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Due to availability of eligible subjects at center and enrollment competition with other studies.
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The purpose of this 8-week study is to compare the effects of switching from therapy with epoprostenol or Flolan to IV Remodulin. This study will also assess the effect that changing to Remodulin will have on patient satisfaction with their treatment and impact on quality of life.
Pulmonary arterial hypertension (PAH), which is defined as an elevation in pulmonary arterial pressure and pulmonary vascular resistance, is a severe hemodynamic abnormality common to a variety of diseases and syndromes. Elevation in pulmonary arterial pressure causes an increase in right ventricular afterload, impairing right ventricular function and ultimately leading to inactivity and death. The goal of PAH treatment is to lengthen survival time, to ameliorate symptoms of PAH and to improve health related quality of life (HRQOL).
Remodulin® (treprostinil sodium), a stable analogue of prostacyclin, possesses potent pulmonary and systemic vasodilatory and platelet anti-aggregatory actions in vitro and in vivo. Recently, Remodulin received FDA approval for intravenous therapy based upon bioequivalence of the IV and SC routes of administration. Remodulin is more chemically stable than epoprostenol and may offer potential safety and convenience advantages compared to intravenous epoprostenol that may impact Health Related Quality of Life (HRQOL) and/or patient satisfaction. Unlike epoprostenol, Remodulin does not need to be mixed daily and is stable at room temperature eliminating the need for ice packs. Furthermore, since Remodulin remains in the body longer than epoprostenol (4 hrs instead of less than 5 minutes) there is less risk of cardiovascular collapse from a sudden interruption of infusion, such as a line clog. In an open-label study in Europe, patients who were using a type of portable medication pump called the CADD Legacy pump were rapidly switched from Flolan to Remodulin with no serious side effects. This study will examine effects of switching from therapy with epoprostenol or Flolan to IV Remodulin and compare changes in HRQOL and treatment satisfaction before and after rapid switch from epoprostenol to Remodulin in patients with pulmonary hypertension using the CADD legacy pump.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| treprostinil sodium | Experimental | all subjects had switched from IV epoprostenol to IV treprostinil sodium |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| treprostinil sodium | Drug | rapid switch from intravenous epoprostenol on CADD ambulatory pump to intravenous treprostinil sodium |
|
| Measure | Description | Time Frame |
|---|---|---|
| Change in Six Minute Walk Distance | Baseline and Week 8 |
| Measure | Description | Time Frame |
|---|---|---|
| Change in WHO Functional Classification | Class I: No limitation of physical activity. Class II: Slight limitation of physical activity. Class III: Marked limitation of physical activity. Class IV: Inability to carry out any physical activity without symptoms. | Baseline and Week 8 |
| Change in Borg Dyspnea Score Immediately After Six Minute Walk |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Victor Tapson, MD | Duke Health | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Duke University Medical Center | Durham | North Carolina | 27705 | United States |
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The first subject was enrolled in March 2008. Given the limited availability of eligible subjects at the investigative center (stable PH patients on stable epoprostenol therapy) and competition for enrollment by other studies, after an extended recruitment period during which no new subjects were enrolled, the study was subsequently closed.
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| ID | Title | Description |
|---|---|---|
| FG000 | Treprostinil Sodium | treprostinil sodium : all subjects underwent a rapid switch from intravenous epoprostenol on CADD ambulatory pump to intravenous treprostinil sodium |
| Title | Milestones | Reasons Not Completed | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
|
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| ID | Title | Description |
|---|---|---|
| BG000 | Treprostinil Sodium | treprostinil sodium : all subjects underwent a rapid switch from intravenous epoprostenol on CADD ambulatory pump to intravenous treprostinil sodium |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Categorical | Count of Participants |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Change in Six Minute Walk Distance | Two subjects had a Week 8 visit that was outside of the visit window and are included in the summary. One subject died prior to Week 8 assessments. | Posted | Mean | Standard Deviation | meter | Baseline and Week 8 |
|
|
Adverse events were assessed upon initiation of Remodulin through to the end of study (Week 8)
Since subjects were transitioning from an existing prostacyclin therapy, prostacylin-class side effects ongoing at Baseline prior to transition were recorded separately on the specific Prostacyclin Side Effects Questionnaire. Events which increased in severity from Baseline were captured and reported as AEs.
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Treprostinil Sodium | treprostinil sodium : all subjects underwent a rapid switch from intravenous epoprostenol on CADD ambulatory pump to intravenous treprostinil sodium |
| Term | Organ System | Source Vocabulary | Assessment Type | Notes | Statistical Information |
|---|---|---|---|---|---|
| Abdominal pain | Gastrointestinal disorders | MedDRA | Non-systematic Assessment | Subject was hospitalized for abdominal pain, nausea, vomiting and dehydration and subsequently died. The investigator assessed the relationship to the study drug as not reasonably attributable to the study drug. |
| Term | Organ System | Source Vocabulary | Assessment Type | Notes | Statistical Information |
|---|---|---|---|---|---|
| Headache | Nervous system disorders | MedDRA | Non-systematic Assessment |
The main limitations of this study are the small sample size, open-label design and relatively short duration of follow-up.
| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Remodulin Program Leader | United Therapeutics Corporation | 919-485-8350 | clinicalrecordsmanagement@unither.com |
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| ID | Term |
|---|---|
| D006976 | Hypertension, Pulmonary |
| D000081029 | Pulmonary Arterial Hypertension |
| ID | Term |
|---|---|
| D008171 | Lung Diseases |
| D012140 | Respiratory Tract Diseases |
| D006973 | Hypertension |
| D014652 | Vascular Diseases |
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| ID | Term |
|---|---|
| C427248 | treprostinil |
| D011464 | Epoprostenol |
| ID | Term |
|---|---|
| D044062 | Prostaglandins I |
| D011453 | Prostaglandins |
| D015777 | Eicosanoids |
| D005231 | Fatty Acids, Unsaturated |
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The Borg Dyspnea Score is a 10-point scale rating the maximum level of dyspnea experienced after the Six-Minute Walk Test. Scores range from 0 (for the best condition) to 10 (for the worst condition). |
| Baseline and Week 8 |
| Change in Score on Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) | The Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR), a validated PAH-specific instrument consisting of 65 items used to assess symptoms, functioning and quality of life. The questionnaire is divided into three sections; Symptoms (Scores 0-25; high scores indicate more symptoms), Activity (Score 0-30; low score indicates good functioning)and Quality of Life (0-25; high scores indicate poor QoL). The sum of these scores equates to the Total score (0-80). In the CAMPHOR scores, lower scores indicate improvements. | Baseline and Week 8 |
| Change in Score on Treatment Satisfaction Questionnaire for Medication | The Treatment Satisfaction Questionnaire for Medication (TSQM), a validated generic measure of treatment satisfaction consisting of 14 Likert-response items comprising four domains: Effectiveness, Side Effects, Convenience, and Global Satisfaction. The TSQM was completed at baseline and at Week 8. The TSQM consists of 13 items that made up three specific scales (Effectiveness, Side effects, Convenience) and one global satisfaction scale. TSQM items are scaled using either a 5-point or 7-point scale. Five-point scales are used for unidimensional continua (e.g. extremely satisfied to not at all), while 7-point scales are used for bipolar continua(e.g., extremely positive to extremely negative. Non-neutral midpoints are used for 7-point scales, resulting in a greater range of positive response options than negative options for these items. Scale scores are transformed into scores ranging from 0 to 100, with a higher score indicating more satisfaction. | Baseline and Week 8 |
| Change in Total Weekly Time Spent With the Specific Activities Associated With Intravenous Remodulin Therapy Compared to Same Activities With Intravenous Epoprostenol | A Drug Administration Activities Diary, used by subjects to record in detail the amount of time (in minutes) spent on specifically-defined drug preparation/administration activities (e.g. diluting drug, preparing reservoir, and changing tubing), was completed over a 7-day period during the Screening period while on epoprostenol and repeated at Week 7 following transition to Remodulin. Drug Administration Activities Diary results are reported as average time per week spent on drug administration activities | Baseline and Week 8 |
| Change in PAH Signs and Symptoms- Fatigue | The presence or absence of fatigue was documented. If present, the intensity of fatigue was rated mild, moderate, or severe. | Baseline and Week 8 |
| Change From in Signs and Symptoms of PAH- Edema | The presence or absence of edema was documented. If present, the intensity of edema was rated mild, moderate, or severe. | Baseline and Week 8 |
| Change in Signs and Symptoms of PAH- Dyspnea | The presence or absence of dyspnea was documented. If present, the intensity of dyspnea was rated mild, moderate, or severe. | Baseline and Week 8 |
| Change in Signs and Symptoms of PAH- Orthopnea | The presence or absence of orthopnea was documented. If present, the intensity of orthopnea was rated mild, moderate, or severe. | Baseline and Week 8 |
| Change in Signs and Symptoms of PAH- Dizziness | The presence or absence of dizziness was documented. If present, the intensity of dizziness was rated mild, moderate, or severe. | Baseline and Week 8 |
| Change in Signs and Symptoms of PAH- Syncope | The presence or absence of syncope was documented. If present, the intensity of syncope was rated mild, moderate, or severe. | Baseline and Week 8 |
| Change in Signs and Symptoms of PAH- Chest Pain | The presence or absence of chest pain was documented. If present, the intensity of chest pain was rated mild, moderate, or severe. | Baseline and Week 8 |
| Patient Impression of Change Questionnaire | A Patient Global Impression of Change Questionnaire, which consists of three items that ask the subject to rate changes (much better, somewhat better, about the same, somewhat worse, much worse) in their symptoms of PAH, the amount of time spent on activities associated with preparing and administering PAH therapy, and their satisfaction with their PAH therapy since transitioning from epoprostenol to intravenous Remodulin was conducted at Week 8 only and responses are reported as frequency distributions. | Week 8 |
| Participants |
|
| Age, Continuous | Mean | Full Range | years |
|
| Sex: Female, Male | Count of Participants | Participants |
|
| Region of Enrollment | Number | participants |
|
| Pulmonary Arterial Hypertension (PAH) etiology | Number | participants |
|
| World Health Organization (WHO) functional Class at time of transition | Class I: No limitation of physical activity. Class II: Slight limitation of physical activity. Class III: Marked limitation of physical activity. Class IV: Inability to carry out any physical activity without symptoms. | Number | participants |
|
| Baseline 6 Minute Walk Distance (6MWD) | Mean | Full Range | meters |
|
|
|
| Secondary | Change in WHO Functional Classification | Class I: No limitation of physical activity. Class II: Slight limitation of physical activity. Class III: Marked limitation of physical activity. Class IV: Inability to carry out any physical activity without symptoms. | Two subjects had a Week 8 visit that was outside of the visit window and are included in the summary. One subject died prior to Week 8 assessments. | Posted | Number | participants | Baseline and Week 8 |
|
|
|
|
| Secondary | Change in Borg Dyspnea Score Immediately After Six Minute Walk | The Borg Dyspnea Score is a 10-point scale rating the maximum level of dyspnea experienced after the Six-Minute Walk Test. Scores range from 0 (for the best condition) to 10 (for the worst condition). | Two subjects had a Week 8 visit that was outside of the visit window and are included in the summary. One subject died prior to Week 8 assessments. | Posted | Mean | Standard Deviation | units on a scale | Baseline and Week 8 |
|
|
|
|
| Secondary | Change in Score on Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) | The Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR), a validated PAH-specific instrument consisting of 65 items used to assess symptoms, functioning and quality of life. The questionnaire is divided into three sections; Symptoms (Scores 0-25; high scores indicate more symptoms), Activity (Score 0-30; low score indicates good functioning)and Quality of Life (0-25; high scores indicate poor QoL). The sum of these scores equates to the Total score (0-80). In the CAMPHOR scores, lower scores indicate improvements. | Two subjects with a Week 8 visit outside of the visit window are included in the summary. One subject died prior to completing the Week 8 visit. One subject had an incomplete Baseline questionnaire and the CAMPHOR Activity component could not be calculated, therefore N=5 Activity and Total Score Components, and N=6 for Symptom and Quality of Life. | Posted | Mean | Standard Deviation | units on a scale | Baseline and Week 8 |
|
|
|
|
| Secondary | Change in Score on Treatment Satisfaction Questionnaire for Medication | The Treatment Satisfaction Questionnaire for Medication (TSQM), a validated generic measure of treatment satisfaction consisting of 14 Likert-response items comprising four domains: Effectiveness, Side Effects, Convenience, and Global Satisfaction. The TSQM was completed at baseline and at Week 8. The TSQM consists of 13 items that made up three specific scales (Effectiveness, Side effects, Convenience) and one global satisfaction scale. TSQM items are scaled using either a 5-point or 7-point scale. Five-point scales are used for unidimensional continua (e.g. extremely satisfied to not at all), while 7-point scales are used for bipolar continua(e.g., extremely positive to extremely negative. Non-neutral midpoints are used for 7-point scales, resulting in a greater range of positive response options than negative options for these items. Scale scores are transformed into scores ranging from 0 to 100, with a higher score indicating more satisfaction. | Two subjects had a Week 8 visit that was outside of the visit window and are included in the summary. One subject died prior to completing the Week 8 visit. | Posted | Mean | Standard Deviation | units on a scale | Baseline and Week 8 |
|
|
|
|
| Secondary | Change in Total Weekly Time Spent With the Specific Activities Associated With Intravenous Remodulin Therapy Compared to Same Activities With Intravenous Epoprostenol | A Drug Administration Activities Diary, used by subjects to record in detail the amount of time (in minutes) spent on specifically-defined drug preparation/administration activities (e.g. diluting drug, preparing reservoir, and changing tubing), was completed over a 7-day period during the Screening period while on epoprostenol and repeated at Week 7 following transition to Remodulin. Drug Administration Activities Diary results are reported as average time per week spent on drug administration activities | Two subjects did not have Week 8 Drug Administration Activity Diaries completed. Connect Drug and Total Time Components: N=4; One subject did not have data recorded for Connect drug activities. Total time could not be calculated for this subject. | Posted | Mean | Standard Deviation | minutes | Baseline and Week 8 |
|
|
|
|
| Secondary | Change in PAH Signs and Symptoms- Fatigue | The presence or absence of fatigue was documented. If present, the intensity of fatigue was rated mild, moderate, or severe. | Two subjects had a Week 8 visit that was outside of the visit window and are included in the summary. One subject died prior to Week 8 assessments. | Posted | Number | participants | Baseline and Week 8 |
|
|
|
|
| Secondary | Change From in Signs and Symptoms of PAH- Edema | The presence or absence of edema was documented. If present, the intensity of edema was rated mild, moderate, or severe. | Posted | Number | participants | Baseline and Week 8 |
|
|
|
|
| Secondary | Change in Signs and Symptoms of PAH- Dyspnea | The presence or absence of dyspnea was documented. If present, the intensity of dyspnea was rated mild, moderate, or severe. | Posted | Number | participants | Baseline and Week 8 |
|
|
|
|
| Secondary | Change in Signs and Symptoms of PAH- Orthopnea | The presence or absence of orthopnea was documented. If present, the intensity of orthopnea was rated mild, moderate, or severe. | Posted | Number | participants | Baseline and Week 8 |
|
|
|
|
| Secondary | Change in Signs and Symptoms of PAH- Dizziness | The presence or absence of dizziness was documented. If present, the intensity of dizziness was rated mild, moderate, or severe. | Posted | Number | participants | Baseline and Week 8 |
|
|
|
|
| Secondary | Change in Signs and Symptoms of PAH- Syncope | The presence or absence of syncope was documented. If present, the intensity of syncope was rated mild, moderate, or severe. | Posted | Number | participants | Baseline and Week 8 |
|
|
|
|
| Secondary | Change in Signs and Symptoms of PAH- Chest Pain | The presence or absence of chest pain was documented. If present, the intensity of chest pain was rated mild, moderate, or severe. | Posted | Number | participants | Baseline and Week 8 |
|
|
|
|
| Secondary | Patient Impression of Change Questionnaire | A Patient Global Impression of Change Questionnaire, which consists of three items that ask the subject to rate changes (much better, somewhat better, about the same, somewhat worse, much worse) in their symptoms of PAH, the amount of time spent on activities associated with preparing and administering PAH therapy, and their satisfaction with their PAH therapy since transitioning from epoprostenol to intravenous Remodulin was conducted at Week 8 only and responses are reported as frequency distributions. | Two subjects had a Week 8 visit that was outside of the visit window and are included in the summary. One subject died prior to completing the Week 8 visit. | Posted | Number | participants | Week 8 |
|
|
|
| 2 |
| 7 |
| 6 |
| 7 |
|
| Bacteraemia | Infections and infestations | MedDRA | Non-systematic Assessment | One subject was hospitalized for bacteraemia attributed to Remodulin. |
|
| Dehydration | Metabolism and nutrition disorders | MedDRA | Non-systematic Assessment | Subject was hospitalized for abdominal pain, nausea, vomiting and dehydration and subsequently died. The investigator assessed the relationship to the study drug as not reasonably attributable to the study drug. |
|
| Nausea | Gastrointestinal disorders | MedDRA | Non-systematic Assessment | Subject was hospitalized for abdominal pain, nausea, vomiting and dehydration and subsequently died. The investigator assessed the relationship to the study drug as not reasonably attributable to the study drug. |
|
| Vomiting | Gastrointestinal disorders | MedDRA | Non-systematic Assessment | Subject was hospitalized for abdominal pain, nausea, vomiting and dehydration and subsequently died. The investigator assessed the relationship to the study drug as not reasonably attributable to the study drug. |
|
| Nausea | Gastrointestinal disorders | MedDRA | Non-systematic Assessment |
|
| Vomiting | Gastrointestinal disorders | MedDRA | Non-systematic Assessment |
|
| Diarrhoea | Gastrointestinal disorders | MedDRA | Non-systematic Assessment |
|
| Pain in Extremity | Musculoskeletal and connective tissue disorders | MedDRA | Non-systematic Assessment |
|
| Anxiety | Psychiatric disorders | MedDRA | Non-systematic Assessment |
|
| Insomnia | Psychiatric disorders | MedDRA | Non-systematic Assessment |
|
| Arthralgia | Musculoskeletal and connective tissue disorders | MedDRA | Non-systematic Assessment |
|
| Back Pain | Musculoskeletal and connective tissue disorders | MedDRA | Non-systematic Assessment |
|
| Cough | Respiratory, thoracic and mediastinal disorders | MedDRA | Non-systematic Assessment |
|
| Dizziness | Nervous system disorders | MedDRA | Non-systematic Assessment |
|
| Dyspnoea | Respiratory, thoracic and mediastinal disorders | MedDRA | Non-systematic Assessment |
|
| Flushing | Vascular disorders | MedDRA | Non-systematic Assessment |
|
| Pain in Jaw | Musculoskeletal and connective tissue disorders | MedDRA | Non-systematic Assessment |
|
| Pyrexia | General disorders | MedDRA | Non-systematic Assessment |
|
| Sinus headache | Nervous system disorders | MedDRA | Non-systematic Assessment |
|
| Tremor | Nervous system disorders | MedDRA | Non-systematic Assessment |
|
| Infusion site reaction | General disorders | MedDRA | Non-systematic Assessment |
|
There is an agreement between the Principal Investigator and the Sponsor (or its agents) that restricts the Principal Investigator's rights to discuss or publish trial results after the trial is completed.
Any publication of the results of this trial must be consistent with the United Therapeutics publication policy. The rights of the investigator and of the sponsor with regard to publication of the results of this trial are described in the Investigator contract.
| D002318 |
| Cardiovascular Diseases |
| D005227 |
| Fatty Acids |
| D008055 | Lipids |
| D012898 | Autacoids |
| D018836 | Inflammation Mediators |
| D001685 | Biological Factors |
| Title | Measurements |
|---|
|
| Title | Measurements |
|---|---|
|
| Total Score |
|
Activity Score N=5; Baseline component score could not be calculated for one subject. Changes between Baseline and Week 8 were assessed using the Wilcoxon signed rank test. A two-sided p value of < 0.05 was considered statistically significant. No imputation was used for missing values. |
| Wilcoxon signed rank test |
| 1.00 |
p value for Activity Score. |
| 95 |
| Superiority or Other (legacy) |
| Quality of Life Score. Changes between Baseline and Week 8 were assessed using the Wilcoxon signed rank test. A two-sided p value of < 0.05 was considered statistically significant. No imputation was used for missing values. | Wilcoxon signed-rank test | 0.31 | 95 | Superiority or Other (legacy) |
| Total Score N=5; Baseline Activity component score could not be calculated for one subject. Total Score could not be calculated for this subject. Wilcoxon signed rank test was used to compare the values at Baseline to values at Week 8. A two-sided p value of < 0.05 was considered statistically significant. No imputation was used for missing values. | Wilcoxon signed-rank test | 0.13 | 95 | Superiority or Other (legacy) |
| Title | Measurements |
|---|---|
|
| Global Satisfaction Score |
|
| Wilcoxon signed-rank test |
| 0.19 |
| 95 |
| Superiority or Other (legacy) |
| Convenience Score. Changes between Baseline and Week 8 were assessed using the Wilcoxon signed rank test. A two-sided p value of < 0.05 was considered statistically significant. No imputation was used for missing values. | Wilcoxon signed-rank test | 0.03 | 95 | Superiority or Other (legacy) |
| Global Satisfaction Score. Changes between Baseline and Week 8 were assessed using the Wilcoxon signed rank test. A two-sided p value of < 0.05 was considered statistically significant. No imputation was used for missing values. | Wilcoxon signed-rank test | 0.88 | 95 | Superiority or Other (legacy) |
| Title | Measurements |
|---|---|
|
| Change Dressing |
|
| Total Time |
|
| Wilcoxon signed-rank test |
| 0.06 |
| 95 |
| Superiority or Other (legacy) |
| Connect Drug. Changes between Baseline and Week 8 were assessed using the Wilcoxon signed rank test. A two-sided p value of < 0.05 was considered statistically significant. No imputation was used for missing values. | Wilcoxon signed-rank test | 0.63 | 95 | Superiority or Other (legacy) |
| Change Dressing. Changes between Baseline and Week 8 were assessed using the Wilcoxon signed rank test. A two-sided p value of < 0.05 was considered statistically significant. No imputation was used for missing values. | Wilcoxon signed-rank test | 0.88 | 95 | Superiority or Other (legacy) |
| Total Time. Changes between Baseline and Week 8 were assessed using the Wilcoxon signed rank test. A two-sided p value of < 0.05 was considered statistically significant. No imputation was used for missing values. | Wilcoxon signed-rank test | 0.13 | 95 | Superiority or Other (legacy) |
| Title | Measurements |
|---|
|
| Title | Measurements |
|---|---|
|
| Symptoms- Somewhat Worse |
|
| Symptoms-Much Worse |
|
| Time Spent- Much Less |
|
| Time Spent- Somewhat Less |
|
| Time Spent- About the Same |
|
| Time Spent- Somewhat More |
|
| Time Spent- Much More |
|
| Satisfaction- Much More Satisfied |
|
| Satisfaction- More Satisfied |
|
| Satisfaction- About the Same |
|
| Satisfaction- Less Satisfied |
|
| Satisfaction- Much Less Satisfied |
|