An analysis of protocols and publications suggested that most discontinuations of clinical trials were not based on preplanned interim analyses or stopping rules.

OBJECTIVES To investigate the frequency of interim analyses, stopping rules, and data safety and monitoring boards (DSMBs) in protocols of randomized controlled trials (RCTs); to examine these features across different reasons for trial discontinuation; and to identify discrepancies in reporting between protocols and publications. STUDY DESIGN AND SETTING We used data from a cohort of RCT protocols approved between 2000 and 2003 by six research ethics committees in Switzerland, Germany, and Canada. RESULTS Of 894 RCT protocols, 289 prespecified interim analyses (32.3%), 153 stopping rules (17.1%), and 257 DSMBs (28.7%). Overall, 249 of 894 RCTs (27.9%) were prematurely discontinued; mostly due to reasons such as poor recruitment, administrative reasons, or unexpected harm. Forty-six of 249 RCTs (18.4%) were discontinued due to early benefit or futility; of those, 37 (80.4%) were stopped outside a formal interim analysis or stopping rule. Of 515 published RCTs, there were discrepancies between protocols and publications for interim analyses (21.1%), stopping rules (14.4%), and DSMBs (19.6%). CONCLUSION Two-thirds of RCT protocols did not consider interim analyses, stopping rules, or DSMBs. Most RCTs discontinued for early benefit or futility were stopped without a prespecified mechanism. When assessing trial manuscripts, journals should require access to the protocol.

Premature Discontinuation of Randomized Trials in Critical and Emergency Care: A Retrospective Cohort Study.

OBJECTIVES Randomized clinical trials that enroll patients in critical or emergency care (acute care) setting are challenging because of narrow time windows for recruitment and the inability of many patients to provide informed consent. To assess the extent that recruitment challenges lead to randomized clinical trial discontinuation, we compared the discontinuation of acute care and nonacute care randomized clinical trials. DESIGN Retrospective cohort of 894 randomized clinical trials approved by six institutional review boards in Switzerland, Germany, and Canada between 2000 and 2003. SETTING Randomized clinical trials involving patients in an acute or nonacute care setting. SUBJECTS AND INTERVENTIONS We recorded trial characteristics, self-reported trial discontinuation, and self-reported reasons for discontinuation from protocols, corresponding publications, institutional review board files, and a survey of investigators. MEASUREMENTS AND MAIN RESULTS Of 894 randomized clinical trials, 64 (7%) were acute care randomized clinical trials (29 critical care and 35 emergency care). Compared with the 830 nonacute care randomized clinical trials, acute care randomized clinical trials were more frequently discontinued (28 of 64, 44% vs 221 of 830, 27%; p = 0.004). Slow recruitment was the most frequent reason for discontinuation, both in acute care (13 of 64, 20%) and in nonacute care randomized clinical trials (7 of 64, 11%). Logistic regression analyses suggested the acute care setting as an independent risk factor for randomized clinical trial discontinuation specifically as a result of slow recruitment (odds ratio, 4.00; 95% CI, 1.72-9.31) after adjusting for other established risk factors, including nonindustry sponsorship and small sample size. CONCLUSIONS Acute care randomized clinical trials are more vulnerable to premature discontinuation than nonacute care randomized clinical trials and have an approximately four-fold higher risk of discontinuation due to slow recruitment. These results highlight the need for strategies to reliably prevent and resolve slow patient recruitment in randomized clinical trials conducted in the critical and emergency care setting.

Planning and reporting of quality-of-life outcomes in cancer trials.

BACKGROUND Information about the impact of cancer treatments on patients' quality of life (QoL) is of paramount importance to patients and treating oncologists. Cancer trials that do not specify QoL as an outcome or fail to report collected QoL data, omit crucial information for decision making. To estimate the magnitude of these problems, we investigated how frequently QoL outcomes were specified in protocols of cancer trials and subsequently reported. DESIGN Retrospective cohort study of RCT protocols approved by six research ethics committees in Switzerland, Germany, and Canada between 2000 and 2003. We compared protocols to corresponding publications, which were identified through literature searches and investigator surveys. RESULTS Of the 173 cancer trials, 90 (52%) specified QoL outcomes in their protocol, 2 (1%) as primary and 88 (51%) as secondary outcome. Of the 173 trials, 35 (20%) reported QoL outcomes in a corresponding publication (4 modified from the protocol), 18 (10%) were published but failed to report QoL outcomes in the primary or a secondary publication, and 37 (21%) were not published at all. Of the 83 (48%) trials that did not specify QoL outcomes in their protocol, none subsequently reported QoL outcomes. Failure to report pre-specified QoL outcomes was not associated with industry sponsorship (versus non-industry), sample size, and multicentre (versus single centre) status but possibly with trial discontinuation. CONCLUSIONS About half of cancer trials specified QoL outcomes in their protocols. However, only 20% reported any QoL data in associated publications. Highly relevant information for decision making is often unavailable to patients, oncologists, and health policymakers.

Pollen record from Kleiner Mochowsee, Germany

A Holocene pollen diagram from Kleiner Mochowsee (northern Niederlausitz, East Germany) shows pine as an important constituent of the woodland south of the Schwielochsee. Oak woodland was widespread since the Atlantic. Betula lost its importance at the end of the Preboreal. Fagus is represented continuously in the pollen record since the Atlantic, Carpinus since the Subboreal. However, the two latter tree species remain without great importance throughout the whole pollen record. The poor sandy soils are furthermore reflected by the low values of Corylus during the Boreal, comparable to other records from Berlin and its surrounding area. The 'classical' elm decline could be shown for the Niederlausitz, radiocarbon dates assume a contemporaneous age for this event with other records from northern Germany. Only small-scaled human impact is indicated in prehistoric times, during the migration period it seems to have ceased completely. Later, in the Medieval, deforestation and tillage can be shown. Secale was cultivated since the early Medieval; an accompanying weed flora appeared at the same time. Cultivation of Fagopyrum and Linum usitatissimum could be shown for the late Medieval times.

Pollen record and age determination of a sediment profile from Frengstadsetra, Norway

Innerdalen was once a mountain valley (ca. 780 m a.s.l.) with birch forests, bogs and several summer farms. Today it is a 6.5 km**2 artifical lake. In 1980 and 1981 archaeological and palynological investigations were carried out due to the hydroelectric power plans. Radiocarbon dated pollen diagrams from 9 different localities in Innerdalen provide information on a mountain environment which has been exploited to varying degrees by human groups for thousands of years. In the Birch Zone, ca. 9500-8500 years B.P., the deglaciated surface is vegetated by the normal sequence of pioneering species, first show-bed communities, then shrub/dwarf-shrub communities, and finally a birch forest community. In the Pine Zone, ca. 8500-7500 years B.P., the mixed Birch-Pine forest which prevailed at the end of the Birch Zone is replaced by a dense pine forest. The tree limit was higher than it is today. In the Alder Zone, ca. 7500-4000 years B.P., the newly arrived alder gradually succeeded pine, particularily on good soils. This alder forest has a modem analog in the pre-alpine gray alder forests in Norway. In the last part of the Alder Zone, ca. 6000-4000 years B.P., elm and hazel are nominally present on particularily rich soils, marking the edaphic and climatic optimum in Innerdalen. During this time the first evidence of human impact on the vegetation is apparent in the pollen diagrams. At both Sætersetra in the south of the valley and Liabekken in the north, forest clearance and the development of grazed grass meadows is documented, and human impact continues until the present. The Herb Zone, ca. 4000 years B.P. to 1600 A.D., is characterized by the rapid decline of alder. The forest is increasingly open, and bog formation is initiated. The sub-alpine belt of birch forest is established, probably due to the shift to a cooler, moister climate. Human activity can also have influenced the vegetational changes, although at 4 of the localities human activity also is first apparent after the alder decline. Some localities show measurably less human impact on the vegetation ca. 2600-2000 years B.P. Grazing intensity increases ca. 2000 years B.P. At the end of the Herb Zone rye and barley pollen is registered at Sætersetra and Flonan, indicating contact between the grazing activities of Innerdal and grain cultivation activities outside the valley. The Spruce Zone, ca. 1600 A.D. to the present, does not begin synchronously since the presence of long-distance transported spruce pollen at a locality is entirely dependent on the density of the vegetation ie. degree of human impact. The youngest spruce rise is ca. 1500 A.D. at Røstvangen, when summerfarming is initiated. Summerfarming activities in Innerdal produce an increasingly open landscape. Rye and barley pollen at several localities may indicate limited local cultivation, but is more likely long-distance transport via humans and domesticated animals from cultivated areas outside Innerdalen.

Pollen records from Elbe-Weser Dreieck

A long-running interdisciplinary research project on the development of landscape, prehistoric habitation and the history of vegetation within a "siedlungskammer" (limited habitation areal from neolithic to modern times has been carried out in the NW German lowlands, The siedlungskammer Flögeln is situated between the rivers Weser and EIbe and comprises about 23.5 km^2. It is an isolated pleistocene area surrounded by bogs, the soils consisting mainly of poor sands. In this siedlungskammer large-seale archaeological excavations and mappings have been performed, parallel to pedological, historical and above all pollen analytical investigations. The aim of the project is to record the individual phases in time, to delimit the respective settlement areas and to reconstruct the conditions of life and economy for each time period. A dense network of 10 pollen diagrams has been constructed. Several of them derive from the marginal area and from the centre of the large raised bog north of the siedlungskammer. These diagrams reflect the history of vegetation and habitation of a large region; due to the large pollen source area the habitation phases in the diagrams are poorly defined. Even in the utmost marginal diagram of this woodless bog, a great village with adjoining fields, situated only 100 m away from it, is registered with only low values of anthropogenic indicators. In contrast to this, the numerous pollen diagrams from kettle-hole bogs inside the siedlungskammer yield an exact picture of the habitation of the siedlungskammer and their individual parts. Early traces of habitation can be identified in the pollen diagram soon after the elm decline (around 5190 BP). Some time later in the middle neolithic period there follows a marked habitation phase, which starts between 4500 and 4400 BP and reflects the immigration of the trichterbecher culture. It corresponds to the landnam phase of Iversen in Denmark and begins with a sharp decline of the pollen curves of lime and oak, followed by the increase of anthropogenic indicators pointing to arable and pastural farming. High values of wild grasses and Calluna witness extensive forest grazing. This middle to late neolithic habitation is also registered archaeologically by settlements and numerous graves. After low human activity during Bronze Age and Older Iron Age times the archaeological and pollen analytical records of Roman and Migration periods is again very strong. This is followed by a gap in habitation during the 6th and 7th centuries and afterwards in the western part of the siedlungskammer from about 700 AD until the 14th century by the activity of the medieval village of Dalem, that was also excavated and whose fields were recorded by phosphate mapping to a size of 117 hectares. This medieval settlement phase is marked by much cereal cultivation (mainly rye). The dense network of pollen diagrams offers an opportunity to register the dispersion of the anthropogenic indicators from the areas of settlement to different distances and thus to obtain quantitative clues for the assessment of these anthropogenic indicators in pollen diagrams. In fig. 4 the reflection of the neolithic culture in the kettle-hole bogs and the large raised bog is shown in 3 phases: a) pre landnam, b) TRB-landnam, c) post landnam. Among arboreal pollen the reaction of Quercus is sharp close to the settlement but is not found at more distant profiles, whilst in contrast to this Tilia shows a significant decline even far away from the settlements. The record of most anthropogenic indicators outside the habitation area is very low, in particular cereal pollen is poorly dispersed; much more certain as an indicator for habitation (also for arable farming!) is Plantago lanceolata. A strong increase of wild grasses (partly Calluna aswell) some distance from the habitation areas indicates far reaching forest grazing. Fig. 5 illustrates the reflection of the anthropogenie indicators from the medieval village Dalem. In this instance the field area could be mapped exactly using phosphate investigations, and it has been possible to indicate the precise distances of the profile sites from the medieval fields. Here also, there is a clear correlation between decreasing anthropogenic indicators and increasing distance. In a kettle-hole bog (FLH) a distance of 3000 m away this marked settlement phase is not registered. The contrast between the pollen diagrams SWK and FLH (fig. 2 + 3, enclosure), illustrates the strong differences between diagrams from kettlehole bogs close to and distant from the settlements, for the neolithic as well as for the medieval period. On the basis of the examples presented here, implications concerning the interpretation of pollen diagrams with respect to habitation phases are discussed.

Estudio de la ecología de Ulmus laevis Pallas en la Península Ibérica

Esta tesis doctoral pretende profundizar en el conocimiento de la ecología de Ulmus laevis Pallas, especie autóctona en peligro de extinción en la Península Ibérica, con el fin de proponer medidas adecuadas para su conservación. Se ha estudiado la distribución natural de la especie atendiendo a aspectos edáficos. Los resultados muestran que U. laevis presenta menor capacidad de acidificación de la rizosfera, menor actividad de la reductasa férrica y menor homeostasis que U. minor Mill. cuando crecen en sustratos con una disponibilidad de hierro limitada. Estas diferencias ayudan a comprender la distribución de ambas especies en la Península Ibérica: U. laevis se ve restringido a suelos ácidos o moderadamente ácidos, mientras que U. minor es capaz de habitar tanto suelos ácidos como básicos. Se han analizado las propiedades hidráulicas y anatómicas de U. laevis, constatando que sus características son favorables en ambientes con gran disponibilidad hídrica y que se trata del olmo ibérico más vulnerable a la cavitación por estrés hídrico, por lo que la aridificación del clima y la pérdida de los freáticos supone un riesgo para sus poblaciones. Para evaluar la capacidad de recuperación de la especie se han estudiado la diversidad y estructura genética espacial de las dos mayores poblaciones españolas. Los resultados evidencian que estas poblaciones mantienen niveles de diversidad equiparables o ligeramente superiores a los europeos, pese a haber sufrido un cuello de botella prolongado durante las glaciaciones y a las reducciones poblacionales recientes. En la actualidad la endogamia no representa un riesgo para estas poblaciones. También se ha analizado la producción, dispersión y predación de semillas en Valdelatas (Madrid). Los resultados han mostrado que el viento dispersa las sámaras a corta distancia (<30 m) y que los años no veceros las probabilidades de establecimiento de regenerado son bajas. Además, la producción de sámaras vanas puede tratarse de un carácter adaptativo que aumenta la eficiencia biológica de la especie, ya que favorece la supervivencia de las semillas embrionadas disminuyendo sus tasas de predación pre- y post-dispersión. La modificación del hábitat de esta especie como consecuencia de las actividades humanas afecta de manera negativa al establecimiento del regenerado. La conservación de esta especie a largo plazo requiere la recuperación de los niveles freáticos y de regímenes hidrológicos que permitan avenidas, ya que estas crean las condiciones adecuadas para el establecimiento de regenerado al eliminar la vegetación preexistente y depositar barro. ABSTRACT Ulmus laevis Pallas is an endangered species in the Iberian Peninsula. Therefore, in order to be able to propose adequate management guidelines for its conservation, this PhD Thesis intends to advance the knowledge on the species ecology in the region. Firstly, the species natural distribution was studied in relation to soil nature. Results show that U. minor Mill. had a higher root ferric reductase activity and proton extrusion capability than U. laevis, and maintained a better nutrient homeostasis when grown under iron limiting conditions. These differences in root Fe acquisition efficiencies proved helpful to understand the distribution of these species in the Iberian Peninsula, where U. laevis is restricted to acid or moderately acid soils, whereas U. minor can grow both in acid and basic soils. Secondly, we studied Ulmus laevis’ xylem anatomy and hydraulic traits. These proved favourable for growing under high water availability, but highly susceptible to drought-stress cavitation. Therefore, this species is vulnerable to the Iberian Peninsula’s aridification. Spatial genetic structure and diversity were evaluated in two of the biggest U. laevis populations in Spain in order to evaluate their recovery capabilities. These populations maintain similar or slightly higher diversity levels than European populations, despite having undergone an ancestral genetic bottleneck and having suffered recent population size reductions. No inbreeding problems have been detected in these populations. Seed production, dispersal and predation were assessed in Valdelatas’ elm grove (Madrid). Despite U. laevis samaras being winged nuts, wind dispersed them short distances from the mother tree (<30 m). The seed shadow models show that non-mast years provide very few chances for the stand to regenerate due to their low full seed flux. Empty samaras deceive pre- and post-dispersal predators increasing full seed survival probabilities. Therefore, empty fruit production might be an adaptive trait that increases plant fitness. Finally, human-induced changes in water-table levels and river regulation may affect U. laevis seed dispersal and regeneration establishment negatively. The long-term conservation and expansion of this species in the Iberian Peninsula requires the recovery of water-tables and of natural hydrological regimes, as flooding eliminates vegetation, creating open microhabitats and deposits mud, creating the ideal conditions for seedling establishment.