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Biomedical subjects

B S Hawkins

Publications and source records attributed to B S Hawkins.

At least 37 records · Page 2Linked to original sources

Data monitoring committees for multicenter clinical trials sponsored by the National Institutes of Health. I. Roles and membership of data monitoring committees for trials sponsored by the National Eye Institute.

The operational aspects of data monitoring committees for multicenter clinical trials have received little attention in the published literature, in contrast to a wealth of publications concerning the statistical aspects of data monitoring. Occasional anecdotal reports suggest that the role of these committees is complex and that responsibilities and decisions extend beyond choice of a stopping rule. In an effort to gain a better appreciation of the domain of responsibilities shared by all or most of the data monitoring committees (DMCs) for the 20 multicenter studies (30 clinical trials) sponsored by the National Eye Institute, one of the National Institutes of Health, published information was studied and key members of the DMCs for these studies were surveyed. Information about the membership of these important groups also was sought in order to guide those with responsibility for appointing future DMCs. Three tasks--all directly associated with monitoring accumulating data for evidence of benefit or harm to trial patients--were reported unanimously to be the responsibility of the DMCs. In addition, many responsibilities concerned with study oversight rather than data monitoring were assigned to the DMC in 75% or more of the trials. The domain of responsibilities common to a majority of the DMCs suggests that these groups function in most NEI-sponsored multicenter trials as combined data monitoring and policy boards, even when not so designated. The median size of the 20 DMCs was 10 members, with six appointed and four ex officio members. Ophthalmologists accounted for 38% of all DMC positions and statisticians for 33%.

Clinical Trials as Topic↗

Relationship between rate of patient enrollment and quality of clinical center performance in two multicenter trials in ophthalmology.

Those responsible for managing and overseeing multicenter clinical trials often express concern that differential rates of patients enrollment among participating clinical centers may be reflected in poorer compliance with study protocols or poorer patient care in the centers enrolling fewer patients. The purposes of the present investigation were (1) to determine whether rate of patient enrollment was related to other measures of clinical center performance in two multicenter clinical trials in ophthalmology, the Macular Photocoagulation Study (MPS) and the Early Treatment Diabetic Retinopathy Study (ETDRS), and (2) to compare findings from these two studies with findings reported from cooperative oncology groups. Percent of major data forms ever failing computerized edit was the only measure of performance examined that demonstrated a strong positive relationship to rate of patient enrollment in both studies under both analytic approaches employed (F test for linear trend in means and Spearman's rank correlation). In the MPS, but not in the ETDRS, percent of patients who had missed all visits scheduled during the past 12 months (inactive patients) also was related to rate of patient enrollment. However, the major finding from this investigation has been that it is not possible to predict overall performance of an individual clinical center based on rate of patient enrollment. Clinical centers enrolling fewer patients in these multicenter clinical trials performed in some areas as well as or better than centers enrolling larger numbers of patients.

Diabetic Retinopathy↗

The use of fundus photographs and fluorescein angiograms in the identification and treatment of choroidal neovascularization in the Macular Photocoagulation Study. The Macular Photocoagulation Study Group.

The Macular Photocoagulation Study (MPS) Fundus Photograph Reading Center has developed a standard set of methods for assessing color photographs and fluorescein angiograms on study patients. For pretreatment angiograms, these methods are used to determine the location and extent of the choroidal neovascularization. For posttreatment color fundus photographs, these methods are used to assess the extent and intensity of treatment. Although these methods were developed to judge eligibility and treatment of patients enrolled in the MPS, they provide an excellent way for all treating ophthalmologists to evaluate their patients' angiograms and to assess immediately the intensity and extent of laser photocoagulation. The technique requires a microfilm reader or slide projection device to determine the completeness of treatment. The authors superimpose independent drawings made from pre- and posttreatment photographs. The techniques described can be applied readily in clinical practice. Since persistent neovascularization is highly correlated with incomplete and/or inadequate photocoagulation treatment, clinicians may adopt these Reading Center techniques to minimize the frequency of persistent neovascularization and, possibly, to reduce the frequency of visual loss in treated eyes.

Choroid↗

Selection of controls for clinical research studies in ophthalmology.

Ophthalmologists are becoming increasingly aware of the need for well-designed, controlled studies to investigate etiology and treatment of ocular conditions. While patients with the conditions of interest, or with characteristics that place them at high risk of eventual development of such conditions, may be readily identified in the ophthalmology clinic, identification of appropriate controls to be used for comparison may be quite difficult. In this article, epidemiologic principles for selection of controls for retrospective (case-control) and prospective (cohort) studies are reviewed. Two related studies, a case-control study in which multiple control groups were employed and a 15-year cohort study of all cases and controls, provided an opportunity to compare controls selected at random from an ophthalmology practice with controls selected at random from the general population. Participation rates were higher among office patients selected for study, both in the case-control study and in the cohort study. In the cohort study, office controls were more likely to lose visual acuity and to develop new degenerative eye conditions. These differences between control groups selected from two different sources emphasize the need for careful evaluation of potential groups of controls with respect to biases that each may bring to interpretation of clinical research findings.

Biometry↗

Enucleation versus plaque irradiation for choroidal melanoma.

The Collaborative Ocular Melanoma Study (COMS) is an international, multicenter-controlled study. The organization includes an Executive Committee, Steering Committee, 6 Central Units, 32 Clinical Centers, and a Data and Safety Monitoring Committee. Scientifically, the COMS consists of (1) a randomized trial of patients with medium choroidal melanoma treated with enucleation versus iodine-125 plaque irradiation, (2) a randomized trial of patients with large choroidal melanoma treated with enucleation versus preenucleation external beam irradiation and enucleation, and (3) a prospective observational study of patients with small choroidal melanoma to determine whether a randomized trial of treatment is appropriate. In design and conduct of the COMS, special consideration is given to biostatistics and sample size considerations, iodine-125 plaque irradiation of choroidal melanoma, and coordinated ocular melanoma research. Recruitment is in progress. However, the pool of eligible patients is limited and the COMS needs the continued support and cooperation of ophthalmologists throughout the United States and Canada.

Brachytherapy↗

Subfoveal choroidal neovascular membranes in age-related macular degeneration. Visual prognosis in eyes with relatively good initial visual acuity.

We determined the visual prognosis of 94 eyes in 92 patients having age-related macular degeneration, a discrete choroidal neovascular membrane directly under the center of the foveal avascular zone (subfoveal), and an initial visual acuity of 20/100 or better. Of the patients who were reexamined 24 months following their initial presentation, 77% had lost at least four lines of vision and 64% had lost at least six lines. Estimation of visual loss using a conservative assessment procedure showed four-line visual loss in 65% of the patients and six-line loss in 50%. In general, the better the visual acuity at the initial examination, the more likely the patient was to have a smaller choroidal neovascular membrane. These results suggest that it may be reasonable to consider a randomized clinical trial of laser photocoagulation for this group of patients with a relatively poor visual prognosis.

Age Factors↗

The Markov process as a general method for nonparametric analysis of right-censored medical data.

The product limit method of Kaplan and Meier for estimating survival functions and the logrank test of Mantel are widely employed for analysis of longitudinal medical data. Developed for analysis of one-time events such as death, survival analysis is also commonly adapted to more complex states such as loss of vision or cancer remission by restricting analysis to first occurrences. The nonparametric discrete time nonhomogeneous Markov process is proposed as a better model for any applications of the latter type. This simple stochastic model allows for an arbitrary number of possible states and for transitions in any direction. Maximum likelihood estimators are easily computed for the stochastic model and are identical to the product-limit estimates in the special case represented by the Kaplan-Meier model. The logrank test extends to evaluation of differences between populations with respect to any specified transition.

Actuarial Analysis↗

Design, development, and implementation of a data processing system for multiple controlled trials and epidemiologic studies.

We were given the opportunity to design and implement a general data processing system to accommodate several different epidemiologic studies to be conducted by a new research group. A survey of 15 operating data centers was conducted in preparation for undertaking the design and development of our system. The results of the survey indicated that data processing activities can be classified, both conceptually and operationally, into three modules: data recording and data entry, data management, and data analysis, and that the data management functions were those amenable to generalization. Based on our survey and the varying needs of our studies, we selected a "mixed" hardware environment, using both a computer center mainframe and microcomputers. We created the systems using commercially available software, including a mainframe database manager and mainframe statistics packages, microcomputer data entry software, and a communications package to link the two environments. Our strategy was to buy software, when possible, rather than to build custom programs, and to let software tools govern hardware needs. Hardware independence, price, and functional capability directed our software choices, while hardware selection was constrained most importantly by available software, then by budget, by available computing resources, and finally by the marketplace. The system has been used successfully in three studies differing in design, size, data collection locale, and rate of data accrual.

Data Collection↗

Evaluating the benefit of clinical trials to future patients.

Large, multicenter clinical trials are expensive to design and to carry out. In spite of the magnitude of expenditures for such endeavors during the past two decades, little attention has been given to evaluating the impact of findings from these trials on those who are expected to benefit from them, i.e., future patients to whom trial findings apply. The implications of failure to demonstrate that results from these large medical experiments have been accepted by medical practitioners and policy makers and applied appropriately to patients must be of concern to all advocates and practitioners of controlled trials. Of the 20 evaluation studies reviewed in this paper, 6 were directed at assessing dollar benefits to the patient or to society. The remaining 14 studies were concerned primarily with physician knowledge and acceptance of trial findings. Investigators and sponsors of each large trial have a responsibility to develop an evaluation strategy during the planning phase of the trial, to publicize findings from the trial, to evaluate the impact of the findings on future patients, to act in response to the results of the evaluation, and to foster integration of findings into patient care policy.

Clinical Trials as Topic↗