The equivalence assessment usually consists of three tests and is often conducted through a three-arm clinical trial. The first two tests are to demonstrate the superiority of the test treatment and the reference treatment to placebo, and they are followed by the equivalence test between the test treatment and the reference treatment. The equivalence is commonly defined in terms of mean difference, mean ratio or ratio of mean differences, i.e. the ratio of the mean difference of the test and placebo to the mean difference of the reference and placebo. In this dissertation, the equivalence assessment for both continuous data and discrete data are discussed. For the continuous case, the test of the ratio of mean differences is applied. The advantage of this test is that it combines a superiority test of the test treatment over the placebo and an equivalence test through one hypothesis. For the discrete case, the two-step equivalence assessment approach is studied for both Poisson and negative binomial data. While a Poisson distribution implies that population mean and variance are the same, the advantage of applying a negative binomial model is that it accounts for overdispersion, which is a common phenomenon of count medical endpoints. The test statistics, power function, and required sample size examples for a three-arm equivalence trial are given for both continuous and discrete cases. In addition, discussions on power comparisons are complemented with numerical results. / Statistics

Background and Objectives: Sharing of interim results by the Data Safety Monitoring Board (DSMB) with non-DSMB members is an important issue that can affect trial integrity. The objective of this dissertation was to determine the views of the stakeholders on what kind of interim results can or should be shared by the DSMB, why, and with whom among those responsible for the conduct of a trial. Methods: We first conducted a systematic search of the literature to assess views and current evidence on sharing interim results. Secondly, we conducted two cross-sectional surveys aimed at those involved in trials to solicit their views on what type of interim results should be shared by the DSMB with non-DSMB members, with whom and under what circumstances. Thirdly, we assessed for any potential association of demographic factors with the sharing of certain interim results and their perceived usefulness, using regression analysis. Results: Mixed views exist in the literature on interim result sharing practices. Evidence from the surveys conducted resulted in the following findings. What to share: Based upon the survey results from our cross-sectional survey (Chapter 4), the interim control event rate (IControlER), the adaptive conditional power (ACP) and the unconditional conditional power (UCP) should not be shared. Most respondents from this survey thought the interim combined event rate (ICombinedER) could be shared provided proper conditions and provisions are in place. However, based on our cross-sectional scenario-based survey (Chapter 3), it was demonstrated that the ICombinedER, when shared at interim, is compatible with three possible interim results (Drug X doing better than placebo, worse than placebo or performing the same as placebo). Why share or not share: Respondents indicate that the ICombinedER can be shared because it does not unmask relative effects between groups, and keeps the steering committee (SC) informed about the trial’s progress; however, with the condition that sharing this type of result should be specified a priori including for what purpose and be at the DSMB’s discretion, especially if the control group rate is known from the literature. However, it is important to note that the ICombinedER, demonstrated with evidence from our cross-sectional scenario-based survey (Chapter 3), is compatible with three possible interim results and should not be shared because it has low usefulness and is flawed due to multiple interpretations. The IControlER and the ACP should not be shared because they are unmasking of interim results. It was mentioned that ICombinedER is usually known by the SC and sponsor making it easy to determine group rates if the IControlER is known. The UCP should not be shared because it is a technical measure that is potentially misleading of interim results. With whom to share: Survey results from Chapter 4 indicated that the ICombinedER can be shared with the SC and that the IControlER, the ACP, and the UCP should not be shared with any non-DSMB members by the DSMB. However, evidence from Chapter 3 also indicates that the ICombinedER should not be shared with any non-DSMB member. Factors associated with sharing: Having experience with greater than 15 trials with private industry sponsorship was found to be associated with not sharing the IControlER and an increase in perceived usefulness in sharing the ACP. Though some other demographic factors were found to be associated with sharing the ICombinedER and the UCP, they were sensitive to missing data upon our sensitivity analysis and will require more validation. Conclusions: Though mixed views exist within an extensive literature review on interim result sharing practices, survey evidence from this dissertation suggests that the ICombinedER, IControlER, the ACP and the UCP should not be shared with any non-DSMB member. The IControlER and ACP can be unmasking of interim results and the UCP is a technical measure that is potentially misleading. We agree with this reasoning. The majority of respondents from the survey in Chapter 4 indicated that the ICombinedER can be shared with the SC because it does not unmask relative effects between groups, however it was also stipulated that sharing this measure should be specified a priori and for what purpose and be at the DSMB’s discretion, especially if the control group rate is known from the literature. Even though the majority from our second survey in Chapter 4 indicate sharing the ICombinedER with the SC, we do not recommend sharing the ICombinedER at interim with any non-DSMB member because, as demonstrated with evidence from our cross-sectional scenario-based survey in Chapter 3, this measure is compatible with three possible interim results potentially leading to the introduction of trial bias at interim by those privy this interim measure and their interpretation. Based on the findings from the survey from Chapter 4, there appears to be a lack of awareness in how sharing the ICombinedER is flawed, of low usefulness, and potentially dangerous. The perceived desire to have this measure shared seems misguided. Experience with greater than 15 trials with private industry sponsorship was found to be associated with not endorsing the sharing the IControlER and an increase in perceived usefulness in sharing the ACP by the DSMB at interim. In regards to implications for future research, this characteristic should be further evaluated to see if this subgroup has insight into interim trial management practices that protect from trial bias. Results from this research have implications for practice and guidelines concerning trial design and protocols, and DSMB charters. These results can also help assess the need for proper safeguards around sharing an interim result when deemed appropriate by the DSMB and under their discretion, that prevent the introduction of bias that could alter the final trial results generated. / Thesis / Doctor of Philosophy (PhD)

The main object of the research is to analyze the effect of the clinical intervention algorithms proposed for reducing antibiotic use for older adults in long-term care facilities (LTCFs) by managing urinary tract infections (UTIs). 20 paired nursing homes were enrolled in the 12-month study. Within each pair, one was randomized to use of the intervention algorithms and the other to use of regular management. Cluster-level paired t-tests (unweighted and weighted) and regression analyses (unweighted and weighted) were used in the analysis of the data. Paired t-tests show that the algorithms did not significantly reduce the antibiotic use, the number of urine cultures or the antibiotic use for urinary infections in most months. However, they did reduce the proportion of antibiotic use for urinary infections significantly in most months. Regression analysis indicates that the difference between the control group and intervention group has no significant increasing or decreasing trend with time (month). And the algorithms significantly reduced the antibiotic use for urinary infections, number of cultures and the proportions through the 12-month study. The analyses reached a similar conclusion using nonparametric methods and weighted analysis. / Thesis / Master of Science (MS)

VAT plays a crucial role in creating a single internal market in the EU. However, the applicability of VAT rules in regard to the conduct of clinical trials and investigational medicinal products (IMPs) remains uncertain due to different interpretations among the Member States and the lack of case laws regarding clinical trials. This thesis examines the EU VAT Directive and the case law provided by the ECJ using a teleological approach to interpret the concept of medical care and identify applicable provisions for the conduct of clinical trials and transactions involving IMPs. The analysis provides insights into the VAT treatment of clinical trials conducted within the EU.

Lanthionine synthetase C-like protein 2 (LANCL2) is a member of the LANCL protein family, which is broadly expressed throughout the body. LANCL2 is the molecular target of abscisic acid (ABA), a compound with insulin-sensitizing and immune modulatory actions. LANCL2 is required for membrane binding and signaling of ABA in immune cells. Direct binding of ABA to LANCL2 was predicted in silico using molecular modeling approaches and validated experimentally using ligand-binding assays and kinetic surface plasmon resonance studies. The therapeutic potential of the LANCL2 pathway ranges from increasing cellular sensitivity to anticancer drugs, insulin-sensitizing effects and modulating immune and inflammatory responses in the context of immune-mediated and infectious diseases. A case for LANCL2-based drug discovery and development is also illustrated by the anti-inflammatory activity of novel LANCL2 ligands such as NSC61610 against inflammatory bowel disease in mice. This dissertation discusses the value of LANCL2 as a novel therapeutic target for the discovery and development of new classes of orally active drugs against chronic metabolic, immune-mediated and infectious diseases and as a validated target that can be used in precision medicine. Specifically, in Chapter 2 of the dissertation, we performed homology modeling to construct a three-dimensional structure of LANCL2 using the crystal structure of LANCL1 as a template. Our molecular docking studies predicted that ABA and other PPAR - agonists share a binding site on the surface of LANCL2. In Chapter 3 of the dissertation, structure-based virtual screening was performed. Several potential ligands were identified using molecular docking. In order to validate the anti-inflammatory efficacy of the top ranked compound (NSC61610) in the NCI Diversity Set II, a series of in vitro and pre-clinical efficacy studies were performed using a mouse model of dextran sodium sulfate (DSS)-induced colitis. In Chapter 4 of the dissertation, we developed a novel integrated approach for creating a synthetic patient population and testing the efficacy of the novel pre-clinical stage LANCL2 therapeutic for Crohn's disease in large clinical cohorts in silico. Efficacy of treatments on Crohn's disease was evaluated by analyzing predicted changes of Crohn's disease activity index (CDAI) scores and correlations with immunological variables were evaluated. The results from our placebo-controlled, randomized, Phase III in silico clinical trial at 6 weeks following the treatment shows a positive correlation between the initial disease activity score and the drop in CDAI score. This observation highlights the need for precision medicine strategies for IBD. / Ph. D.

<p dir="ltr">Accumulating evidence suggests a potential role for almond consumption in ameliorating post-prandial glycemia. Yet their effect on HbA1c, an indicator of long-term glycemic control, is mixed. The purpose of this study was to examine the potential of sustained almond consumption to reduce HbA1c concentrations among individuals with elevated HbA1c concentrations. A 16-week randomized, parallel-arm, controlled trial was conducted. Eighty-one adults with elevated HbA1c concentrations (>5.7%) were randomly assigned to incorporate two servings (2 oz) of raw almonds (A group; N=39) or energy-matched snacks (pretzels C group; N=42) into their daily diets. Half of these intervention foods were to be ingested at breakfast and the other half as a replacement for either a mid-morning or mid-afternoon snack. Throughout the intervention period, measurements were made of body weight, body composition, plasma lipids, HbA1c, alpha and gamma-tocopherol, glycemia (by meal tolerance test) and continuous glucose monitoring, dietary intake, and hedonic responses to test foods at stipulated time points. Participants consuming almonds ingested 253 kcal/d more than participants in the control group (p=0.02), but this did not result in a significant difference in body weight (A: 0.2kg SEM ±0.5, C: 0.4kg SEM ±0.5); p>0.05). No statistically significant differences were observed in HbA1c concentrations (A: 0.1% SEM ±0.1, C: 0% SEM ±0.1; p>0·05), blood chemistries, body composition, or glycemia over time or between groups. However, Healthy Eating Index scores improved within the almond group as compared to the control group (A: 8.3 points SEM ±1.9, C: -2.3 points SEM ±2.1; p<0.001). Additionally, the hedonic rating of almonds did not decline within the almond group in comparison to the control group's reduced liking of the pretzel snack. Alpha-tocopherol increased significantly, and gamma-tocopherol tended to decrease in the almond group, indicating compliance with the dietary intervention. Overall, daily ingestion of 2 oz of raw almonds in a regular diet for 16 weeks did not alter short-term or longer-term glycemia or HbA1c concentrations in adults with elevated HbA1c concentrations, but they were well-tolerated and improved diet quality without promoting weight gain.</p>

Factorial randomised controlled trials (RCTs) evaluate two or more interventions simultaneously, enabling assessment of interactions between treatments. This thesis presents literature reviews, methodological reviews, simulation studies and applied case studies that explore methods for assessing cost-effectiveness based on factorial RCTs. My systematic review suggests that factorial RCTs account for around 3% of trial-based economic evaluations, although there is currently no guidance or methodological work indicating the most appropriate methods. Around 40% of published studies assumed no interaction between treatments and many were poorly-reported. Various mechanisms are likely to produce large interactions within economic endpoints such as costs, quality-adjusted life-years (QALYs) and net benefits. Failing to take account of interactions can introduce bias and prevent efficient allocation of healthcare resources. I developed the opportunity cost of ignoring interactions as a measure of the implications of this bias. However, allowing for small, chance interactions is inefficient, potentially leading to over-investment in research if trial-based evaluations are used to inform decisions about subsequent research. Nonetheless, analyses on simulated trial data suggest that the opportunity cost of adopting a treatment that will not maximise health gains from the healthcare budget is minimised by including all interactions regardless of magnitude or statistical significance. Different approaches for conducting economic evaluations of factorial RCTs (including regression techniques, extrapolation using patient-level simulation, and considering different components of net benefit separately) are evaluated within three applied studies, including both full and partial factorials with 2x2 and 2x2x2 designs. I demonstrate that within both trial-based and model-based economic evaluation, efficient allocation of healthcare resources requires consideration of interactions between treatments, and joint decisions about interacting treatments based on incremental cost-effectiveness evaluated “inside-the-table” on a natural scale. I make recommendations for the design, analysis and reporting of factorial trial-based economic evaluations based on the results of this thesis.

Current treatments for obesity have been unsuccessful. It is essential that a patient-centred approach for obesity management is developed and for this to be successful other diet and lifestyle approaches need to be considered. A systematic review comparing low carbohydrate vs. low fat diets for the treatment of obesity was carried out. It found that low carbohydrate/high protein diets are as effective as, if not better, for treating obesity and cardiovascular disease risk factors. A randomised controlled trial investigating dietary approaches for the treatment of obesity and its co morbidities was carried out. Variables including weight and body composition, cardiovascular risk factors, adipokines, liver and kidney function, and health and lifestyle factors were measured. Those with metabolic syndrome were also examined. It was hypothesised that there are alternative ways of treating obese subjects depending on their phenotype. Those with a higher BMI tend to have a higher carbohydrate intake rather that a higher fat intake so may be better suited to a low carbohydrate/high protein diet rather than the conventional low fat/energy reduced diet. Subjects were initially treated with the standard dietary approach for obesity (health eating, HE) and if not successful after 3 months were randomised to either a very low calorie diet (Lighterlife, LL) or a protein sparing modified fast (PSMF). All three groups showed a significant weight loss and reduced risk for CVD at 12 months. Significant improvements were seen for plasminogen-activated receptor-1, adiponectin, leptin and IL-6 on HE and LL, but only adiponectin significantly improved on the PSMF. Neither diet showed any detrimental effects for those with a healthy liver and kidney function. Quality of life and levels of depression improved at 12 months. Of the 54 subjects with metabolic syndrome at baseline, 12 remained on HE and 32 were randomised to LL and PSMF. This indicates that most subjects did not suit a low fat dietary approach. They were successful at losing weight on LL and PSMF and showed improvement in MS risk factors, and adipokine levels at 12 months. In conclusion, the study demonstrates that a low fat diet may not necessarily be the first line of approach to treat obese subjects with a BMI over 35 kg/m2, including those with MS. A very low calorie diet such as LL or a PSMF may be better suited to the subject.

A nefrolitíase é uma doença comum e recorrente com prevalência mundial variando de 5 a 20%, com pico de incidência entre a 3ª e 4ª década de vida e com maior prevalência em homens (3:1), frequentemente associado a atendimento de urgência. O tratamento da litíase ocorre em duas fases. Inicialmente, no episódio agudo de dor pela passagem do cálculo pelas vias urinárias, cujo objetivo terapêutico é o alívio da dor e a expulsão do cálculo. Para aqueles doentes com cálculos de repetição, o objetivo terapêutico será o de reduzir a formação de novos cálculos. Para ambos os objetivos, o arsenal terapêutico disponível é limitado. Estudos pré-clínicos com o Extrato Padronizado de C. langsdorffi - EPC-AF® (Apis-Flora, Ribeirão Preto, Brasil), um composto vegetal extraído da bioflora nacional, mostraram perfil de segurança e eficácia deste composto como potencial medicamento para o tratamento da litíase renal. Desta forma, o objetivo deste estudo foi o de avaliar o perfil de segurança em humanos e eficácia preliminar do EPC-AF®. Foi realizado um estudo clínico fase I/IIa, randomizado, duplo-cego, comparado com placebo, de dose única de forma ascendente. As doses utilizadas foram de 175 mg, 350 mg,700 mg, 1,4 g e 2,8 g administradas por via oral em dose única após jejum de 12h. Foram estudados grupos de 6 voluntários sadios por dose. Em cada grupo, 4 voluntários receberam de forma randomizada e cega o EPC-AF® e 2 voluntários placebo. O escalonamento para doses mais altas foi feito após a comprovação de que não houve eventos adversos com a dose previamente usada. No total, 30 voluntários sadios foram estudados na Unidade de Pesquisa Clínica do HCFMRP-USP. Foram coletados dados clínicos e laboratoriais para segurança, com destaque para toxicidade renal, onde foram estudados variação das concentrações urinárias de NGAL (neutrophil gelatinaseassociated lipocalin), NAG (N-acetyl-beta-D-glucosaminidase), KIM-1 (Kidney injury molecule-1) e alfa-1-microglobulina, além da dosagem sérica de cistatina C, um marcador da taxa de filtração glomerular. Os dados de eficácia preliminar foramcentrados na análise do perfil bioquímico urinário (pH, cálcio, citrato, oxalato, ácido úrico, magnésio e fosforo) em amostras de urina de 24h, coletadas antes e imediatamente após o uso de EPC-AF® ou placebo. Os resultados obtidos mostraram que o EPC-AF® é seguro nas doses de 175 a 2,8 g por via oral. Não foi observada variações significativas das concentrações de 24h dos principais componentes facilitadores ou inibidores da formação de cálculos urinários / Nephrolithiasis is a common and recurrent disease with a worldwide prevalence varying from 5 to 20%, with a incidence peak between the 3rd and 4th decade of life and with a higher prevalence in men than women (3: 1), often associated with urgent care. The treatment of lithiasis occurs in two phases. Firstly, in the acute episode of pain by the passage of the calculus through the urinary tract, whose therapeutic objective is to relieve pain and expel the stone. For those patients with recurrent stones the therapeutic goal will be reducing the formation of new stones. For both objectives, the available therapeutic arsenal is limited. Preclinical studies with C. langsdorffi standard extract (EPC-AF®, Apis-Flora, Ribeirão Preto, Brazil), an herbal compound extracted from a Brazilian native plant, showed a safety and efficacy profile of this compound as a potential drug for the treatment of renal lithiasis. Thus, the objective of this study was to evaluate the safety profile and the preliminary efficacy of EPC-AF® in healthy volunteers. A phase I/IIa clinical trial, randomized, double-blinded, placebocontrolled single-ascending dose was conducted. The doses used were 175 mg, 350 mg, 700 mg, 1.4 g and 2.8 g administered orally in a single dose after 12 h fasting. Groups of 6 healthy volunteers per dose were studied. In each group, 4 volunteers randomly and blindly received EPC-AF® and 2 volunteers received placebo. The escalation to higher doses was done after the confirmation that there were no adverse events with the dose previously used. In total, 30 healthy volunteers were studied on the General Clinical Research Centre of local teaching Hospital. Clinical and laboratory data were collected for safety, with emphasis on renal toxicity, where urinary concentrations of NGAL (neutrophil gelatinase-associated lipocalin), NAG (N-acetylbeta-D-glucosaminidase), KIM-1 (Kidney injury molecule-1) and alpha-1-microglobulin were measured, in addition to serum cystatin C, a marker of the glomerular filtration rate. Preliminary efficacy data were centered on urinary biochemical profile analysis (pH, calcium, citrate, oxalate, uric acid, magnesium and phosphorus) in 24-hour urinesamples collected before and immediately after use of EPC-AF® or placebo. The results showed that EPC-AF® is safe in doses of 175 to 2.8 g orally. No significant variations in 24-h concentrations of the major components facilitating or inhibiting the formation of urinary stones were observed

Objetivo: Avaliar o controle glicêmico em pacientes que utilizaram metformina ou insulina para tratamento do diabetes gestacional, identificando fatores preditores da necessidade de insulina complementar nas pacientes que tiveram, como terapêutica inicial, a metformina. Método: pacientes com DG que não obtiveram controle glicêmico com dieta e exercícios físicos foram randomizadas para receber metformina (n=46) ou insulina (n=46). Os critérios de inclusão foram: gestação única, realização de dieta e exercícios físicos por período mínimo de uma semana, sem controle glicêmico satisfatório, ausência de fatores de risco para acidose láctica, ausência de anormalidades anatômicas e/ou cromossômicas do produto conceptual. Foram excluídas as gestantes que apresentaram perda de seguimento pré-natal. Resultado: A comparação das médias glicêmicas pré-tratamento medicamentoso não mostrou diferença estatisticamente significativa entre os grupos (p=0,790). Porém, após a introdução dos medicamentos, foram observados médias glicêmicas menores no grupo metformina, ao longo do dia (p=0,020), principalmente, após o jantar (p=0,042). Pacientes que utilizaram metformina tiveram menor ganho de peso (p=0,002) e, também, menor frequência de hipoglicemia neonatal (p=0,032). Doze pacientes do grupo metformina (26,08%) necessitaram de insulina complementar para controle glicêmico. A idade gestacional precoce (odds ratio 0,71, CI95% 0,52-0,97; p=0,032) e a média glicêmica pré-tratamento medicamentoso (odds ratio 1,061, CI95% 1,001-1,124; p=0,046) foram identificadas como preditoras da necessidade de insulina complementar. Conclusão: A metformina foi eficaz em propiciar controle glicêmico adequado, com menor ganho de peso e menor frequência de hipoglicemia neonatal. Foi identificado grupo de pacientes com maior probabilidade de necessitar de complementação com insulina para atingir controle glicêmico / Objective: To evaluate glycemic control in women receiving metformin or insulin for the treatment of gestational diabetes, and to identify factors predicting the need for supplemental insulin in women initially treated with metformin. Methods: Women with gestational diabetes who did not achieve glycemic control with diet and exercise were randomized to receive either metformin (n=46) or insulin (n=46). Criteria for inclusion were singleton pregnancy, diet and exercise for a minimum period of one week without satisfactory glycemic control, absence of risk factors for lactic acidosis, and absence of anatomic and/or chromosome anomalies of the conceptus. Patients who were lost to prenatal follow-up were excluded. Results: Comparison of mean pretreatment glucose levels showed no significant difference between groups (P=.790). However, lower mean glucose levels across the day were observed in the metformin group after introduction of the drug (P=.020), especially after dinner (P=.042). Women using metformin presented less weight gain (P=.002) and a lower frequency of neonatal hypoglycemia (P=.032). Twelve women in the metformin group (26.08%) required supplemental insulin for glycemic control. Early gestational age (OR=0.71, 95%CI: 0.52-0.97; P=.032) and mean pretreatment glucose level (OR=1.061, 95%CI: 1.001-1.124; P=.046) were identified as predictors of insulin need. Conclusion: Metformin was found to provide adequate glycemic controlwith lower mean glucose levels across the day, less weight gain and a lower frequency of neonatal hypoglycemia. Logistic regression analysis showed that gestational age at diagnosis and mean pretreatment glucose level were predictors of the need for supplemental insulin therapy in women initially treated with metformin