Adding a treatment arm to an ongoing clinical trial: a review of methodology and practice

Incorporating an emerging therapy as a new randomisation arm in a clinical trial that is open to recruitment would be desirable to researchers, regulators and patients to ensure that the trial remains current, new treatments are evaluated as quickly as possible, and the time and cost for determining optimal therapies is minimised. It may take many years to run a clinical trial from concept to reporting within a rapidly changing drug development environment; hence, in order for trials to be most useful to inform policy and practice, it is advantageous for them to be able to adapt to emerging therapeutic developments. This paper reports a comprehensive literature review on methodologies for, and practical examples of, amending an ongoing clinical trial by adding a new treatment arm. Relevant methodological literature describing statistical considerations required when making this specific type of amendment is identified, and the key statistical concepts when planning the addition of a new treatment arm are extracted, assessed and summarised. For completeness, this includes an assessment of statistical recommendations within general adaptive design guidance documents. Examples of confirmatory ongoing trials designed within the frequentist framework that have added an arm in practice are reported; and the details of the amendment are reviewed. An assessment is made as to how well the relevant statistical considerations were addressed in practice, and the related implications. The literature review confirmed that there is currently no clear methodological guidance on this topic, but that guidance would be advantageous to help this efficient design amendment to be used more frequently and appropriately in practice. Eight confirmatory trials were identified to have added a treatment arm, suggesting that trials can benefit from this amendment and that it can be practically feasible; however, the trials were not always able to address the key statistical considerations, often leading to uninterpretable or invalid outcomes. If the statistical concepts identified within this review are considered and addressed during the design of a trial amendment, it is possible to effectively assess a new treatment arm within an ongoing trial without compromising the original trial outcomes.

Engineering a plant community to deliver multiple ecosystem services

The sustainable delivery of multiple ecosystem services requires the management of functionally diverse biological communities. In an agricultural context, an emphasis on food production has often led to a loss of biodiversity to the detriment of other ecosystem services such as the maintenance of soil health and pest regulation. In scenarios where multiple species can be grown together, it may be possible to better balance environmental and agronomic services through the targeted selection of companion species. We used the case study of legume-based cover crops to engineer a plant community that delivered the optimal balance of six ecosystem services: early productivity, regrowth following mowing, weed suppression, support of invertebrates, soil fertility building (measured as yield of following crop), and conservation of nutrients in the soil. An experimental species pool of 12 cultivated legume species was screened for a range of functional traits and ecosystem services at five sites across a geographical gradient in the United Kingdom. All possible species combinations were then analyzed, using a process-based model of plant competition, to identify the community that delivered the best balance of services at each site. In our system, low to intermediate levels of species richness (one to four species) that exploited functional contrasts in growth habit and phenology were identified as being optimal. The optimal solution was determined largely by the number of species and functional diversity represented by the starting species pool, emphasizing the importance of the initial selection of species for the screening experiments. The approach of using relationships between functional traits and ecosystem services to design multifunctional biological communities has the potential to inform the design of agricultural systems that better balance agronomic and environmental services and meet the current objective of European agricultural policy to maintain viable food production in the context of the sustainable management of natural resources.

Using eye movements to investigate word frequency effects in children’s sentence reading

While eye movements have been used widely to investigate how skilled adult readers process written language, relatively little research has used this methodology with children. This is unfortunate as, as we discuss here, eye-movement studies have significant potential to inform our understanding of children’s reading development. We consider some of the empirical and theoretical issues that arise when using this methodology with children, illustrating our points with data from an experiment examining word frequency effects in 8-year-old children’s sentence reading. Children showed significantly longer gaze durations to low than high-frequency words, demonstrating that linguistic characteristics of text drive children’s eye movements as they read. We discuss these findings within the broader context of how eye-movement studies can inform our understanding of children’s reading, and can assist with the development of appropriately targeted interventions to support children as they learn to read.

The use and usefulness of a parent questionnaire to help schools identify disability

The Equality Act 2010 will be implemented in full in 2011, and schools in the UK will have to provide special aids or services for children with disabilities where this provision is considered reasonable. This paper reports on staff perspectives on the use and usefulness of a parental questionnaire on disability from a sample of 49 schools (mainstream and special) located in 12 local authorities. Most schools found the process of administering the parent questionnaire undemanding; just under half of the sample indicated that they would take some action as a result of the data collected from the parental questionnaire (e.g., to inform plans for targeting or monitoring support for children, and to contact parents and follow-up issues they had mentioned); and about one-third of schools recorded unanticipated findings from the parental questionnaire, that is, the identification of children whose disabilities were not previously known to the school. Implications for schools are discussed.

Product development process: Using real options for assessments and to support the decision-making at decision gates

Enterprises need continuous product development activities to remain competitive in the marketplace. Their product development process (PDP) must manage stakeholders' needs - technical, financial, legal, and environmental aspects, customer requirements, Corporate strategy, etc. -, being a multidisciplinary and strategic issue. An approach to use real option to support the decision-making process at PDP phases in taken. The real option valuation method is often presented as an alternative to the conventional net present value (NPV) approach. It is based on the same principals of financial options: the right to buy or sell financial values (mostly stocks) at a predetermined price, with no obligation to do so. In PDP, a multi-period approach that takes into account the flexibility of, for instance, being able to postpone prototyping and design decisions, waiting for more information about technologies, customer acceptance, funding, etc. In the present article, the state of the art of real options theory is prospected and a model to use the real options in PDP is proposed, so that financial aspects can be properly considered at each project phase of the product development. Conclusion is that such model can provide more robustness to the decisions processes within PDP.

Study of thresholds to burning in surface grinding process

This work aims at finding out the threshold to burning in surface grinding process. Acoustic emission and electric power signals are acquired from an analog-digital converter and processed through algorithms in order to generate a control signal to inform the operator or interrupt the process in the case of burning occurrence. The thresholds that dictate the situation of burn and non-burn were studied as well as a comparison between the two parameters was carried out. In the experimental work one type of steel (ABNT-1045 annealed) and one type of grinding wheel referred to as TARGA model 3TG80.3-NV were employed. Copyright © 2005 by ABCM.

Evaluation report of the training workshop on the use of the module to analyse growth of international commerce (Magic Plus) and the competitive analysis of nations (TRADECAN 2009) software

The aim of the workshop was to provide a functional overview of the software package, to enable participants to use the software in order to inform more evidence-based trade strategies, and build capacity for researchers and trade negotiators to provide more rigorous, analytical policy research to inform future trade negotiations. Participants came from the ministries of trade of the following CDCC member countries: Dominica, Grenada, Jamaica, Saint Lucia, Saint Kitts and Nevis, Saint Vincent and the Grenadines, and Trinidad and Tobago. Representatives of the following regional institutions were represented: the Caribbean Community/Caribbean Regional Negotiating Mechanism (CARICOM/CRNM); the Organisation of Eastern Caribbean States (OECS); the University of Guyana, University of Suriname and the University of the West Indies (UWI). It was hoped the workshop would be a stepping stone towards more advanced trade analysis training. The list of participants appears as Annex I.

The CARIFORUM-EU Economic Partnership Agreement (EPA): an assessment of issues relating to market access, safeguards and implications for regional integration

The recent collapse of the Doha round once again underscores the tenuous nature of international trade negotiations. Likewise, the Economic Partnership Agreement (EPA) between the CARIFORUM grouping and the European Union (EU) has generated a great deal of discussion and debate over the past several months. What has clearly emerged is the existence of two diametrically opposed views on the impact and usefulness of the agreement. One view has it that the EPA is a major breakthrough in trade relations that will greatly benefit the region. On the other hand, some see it as being detrimental to the region and perhaps a total capitulation to the EU on the part of the CARIFORUM. They assert that it is part of a global EU strategy to impose World Trade Organization (WTO) policies on developing nations and get around the Doha obstacles. Both sides in this debate attempt to back up their views with reference to the text of the agreement. The objective of this review is to shed some light on the issues driving this debate particularly in the areas of market access, the impact on tariff revenues, and the implications for regional integration. This review also attempts to clarify and distill some of the main contentious issues regarding the EPA and to inform further discussion regarding an implementation plan. The approach is based on detailed study of the EPA text and its annexes plus extensive interviews with some of the main negotiators on the CARIFORUM side. Interviews were conducted both in person and via the Internet as many of the regional negotiators live or work outside of the region. The reviewer also attended presentations and discussions with some of the leading regional critics of the agreement.

Review of Harvest for Hope: A Guide to Mindful Eating by Jane Goodall with Gary McAvoy and Gail Hudson

One of the world's preeminent experts on primate behavior, author Jane Goodall now invests her boundless energy traveling and speaking about conservation. After years of studying chimpanzees in the Gombe National Park in Tanzania, Goodall found their very existence threatened by poachers, by encroachment of farming into their habitat, and by global forces far from their wild environment. She is now on a mission to inform the public about what is wrong with our society and its impact on the planet. Harvest for Hope catalogs the problems and provides practical solutions.

Adopting an integrated, flexible approach to reducing the birdstrike risk from Canada geese

Canada Geese overflying the runways at London’s Heathrow Airport have been struck on eleven occasions by aircraft during the last ten years. Four of these occurred during the pre-breeding season and seven during the post moult period. A monitoring study was initiated in 1999 to evaluate the movements of geese around the airport and determine appropriate mitigation strategies to reduce the risk of birdstrike. Moult sites within 13km of the airport were identified. 4,900 moulting geese were caught and fitted with colour rings and radio-transmitters between 1999 and 2004. 2,500 visits were made to over 300 sites resulting in over 10,000 sightings of known individuals. Birds that crossed the airport approaches whilst moving between roost sites and feeding areas in newly harvested cereal crops were identified. Throughout the monitoring period efforts were made to control the risk, but by 2003 it was estimated that 10,000 bird transits of the approaches involving almost 700 individuals occurred during a 50 day period. The knowledge of the movements of ringed and tagged birds was used to inform a revised habitat management, daily roost dispersal and on-airfield bird deterrence programme in 2004. By adopting a flexible approach to management, an estimated 70% reduction in bird transits was achieved. This paper discusses the techniques used to achieve this reduction.

Implant-Supported Prosthesis Misalignment Related to the Dental Arch: A 14-Year Clinical Follow-up

The purpose of this study was to warn the dental community about a possible problem in function with partial implant-supported prostheses used for long periods. The misalignment between natural teeth and the implant-supported prosthesis on teeth 11 and 12, observed in a 14-year clinical follow-up, illustrates the fact. The metal-ceramic crowns were placed in 1995 after a rigorous occlusal adjustment. Evaluations were made at 4, 6, 9, and 14 years, when it was noticed that the restorations were positioned palatally and extruded in comparison with the natural teeth. After 9 years, a greater discrepancy was noticed, with anterior occlusion and esthetic changes. The possible causes have been discussed: occlusal problems, parafunctional habits, and natural movement. The first 2 options were discarded after clinical analysis and diagnosis. Therefore, the natural movement probably deriving from an interaction of mechanical and genetic factors might have been the cause. The implants do not have periodontal ligaments but rather ankylosis, so they do not suffer those movements. This case emphasizes the need to inform patients that implants can last more than 10 years in function, but this is not the case with restorations, which lose function and esthetics and must be replaced.

Incident cancer burden attributable to excess body mass index in 30 European countries

Excess adiposity is associated with increased risks of developing adult malignancies. To inform public health policy and guide further research, the incident cancer burden attributable to excess body mass index (BMI >or= 25 kg/m(2)) across 30 European countries were estimated. Population attributable risks (PARs) were calculated using European- and gender-specific risk estimates from a published meta-analysis and gender-specific mean BMI estimates from a World Health Organization Global Infobase. Country-specific numbers of new cancers were derived from Globocan2002. A ten-year lag-period between risk exposure and cancer incidence was assumed and 95% confidence intervals (CI) were estimated in Monte Carlo simulations. In 2002, there were 2,171,351 new all cancer diagnoses in the 30 countries of Europe. Estimated PARs were 2.5% (95% CI 1.5-3.6%) in men and 4.1% (2.3-5.9%) in women. These collectively corresponded to 70,288 (95% CI 40,069-100,668) new cases. Sensitivity analyses revealed estimates were most influenced by the assumed shape of the BMI distribution in the population and cancer-specific risk estimates. In a scenario analysis of a plausible contemporary (2008) population, the estimated PARs increased to 3.2% (2.1-4.3%) and 8.6% (5.6-11.5%), respectively, in men and women. Endometrial, post-menopausal breast and colorectal cancers accounted for 65% of these cancers. This analysis quantifies the burden of incident cancers attributable to excess BMI in Europe. The estimates reported here provide a baseline for future modelling, and underline the need for research into interventions to control weight in the context of endometrial, breast and colorectal cancer.

Toward optimal early management after whiplash injury to lessen the rate of transition to chronicity: discussion paper 5

Expert debate and synthesis of research to inform future management approaches for acute whiplash disorders.

[Consensus recommendations for the assessment of fitness to drive in cognitively impaired patients]

Memory Clinics provide evidence based diagnosis and treatment of dementia. Whenever a diagnosis of dementia is made, it is important to inform the patients about the possible impact of dementia on driving. Patients and their next of kin require competent advice whenever this difficult question is addressed and the mobility desire and the risks related to driving need to be carefully weight up. The time of diagnosis does not necessarily equate to the time when a person with dementia becomes an unsafe driver. The cause and severity of dementia, comorbidities and the current medication need to be carefully taken into account for this decision. On behalf of the association of the Swiss Memory Clinics, a group of experts has developed recommendations to assess fitness to drive in cognitively impaired older adults.

Adapting health-risk communication to the specific cultural contexts of diverse populations : an assessment of malaria-treatment programs in Liberia

Drawing on theories of technical communication, rhetoric, literacy, language and culture, and medical anthropology, this dissertation explores how local culture and traditions can be incorporated into health-risk-communication-program design and implementation, including the design and dissemination of health-risk messages. In a modern world with increasing global economic partnerships, mounting health and environmental risks, and cross-cultural collaborations, those who interact with people of different cultures have “a moral obligation to take those cultures seriously, including their social organization and values” (Hahn and Inhorn 10). Paradoxically, at the same time as we must carefully adapt health, safety, and environmental-risk messages to diverse cultures and populations, we must also recognize the increasing extent to which we are all becoming part of one, vast, interrelated global village. This, too, has a significant impact on the ways in which healthcare plans should be designed, communicated, and implemented. Because communicating across diverse cultures requires a system for “bridging the gap between individual differences and negotiating individual realities” (Kim and Gudykunst 50), both administrators and beneficiaries of malaria-treatment-and-control programs (MTCPs) in Liberia were targeted to participate in this study. A total of 105 people participated in this study: 21 MTCP administrators (including designers and implementers) completed survey questionnaires on program design, implementation, and outcomes; and 84 MTCP beneficiaries (e.g., traditional leaders and young adults) were interviewed about their knowledge of malaria and methods for communicating health risks in their tribe or culture. All participants showed a tremendous sense of courage, commitment, resilience, and pragmatism, especially in light of the fact that many of them live and work under dire socioeconomic conditions (e.g., no electricity and poor communication networks). Although many MTCP beneficiaries interviewed for this study had bed nets in their homes, a majority (46.34 percent) used a combination of traditional herbal medicine and Western medicine to treat malaria. MTCP administrators who participated in this study rated the impacts of their programs on reducing malaria in Liberia as moderately successful (61.90 percent) or greatly successful (38.10 percent), and they offered a variety of insights on what they might do differently in the future to incorporate local culture and traditions into program design and implementation. Participating MTCP administrators and beneficiaries differed in their understanding of what “cultural incorporation” meant, but they agreed that using local indigenous languages to communicate health-risk messages was essential for effective health-risk communication. They also suggested that understanding the literacy practices and linguistic cultures of the local people is essential to communicating health risks across diverse cultures and populations.