Assessing the potential for prevention or earlier detection of on-site monitoring findings from randomised controlled trials: Further analyses of findings from the prospective TEMPER triggered monitoring study

BACKGROUND/AIMS: Clinical trials should be designed and managed to minimise important errors with potential to compromise patient safety or data integrity, employ monitoring practices that detect and correct important errors quickly, and take robust action to prevent repetition. Regulators highlight the use of risk-based monitoring, making greater use of centralised monitoring and reducing reliance on centre visits. The TEMPER study was a prospective evaluation of triggered monitoring (a risk-based monitoring method), whereby centres are prioritised for visits based on central monitoring results. Conducted in three UK-based randomised cancer treatment trials of investigational medicine products with time-to-event outcomes, it found high levels of serious findings at triggered centre visits but also at visits to matched control centres that, based on central monitoring, were not of concern. Here, we report a detailed review of the serious findings from TEMPER centre visits. We sought to identify feasible, centralised processes which might detect or prevent these findings without a centre visit. METHODS: The primary outcome of this study was the proportion of all 'major' and 'critical' TEMPER centre visit findings theoretically detectable or preventable through a feasible, centralised process. To devise processes, we considered a representative example of each finding type through an internal consensus exercise. This involved (a) agreeing the potential, by some described process, for each finding type to be centrally detected or prevented and (b) agreeing a proposed feasibility score for each proposed process. To further assess feasibility, we ran a consultation exercise, whereby the proposed processes were reviewed and rated for feasibility by invited external trialists. RESULTS: In TEMPER, 312 major or critical findings were identified at 94 visits. These findings comprised 120 distinct issues, for which we proposed 56 different centralised processes. Following independent review of the feasibility of the proposed processes by 87 consultation respondents across eight different trial stakeholder groups, we conclude that 306/312 (98%) findings could theoretically be prevented or identified centrally. Of the processes deemed feasible, those relating to informed consent could have the most impact. Of processes not currently deemed feasible, those involving use of electronic health records are among those with the largest potential benefit. CONCLUSIONS: This work presents a best-case scenario, where a large majority of monitoring findings were deemed theoretically preventable or detectable by central processes. Caveats include the cost of applying all necessary methods, and the resource implications of enhanced central monitoring for both centre and trials unit staff. Our results will inform future monitoring plans and emphasise the importance of continued critical review of monitoring processes and outcomes to ensure they remain appropriate

Dynamic methods for ongoing assessment of site-level risk in risk-based monitoring of clinical trials: A scoping review

BACKGROUND/AIMS: It is increasingly recognised that reliance on frequent site visits for monitoring clinical trials is inefficient. Regulators and trialists have recently encouraged more risk-based monitoring. Risk assessment should take place before a trial begins to define the overarching monitoring strategy. It can also be done on an ongoing basis, to target sites for monitoring activity. Various methods have been proposed for such prioritisation, often using terms like 'central statistical monitoring', 'triggered monitoring' or, as in the International Conference on Harmonization Good Clinical Practice guidance, 'targeted on-site monitoring'. We conducted a scoping review to identify such methods, to establish if any were supported by adequate evidence to allow wider implementation, and to guide future developments in this field of research. METHODS: We used seven publication databases, two sets of methodological conference abstracts and an Internet search engine to identify methods for using centrally held trial data to assess site conduct during a trial. We included only reports in English, and excluded reports published before 1996 or not directly relevant to our research question. We used reference and citation searches to find additional relevant reports. We extracted data using a predefined template. We contacted authors to request additional information about included reports. RESULTS: We included 30 reports in our final dataset, of which 21 were peer-reviewed publications. In all, 20 reports described central statistical monitoring methods (of which 7 focussed on detection of fraud or misconduct) and 9 described triggered monitoring methods; 21 reports included some assessment of their methods' effectiveness, typically exploring the methods' characteristics using real trial data without known integrity issues. Of the 21 with some effectiveness assessment, most contained limited information about whether or not concerns identified through central monitoring constituted meaningful problems. Several reports demonstrated good classification ability based on more than one classification statistic, but never without caveats of unclear reporting or other classification statistics being low or unavailable. Some reports commented on cost savings from reduced on-site monitoring, but none gave detailed costings for the development and maintenance of central monitoring methods themselves. CONCLUSION: Our review identified various proposed methods, some of which could be combined within the same trial. The apparent emphasis on fraud detection may not be proportionate in all trial settings. Despite some promising evidence and some self-justifying benefits for data cleaning activity, many proposed methods have limitations that may currently prevent their routine use for targeting trial monitoring activity. The implementation costs, or uncertainty about these, may also be a barrier. We make recommendations for how the evidence-base supporting these methods could be improved

Deformation of lamellar TiAl alloys by longitudinal twinning

© 2016 Elsevier Ltd. The occurrence of longitudinal twinning in the engineering alloy Ti-45Al-2Nb-2Mn (at.%)-0.8 vol.% TiB2 has been studied by measuring the changes in crystallographic orientation within individual lamellae during microcompression. Twinning in this alloy appeared to be a nucleation-limited process with the twins growing from lamellar boundaries at resolved shear stresses as low as 100 MPa, consistent with observations elsewhere. However, instead of forming twins ∼ 10-200 nm in thickness, as in polysynthetically twinned crystals, the longitudinal twins in this alloy were initiated at a lamellar boundary and then spread through the whole lamella.The work was supported by the EPSRC / Rolls-Royce Strategic Partnership (EP/H500375/1). Alberto Palomares Garcia, Claire Davis and Robert Jones are acknowledged for discussions and help with the TEM respectively

The effect of an alginate carrier on bone formation in a hydroxyapatite scaffold.

This study investigated the osteoconductive properties of a porous hydroxyapatite (HA) scaffold manufactured using a novel technique similar to the bread-making process, alone and in combination with an alginate polysaccharide fiber gel (HA/APFG putty) and autologous bone marrow aspirate (BMA). The hypothesis was that the HA/APFG putty would be as osteoconductive as granular HA and that the presence of BMA would further enhance bone formation in an ovine femoral condyle critical defect model. Thirty-six defects were created and either (1) porous HA granules, (2) HA/APFG putty, or (3) HA/APFG putty + BMA were implanted. After retrieval at 6 and 12 weeks, image analysis techniques were used to quantify bone apposition rates, new bone area, bone-HA scaffold contact, and implant resorption. At 6 weeks postsurgery, significantly lower bone apposition rates were observed in the HA/APFG putty group when compared to the HA (p = 0.014) and HA/APFG putty + BMA (p = 0.014) groups. At 12 weeks, significantly increased amounts of new bone formation were measured within the HA scaffold (33.56 ± 3.53%) when compared to both the HA/APFG putty (16.69 ± 2.7%; p = 0.043) and the defects containing HA/APFG putty + BMA (19.31 ± 3.8%; p = 0.043). The use of an APFG gel as a carrier for injectable CaP bone substitute materials delayed bone formation in this model compared to HA granules alone which enhanced bone formation especially within the interconnected smaller pores. Our results also showed that the addition of autologous BMA did not further enhance its osteoconductive properties. Further study is required to optimize the degradation rate of this APFG binding agent before using as a directly injectable material for repair of bone defect. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2015

Stable Speckle Patterns for Nano-scale Strain Mapping up to 700 °C

The digital image correlation (DIC) of speckle patterns obtained by vapour-assisted gold remodelling at 200 – 350 °C has already been used to map plastic strains with submicron resolution. However, it has not so far proved possible to use such patterns for testing at high temperatures. Here we demonstrate how a gold speckle pattern can be made that is stable at 700 °C, to study deformation in a commercial TiAl alloy (Ti-45Al-2Nb- 2Mn(at%)-0.8 vol% TiB$_2$). The pattern is made up of a uniformly sized random array of Au islands as small as 15 nm in diameter, depending on reconstruction parameters, with a sufficiently small spacing to be suitable for nano-scale, nDIC, strain mapping at a subset size of 60 × 60 nm$^2$ . It can be used at temperatures up to 700 °C for many hours, for high cycle fatigue testing for instance. There is good particle attachment to the substrate. It can withstand ultra-sound cleaning, is thermally stable and has a high atomic number contrast for topography-free backscatter electron imaging.EPSRC / Rolls-Royce Strategic Partnership (EP/M005607/1

Longitudinal twinning in a TiAl alloy at high temperature by in situ microcompression

The stress required to activate twinning of the longitudinal <11bar2]{111} system in the lamellar γ-TiAl phase of the alloy Ti-45Al-2Nb-2Mn (at.%)-0.8 vol.% TiB2 was measured at several temperatures up to 700 ºC by in situ micropillar compression of soft mode oriented γ-TiAl/α2-Ti3Al lamellar stacks. The lamellae undergoing deformation twinning were identified by electron backscatter diffraction orientation mapping. In some cases, such lamellae were not constrained by domain or colony boundaries and longitudinal twinning was the only deformation mechanism observed based on digital image correlation strain maps. The resolved shear stress for such unconstrained twinning was found to increase monotonically with temperature from 25 ºC to 700 ºC. This is consistent with the stacking fault energy increasing with temperature as found in many metallic alloys, suggesting that the increased ease of deformation twinning at high temperature in bulk TiAl alloys is due to the increased ease with which the twinning shear can be accommodated by the neighbouring domains and lamellae with increasing temperature, rather than a thermal softening of the intrinsic twinning mechanism

Deformation of lamellar γ-TiAl below the general yield stress

The occurrence of plasticity below the macroscopic yield stress during tensile monotonic loading of nearly lamellar Ti-45Al-2Nb-2Mn(at%)-0.8vol% TiB2 at both 25 °C and 700 °C, and in two conditions of lamellar thickness, was measured by digital image correlation strain mapping of a remodelled Au surface speckle pattern. Such initial plasticity, not necessarily related to the presence of common stress concentrators such as hard particles or cracks, could occur at applied stresses as low as 64 % of the general yield stress. For a same applied strain it was more prominent at room temperature, and located as slip and twinning parallel to, and near to or at (respect.) lamellar interfaces of all types in soft modeoriented colonies. These stretched the full colony width and the shear strain was most intense in the centre of the colonies. Further, the most highly operative microbands of plasticity at specimen fracture were not those most active prior to yielding. The strain mapping results from polycrystalline tensile loading were further compared to those from microcompression testing of soft-mode stacks of lamellae milled from single colonies performed at the same temperatures. Combined with post-mortem transmission electron microscopy of the pillars, the initial plasticity by longitudinal dislocation glide was found to locate within 30 – 50 nm of the lamellar interfaces, and not at the interfaces themselves. The highly localised plasticity that precedes high cycle fatigue failure is therefore inherently related to the lamellar structure, which predetermines the locations of plastic strain accumulation, even in a single loading cycle.The work was supported by the EPSRC / Rolls-Royce Strategic Partnership (EP/M005607/1). T.E.J.E. also acknowledges the kind support of the Worshipful Company of Armourers and Brasiers’ Gauntlet Trust

The interaction of borides and longitudinal twinning in polycrystalline TiAl alloys

In this paper the occurrence of twinning parallel to the lamellae during compression at 700 °C of a polycrystalline nearly lamellar commercial γ-TiAl alloy, Ti-45Al-2Nb-2Mn(at%)-0.8 vol% TiB2, has been studied and shown to lead to the formation of cracks at colony boundaries. However, the occurrence of this longitudinal twinning mode was less common by at least a factor of ten in tests at room temperature. Furthermore, the debonding of colony boundaries caused by the shear strain of longitudinal twinning is exacerbated when the same γ-TiAl variant favourably oriented for twinning occurs repeatedly in the lamellar structure. This effect was caused by the preferential nucleation of certain γ-TiAl variants in the presence of TiB2 boride reinforcement. It is shown that the boride additions increase the probability of double, triple or even higher order multiply stacked γ-variants. This increases the resulting shear strain that must be accommodated and hence the probability of crack nucleation.The work was supported by the EPSRC/Rolls-Royce Strategic Partnership (EP/M005607/1)

Opposing associations of depression with sexual behaviour: implications for epidemiological investigation among gay, bisexual and other men who have sex with men

OBJECTIVE: The aim of this report is to investigate the nature of the relationship between depression and condomless sex (CLS) among gay, bisexual and other men who have sex with men (GBMSM). METHODS: Data are from the Antiretrovirals, Sexual Transmission Risk and Attitude (ASTRA) study of people living with HIV and attending one of eight HIV outpatient clinics in England (2011-2012) and the Attitudes to and Understanding of Risk of Acquisition of HIV (AURAH) study of HIV-negative/unknown status individuals attending one of 20 genitourinary medicine clinics in England (2013-2014). This analysis included GBMSM only. For each study, the prevalence of depressive symptoms (Patient Health Questionnaire-9 score ≥10) was presented according to three categories of sex in the past 3 months (considering anal/vaginal sex with men/women and anal sex with men in separate definitions): (1) no sex, (2) condom-protected sex only and (3) CLS. Multinomial logistic regression with 'condom-protected sex only' as the reference group was used to adjust for age and (for ASTRA participants) time since HIV diagnosis. RESULTS: There were opposing associations of depression with recent sexual behaviour: the prevalence of depression was higher among those who reported no sex and those who reported CLS, compared with those who reported condom-protected sex only. Among the 2170 HIV-positive GBMSM in ASTRA, considering anal/vaginal sex with men/women, the prevalence of depressive symptoms was 32%, 20% and 28%, respectively, among men reporting no sex (n=783), condom-protected sex only (n=551) and CLS (n=836) (global p<0.001). Among the 1477 HIV-negative GBMSM in AURAH, the prevalence of depressive symptoms was 12%, 8% and 13%, respectively, for no sex (n=137), condom-protected sex only (n=487) and CLS (n=853) (global p=0.017). Patterns were similar after adjustment and when only considering anal sex between men. CONCLUSIONS: Depression may be linked both to lack of sexual activity and to sexual risk taking. When investigating associations between depression and CLS, it is important to separate out individuals reporting condom-protected sex only from those reporting no sex

Methodological criteria for the assessment of moderators in systematic reviews of randomised controlled trials : a consensus study

Background: Current methodological guidelines provide advice about the assessment of sub-group analysis within RCTs, but do not specify explicit criteria for assessment. Our objective was to provide researchers with a set of criteria that will facilitate the grading of evidence for moderators, in systematic reviews. Method: We developed a set of criteria from methodological manuscripts (n = 18) using snowballing technique, and electronic database searches. Criteria were reviewed by an international Delphi panel (n = 21), comprising authors who have published methodological papers in this area, and researchers who have been active in the study of sub-group analysis in RCTs. We used the Research ANd Development/University of California Los Angeles appropriateness method to assess consensus on the quantitative data. Free responses were coded for consensus and disagreement. In a subsequent round additional criteria were extracted from the Cochrane Reviewers’ Handbook, and the process was repeated. Results: The recommendations are that meta-analysts report both confirmatory and exploratory findings for subgroups analysis. Confirmatory findings must only come from studies in which a specific theory/evidence based apriori statement is made. Exploratory findings may be used to inform future/subsequent trials. However, for inclusion in the meta-analysis of moderators, the following additional criteria should be applied to each study: Baseline factors should be measured prior to randomisation, measurement of baseline factors should be of adequate reliability and validity, and a specific test of the interaction between baseline factors and interventions must be presented. Conclusions: There is consensus from a group of 21 international experts that methodological criteria to assess moderators within systematic reviews of RCTs is both timely and necessary. The consensus from the experts resulted in five criteria divided into two groups when synthesising evidence: confirmatory findings to support hypotheses about moderators and exploratory findings to inform future research. These recommendations are discussed in reference to previous recommendations for evaluating and reporting moderator studies