Gurugram (gurgaon), India

Effectiveness of Decision Support for Cardiovascular Risk Management in People With Cardiovascular Disease

A Phase III Renal Outcomes and Cardiovascular Mortality Study to Investigate the Efficacy and Safety of Baxdrostat in Combination With Dapagliflozin in Participants With Chronic Kidney Disease and High Blood Pressure

The purpose of this study is to investigate the efficacy, safety, and tolerability of baxdrostat in combination with dapagliflozin, compared with placebo and dapagliflozin, in reducing the risk of the composite of > 50% decline in eGFR, kidney failure, or CV death, in individuals with CKD and HTN. This study consists of a 4-week dapagliflozin Run-in Period for participants untreated with SGLT2i at screening, and a double-blinded period where participants will receive either baxdrostat/dapagliflozin or placebo/dapagliflozin. Site visits will take place at 2-, 4-, 8-, 16-, 34, and 52-weeks following randomisation. Thereafter visits will occur approximately every 4 months. The study closure procedures will be initiated when the predetermined number of primary endpoint events is predicted to have occurred ie, the PACD. All randomised participants including any participants who have prematurely discontinued study intervention will be scheduled for a SCV within a few weeks of the PACD. This period can be extended by the Sponsor. In case of premature discontinuation of blinded study intervention, participants will continue in the study and receive dapagliflozin 10 mg, unless the participant meets dapagliflozin specific discontinuation criteria. If study intervention is temporarily or permanently discontinued, the participant should remain in the study, and it is important that the scheduled study visits (including the PTDV for participants with permanent discontinuation of study intervention) and data collection continue according to the study protocol until the SCV.

The Radium-select Study

Study design: The investigators will conduct a prospective clinical study in which patients with mCRPC and bone-only disease according to ceCT and bone scan will receive standard-of-care treatment with Radium-223. In addition to standard-of-care systemic treatment, each patient will undergo an additional 68Ga-PSMA-PET/CT scan at baseline and will be followed throughout the treatment with patient reported outcome measure (PROM) questionnaires (Kaiku application) and blood sampling for circulating tumor DNA (ctDNA) analysis. The treating physicians will be blinded to the result of the baseline 68Ga-PSMA-PET/CT scan. Each patient will receive a maximum number of 6 cycles of Radium-223 therapy according to current clinical guidelines and will undergo response evaluation by ceCT and bone scans upon clinical progression. At clinical progression, each patient will undergo a second 68Ga-PSMA-PET/CT to determine the location of disease progression and assess the value of 68Ga-PSMA-PET/CT imaging as a response measure. The clinical response of Radium-223 therapy in the patients with bone-only disease according to 68Ga-PSMA-PET/CT scanning, will be compared to the treatment outcomes collected in our previously reported ROTOR registry. Secondary aims are to determine the value of ctDNA as predictive biomarker and the value of 68Ga-PSMA-PET/CT imaging in the response assessment.

Biological OviTex Versus Synthetic Graft in Robotic Prolapse Surgery

Minimal-invasive ventral mesh rectopexy (VMR) and sacrocolporectopexy (SCR) or cervicopexy are widely accepted treatments for patients suffering from pelvic prolapse. Choice of material used in VMR or SCRP - synthetic or biologic surgical mesh - remains subject of debate. Recent ban in the usage of non abdominal but transvaginal, mesh for pelvic organ prolapse (POP) in April 2019, by the Food and Drug Administration (FDA) has negatively influenced the perception on all sorts of surgical mesh. Currently, the most widely used mesh in VMR is synthetic and has shown good results regarding recurrence, mesh exposure and functional outcome. Although complication rates are low, the serious complications of fistulation, exposition, and dyspareunia are reasons to opt for a more expensive biological mesh. High-quality evidence of synthetic versus biological mesh is lacking, which does not stop resistance against synthetic mesh from growing. This has even led to concerns and questions about synthetic mesh use from the Dutch government addressed at the medical professionals and options for alternatives are being asked. Biological grafts are characterized by degradation of the implant and regeneration of host tissue. It is assumed that this process of degradation and remodeling decreases the risk of exposition and infection. However, this transformation may possibly lead to a higher chance of recurrence in the long term. Rate of recurrence, but also graft-related complications (GRC) to a lesser extent, largely depends on duration of follow-up. Since biological graft implementation in VMR and SCR is relatively new and its usage is restricted due to higher costs, evidence on biological mesh with long term follow-up is limited. In addition, there is a significant difference in various described biological meshes. This is important to keep in mind when comparing outcome of VMR or SCR with synthetic versus biologic mesh. In VMR there are no randomised controlled trials on synthetic versus biological mesh. The biological meshes studied thus far are Biodesign and Permacol. Mesh exposure rates after VMR with Biodesign and Permacol have both been studied in three studies in total (N = 349 and N = 425 in total respectively) and show low mesh exposure rates of 0 to 0.1%. In comparison, GRC after VMR with synthetic non-resorbable mesh (like polypropylene) are around 2%. Recurrence rates after synthetic mesh in VMR range between 2% and 14% after a median follow-up of 12-61 months. When comparing studies on biologic implants that report on recurrence rates there seems to be a slight difference in favor of Biodesign. Studies on Biodesign in VMR with a median follow-up ranging between 12 and 47 months show a recurrence rate around 5%. Literature on Permacol shows higher recurrence rates ranging between 5 to 14% after a median follow-up of 12 to 29 months. In sacrocolpopexy (SCP) allografts and xenografts have been investigated as an alternative for polypropylene. A randomised controlled trial compared SCP using polypropylene mesh with solvent cadaveric fascia lata. After one year of follow-up, polypropylene mesh had a higher anatomical cure rate than cadaveric fascia lata (91 percent versus 68 percent; p=0.007). Two GRC occurred in patients who received polypropylene mesh, while none occurred in the allograft group (p= 0.5). Another RCT with the same comparison and a follow-up of 5 years showed similar results, with considering cadaveric fascia not as strong of a support. Deprest et al. compared polypropylene mesh with porcine grafts in a prospective study and found xenografts to be associated with more apical failures and reoperations than with a polypropylene mesh (21 percent versus 3 percent; p = 0.01).However, there was no significant difference in functional outcomes between the two groups. An exposure rate of 11 percent was described in both groups. A more recent study concluded, by analyzing clinical outcomes and patients satisfaction, that a non-crosslinked ADM patch can be a good alternative to synthetic polypropylene mesh in patients undergoing SCP. Although Biodesign (Surgisis), Permacol and other are all grouped under the common denominator 'Biologic mesh', each of these products is unique. There are differences in tissue source, differences in the processes used to decellularize the tissue and differences in the final processing steps such as sterilization and preservation. As a result, there are significant variations in biological and clinical performance between these products. Permacol, which is purposely cross-linked pig dermis, behaves like a synthetic material in-vivo and induces a permanent foreign body response, leading to encapsulation. This prevents integration with and in the surrounding tissue. Consequently, high rates of mesh exposure occur with Permacol implants. Biodesign, one of the early biologics, is derived from small intestinal submucosa and is a non-cross-linked mesh. Likely due to its (proprietary) processing, Biodesign in practice often dissolves before healing and remodeling can take place. A novelty on the surgical mesh market is OviTex. It is produced by Aroa Biosurgery and consist of sterile sheep extracellular matrix (ECM) interwoven with a (absorbable or non-absorbable) synthetic fiber. OviTex comes with a grid of absorbable polyglycolic acid (PGA) or permanent polypropylene and with differing amounts of layers (Core, 1S and 2S). Unique to OviTex is its composition, which consists of essential components required for regeneration of host tissue. Additionally, the coupling of an ECM with a (absorbable) synthetic fiber provide strength without the need to cross-link the ECM. Moreover, OviTex is lower in costs than any other biological mesh on the market. Since the use of synthetic meshes in pelvic floor surgery has come under scrutiny, patients are tempted to undergo a resection rectopexy as an alternative to VMR with polypropylene. Apart from the fact that the resection is associated with a higher risk of complications due to the application of an anastomosis, the recovery time is much longer. The hospitalization period would be longer and therefore the costs compared to prolapse surgery with OviTex would be higher. Preliminary results of a recent pilot study at Meander MC showed that the use of an OviTex PGA (with absorbable grid) mesh in the pelvic floor is feasible and safe. Nevertheless, 2 out of 11 patients who completed follow-up of 6 months showed an early anatomical recurrence. This suggests that the use of permanent synthetic fiber may be necessary for a more durable repair and fewer recurrences than using OviTex PGA. Although resistance against synthetic grafts is growing, OviTex Permanent contains 96% sheep ECM and only 4% polymer, compared to the standard Prolene mesh which is 100% polymer (polymer areal density 16g/m2 OviTex 1S vs. 76g/m2 prolene). Furthermore, the polymer is embedded in the ECM which further attenuates any inflammatory response. Observations in primates show that the minimized amount of embedded synthetic reinforcement results in an implant that, histologically, behaves like a biologic mesh yet maintains its functional structure. This is the first prospective multicenter study using a OviTex 1S mesh. Although the material ovine was studies before, little is known about the feasibility of enrolling these patients into randomised studies in the Netherlands and about the feasibility, safety, and tolerance of the OviTex 1s is this setting. Therefore, the investigators decided to start with a phase II study. This allows for adequate monitoring of the feasibility, safety, and tolerance of the experimental treatment. There are no studies comparing OviTex to the current standard (Prolene, PMN3, Ethicon Inc Johnson & Johnson, Amersfoort, The Netherlands) Therefore, a comparative study should be conducted before OviTex is used as a biologic alternative for polypropylene in VMR on a larger scale. Following the OviTex pilot study, the investigators aim to conduct a follow-up study (ProTex trial) in which, both in the short and longer term, the efficacy of the OviTex mesh in pelvic floor surgery will be assessed in comparison with the current standard polypropylene, by means of a non-inferiority test.

Circulating Tumor DNA Based Adjuvant Chemotherapy in Stage II Colon Cancer Patients: the MEDOCC-CrEATE Trial

Sentinel Node and Organ-sparing Surgery in Stage I Colon Carcinoma

Colorectal cancer is the third most common type of cancer in the Netherlands and the second leading cause of cancer-related deaths. An increased incidence of T1-T2 tumors has been observed following the introduction of population screening programs, leading to more frequent endoscopic excisions. The risk of lymph node metastasis in high-risk T1 and low-risk T2 colon cancers is relatively low. However, the diagnostic accuracy of abdominal CT scans for detecting lymph node metastasis is limited, necessitating a formal segmental colonic resection to allow definitive nodal staging through pathological examination of the draining lymph nodes. Nevertheless, segmental resections following endoscopic excision of early-stage colon cancer will overtreat 85-95% of patients, depending on the histological risk profile, as the majority do not have lymph node metastases. Segmental colonic resections are associated with substantial morbidity. Based on large population-based data, 33% of patients experience at least one complication including anastomotic leakage, with a postoperative mortality rate of 1.5-3.1%. Morbidity is known to substantially impact quality of life and contribute to a high economic burden. Additionally, major symptoms of low anterior resection syndrome (LARS) is present in 21% of patients after segmental resection, with reported effects on quality of life comparable to those experienced by patients who undergo rectal cancer resection and develop LARS. To reduce the number of segmental resections in early colon cancer, risk stratification is applied based on histopathological examination of locally excised lesions. In low-risk T1 cancer, segmental resections are already omitted. The risk of lymph node metastasis varies between 5-15%, depending on the presence of one or more risk factors. For low-risk T2 tumors, the risk of lymph node metastasis ranges from 10.5-14%. As a result, the vast majority of patients still undergo surgery with potential harm but no benefit. The investigators hypothesize that in patients who have undergone R0/R1/Rx endoscopic excision of high-risk T1 or low-risk T2 colon cancer, sentinel lymph node (SLN) biopsy combined with wedge resection of the residual tumor or scar can safely spare the majority of patients with negative SLNs from undergoing segmental resection. For reliable identification of high-risk features, endoscopic resection with pathological examination of a complete specimen is required; therefore, only patients who have had endoscopic resection will be included in this study. In our systematic review and meta-analysis, the investigators found a pooled accuracy of 98% and a sensitivity of 80% for SLN detection in T1-2 colon cancer. The investigatorsuse endoscopic submucosal injection of indocyanine green (ICG) at the tumor site, which carries a low risk of intra-abdominal spillage that could hinder SLN identification. The SLN biopsy will be combined with an endoscopy-assisted wedge resection of the residual tumor or scar following endoscopic resection. During the endoscopy-assisted wedge resection, the surgeon first identifies and mobilizes the colon to facilitate the wedge resection. A gastroenterologist then performs a colonoscopy to visualize the scar from the previously resected tumor. With intraluminal endoscopic visualization, the surgeon places a suture, which allows for traction to position the linear stapler. The gastroenterologist confirms complete inclusion of the scar and ensures lumen patency before the stapler is fired. Endoscopy-assisted limited wedge resection is associated with low complication rates and is performed at a lower cost compared to laparoscopic segmental resection. Since no anastomosis is created, the risk of anastomotic leakage is eliminated. This approach could reduce morbidity, mortality, hospital stay, and stoma rates. Although staple line failure and leakage are theoretical risks, such complications have not been reported in previous cases. Patients with a positive SLN (macro- or micrometastasis) are offered segmental resection with adjuvant chemotherapy. SLN-negative patients do not undergo further surgery and are managed with an intensive follow-up strategy. A conservative estimate of 80% sensitivity and an average of 10% lymph node metastases results in a 2% risk of retained positive nodes after SLN biopsy. Additionally, tumor deposits (TDs) could potentially be missed when patients are treated with the SLN biopsy and wedge resection. However, only 0.45% of patients with stage I disease are TD-positive. The investigators consider the absolute risks of missed lymph node metastases and TDs acceptable, given the reduced perioperative morbidity and mortality associated with segmental colectomy. The SENTRY trial will be the first to offer organ-sparing surgery combined with a SLN biopsy for patients with early-stage colon cancer following endoscopic resection. This organ-sparing approach is anticipated to improve postoperative mortality, morbidity, hospital stay, quality of life, and costs compared to standard segmental resection, without compromising oncological outcomes. This multicenter, partially randomized patient preference trial will compare the organ-sparing approach to the standard of care segmental resection to assess oncologic safety.

Revumenib in Combination With Azacitidine + Venetoclax in Patients NPM1-mutated or KMT2A-rearranged AML

OPTImaL:Optimisation of Treatment for Patients With Low Stage Triple-negative Breast Cancer With High Stromal Tumor-infiltrating Lymphocytes

A Study to Investigate the Effect of Lepodisiran on the Reduction of Major Adverse Cardiovascular Events in Adults With Elevated Lipoprotein(a) - ACCLAIM-Lp(a)

Quality of Life After Hyperbaric Oxygen Therapy in Post-COVID Patients

The study design is a prospective observational cohort study. Questionnaires and medical doctor consultations will be used in order to collect all data. All patients treated with HBOT have medical doctor consultations at baseline and every 10th session of HBOT (standard clinical care). At baseline, the following characteristics will be collected: gender, age, BMI, medical history, Covid infection information, vaccination status, work status before Covid infection, previous Covid treatments, hospital and/or intensive care unit admission during Covid infection and smoking status. Furthermore, all patients treated are asked to fill out the SF-36 and EQ-5D questionnaires, a proprietary post-Covid symptoms questionnaire, and a questionnaire regaring work status. These questionnaires are repeated after 20, 40 (50) sessions of HBOT and after 3 and 12 months after the last treatment session. During the following medical doctor consultations, side effects, changes in medication and interruptions of HBOT will be recorded as well to monitor compliance. An interim analysis will be performed after 6 months to continue or stop treatments, based on the clinical results (as measured with the Physical Component Score of the SF-36 questionnaire). The minimal clinically important difference (MCID) to warrant early termination of therapy is if <5% of patients improves 3 points. The upper limit (and reason to continue) is if >50% achieve an MCID of 7 points.