose and lipids (same amounts as above), respectively. Blood samples were collected at baseline and at 0.5, 1, 2, 4, 6, 8 and 10 h after consumption of the treatment products. Inflammation (IFNγ, IL-1ß, IL-6, IL-8, IL-10, IL-12p70, TNF-α CRP, ICAM-1, VCAM-1, SAA, E-selectin, P-selectin, thrombomodulin, leukocytes, neutrophils, lymphocytes) and clinical (e.g. glucose, insulin, triglycerides) markers as well as gene expression in blood cells and plasma oxylipin profiles were measured. RESULTS: All three dietary challenges induced changes related to metabolic control such as increases in glucose and insulin after the glucose challenge and increases in triglycerides after the lipid challenge. In addition, differences between the challenges were observed for precursor oxylipins and some downstream metabolites including DiHETrE's and HODE's. However, none of the dietary challenges induced an acute inflammatory response, except for a modest increase in circulating leukocyte numbers after the glucose and mix challenges. Furthermore, subtle, yet statistically significant increases in vascular inflammatory markers (sICAM-1 and sVCAM-1) were found after the mix challenge, when compared to the water control challenge. CONCLUSIONS: This study shows that dietary glucose and lipid challenges did not induce a strong acute inflammatory response in healthy subjects, as quantified by an accurate and broad panel of parameters.

Metabolic response to green tea extract during rest and moderate-intensity exercise.

BACKGROUND: Green tea catechins have been hypothesized to increase energy expenditure and fat oxidation by inhibiting catechol-O-methyltransferase (COMT) and thus promoting more sustained adrenergic stimulation. Metabolomics may help to clarify the mechanisms underlying their putative physiological effects. OBJECTIVE: The study investigated the effects of 7-day ingestion of green tea extract (GTE) on the plasma metabolite profile at rest and during exercise. METHODS: In a placebo-controlled, double-blind, randomized, parallel study, 27 healthy physically active males consumed either GTE (n=13, 1200 mg catechins, 240 mg caffeine/day) or placebo (n=14, PLA) drinks for 7 days. After consuming a final drink (day 8), they rested for 2 h and then completed 60 min of moderate-intensity cycling exercise (56% ± 4% VO(2)max). Blood samples were collected before and during exercise. Plasma was analyzed using untargeted four-phase metabolite profiling and targeted profiling of catecholamines. RESULTS: Using the metabolomic approach, we observed that GTE did not enhance adrenergic stimulation (adrenaline and noradrenaline) during rest or exercise. At rest, GTE led to changes in metabolite concentrations related to fat metabolism (3-ß-hydroxybutyrate), lipolysis (glycerol) and tricarboxylic acid cycle (TCA) cycle intermediates (citrate) when compared to PLA. GTE during exercise caused reductions in 3-ß-hydroxybutyrate concentrations as well as increases in pyruvate, lactate and alanine concentrations when compared to PLA. CONCLUSIONS: GTE supplementation resulted in marked metabolic differences during rest and exercise. Yet these metabolic differences were not related to the adrenergic system, which questions the in vivo relevance of the COMT inhibition mechanism of action for GTE.

Impact of short-term intake of red wine and grape polyphenol extract on the human metabolome.

Red wine and grape polyphenols are considered to promote cardiovascular health and are involved in multiple biological functions. Their overall impact on the human metabolome is not known. Therefore, exogenous and endogenous metabolic effects were determined in fasting plasma and 24 h urine from healthy male adults consuming a mix of red wine and grape juice extracts (WGM) for 4 days in a placebo-controlled, crossover study. Syringic acid, 3-hydroxyhippuric acid, pyrogallol, 3-hydroxyphenylacetic acid, and 3-hydroxyphenylpropionic acid were confirmed as the strongest urinary markers of WGM intake. Overall, WGM had a mild impact on the endogenous metabolism. Most noticeable were changes in several amino acids deriving from tyrosine and tryptophan. Reductions in the microbial metabolites p-cresol sulfate and 3-indoxylsulfuric acid and increases in indole-3-lactic acid and nicotinic acid were observed in urine. In plasma, tyrosine was reduced. The results suggest that short-term intake of WGM altered microbial protein fermentation and/or amino acid metabolism.

Relationships between tea and other beverage consumption to work performance and mood.

The aim of this research was to examine relationships between tea, coffee and other beverage consumption and associates of work performance and mood among individuals in relatively stressful and cognitively demanding work-place settings. Using a naturalistic, cross-sectional study design, 95 professional and academic staff logged their beverage intake and completed self-reports of associates of work performance (fatigue/exhaustion, mindfulness, work engagement), subjective work performance, mood, work-related strain and recovery four times daily during ten working days. Data were analysed using multilevel modelling in keeping with the hierarchical structure of the data. Tea consumption was associated with increased perceived work performance and reduced tiredness, especially when consumed without milk or sugar. Consumption of non-caffeinated beverages was associated with increased relaxation and recovery from work. In contrast, tea and other caffeinated beverages were found to enhance the negative effects of evening recovery and morning mood on mindfulness during the day. The findings suggest that beverage intake may have a role in optimising work-related psychological states and performance.

Improved diagnosis of colorectal cancer using a combination of fecal occult blood and novel fecal protein markers.

BACKGROUND & AIMS: Annual testing for fecal occult blood is recommended as first-line screening for the detection of colorectal cancer (CRC), but is affected by limited sensitivity. We initiated a proteomics-based search for novel biomarkers to improve the sensitivity of detection of CRC in stool samples. METHODS: Six markers, including immunologic fecal occult blood test (iFOBT), were evaluated in a collective of 551 samples (186 CRC, 113 advanced adenoma, and 252 control patients) to establish the diagnostic performance of each marker and marker combinations. RESULTS: We tested the known stool markers hemoglobin (iFOBT), hemoglobin-haptoglobin, calprotectin, carcinoembryogenic antigen, and the novel fecal markers tissue inhibitor of metalloproteinase-1 (TIMP-1) and S100A12. The best diagnostic performance was found for S100A12 with an area under the curve of 0.95, followed by TIMP-1 (0.92), hemoglobin-haptoglobin (0.92), hemoglobin (0.91), calprotectin (0.90), and carcinoembryogenic antigen (0.66). By using Bayes logistic regression as a mathematic model, the highest sensitivity (88%) for the detection of CRC at 95% specificity was obtained with the marker pair S100A12 and hemoglobin-haptoglobin. Increasing the specificity to 98%, the combination of S100A12, hemoglobin-haptoglobin, and TIMP-1 resulted in a sensitivity of 82%, with the highest increase of sensitivity found in early tumor stages (international union against cancer stage I: 74% sensitivity vs 57% of the best single marker). CONCLUSIONS: Depending on the specificity selected, a marker pair, S100A12 and hemoglobin-haptoglobin, or a triple combination including TIMP-1, allowed the detection of CRC at significantly higher rates than can be obtained with iFOBT alone.

Diagnosis of rheumatoid arthritis: multivariate analysis of biomarkers.

OBJECTIVE: To test if a combination of biomarkers can increase the classification power of autoantibodies to cyclic citrullinated peptides (anti-CCP) in the diagnosis of rheumatoid arthritis (RA) depending on the diagnostic situation. METHODS: Biomarkers were subject to three inclusion/exclusion criteria (discrimination between RA patients and healthy blood donors, ability to identify anti-CCP-negative RA patients, specificity in a panel with major non-rheumatological diseases) before univariate ranking and multivariate analysis was carried out using a modelling panel (n = 906). To enable the evaluation of the classification power in different diagnostic settings the disease controls (n = 542) were weighted according to the admission rates in rheumatology clinics modelling a clinic panel or according to the relative prevalences of musculoskeletal disorders in the general population seen by general practitioners modelling a GP panel. RESULT: Out of 131 biomarkers considered originally, we evaluated 32 biomarkers in this study, of which only seven passed the three inclusion/exclusion criteria and were combined by multivariate analysis using four different mathematical models. In the modelled clinic panel, anti-CCP was the lead marker with a sensitivity of 75.8% and a specificity of 94.0%. Due to the lack in specificity of the markers other than anti-CCP in this diagnostic setting, any gain in sensitivity by any marker combination is off-set by a corresponding loss in specificity. In the modelled GP panel, the best marker combination of anti-CCP and interleukin (IL)-6 resulted in a sensitivity gain of 7.6% (85.9% vs. 78.3%) at a minor loss in specificity of 1.6% (90.3% vs. 91.9%) compared with anti-CCP as the best single marker. CONCLUSION: Depending on the composition of the sample panel, anti-CCP alone or anti-CCP in combination with IL-6 has the highest classification power for the diagnosis of established RA.