In the Interim...

On the latest episode of "In the Interim…", Dr. Scott Berry provides an empirical examination of two recent JAMA trials: TRACK (low-dose rivaroxaban in advanced kidney disease) and VICTORY (IV vitamin C in severe burn injury). The TRACK trial lacked any pre-specified futility criteria, with a DSMB-initiated stop based on conditional power calculations. Scott argues that conditional power, especially in this interim context, is a poor, misleading tool—contrasting it against a Bayesian predictive probability calculation that produced a much lower and more realistic estimate of success. In VICTORY, a pre-specified risk ratio threshold for futility was incorporated, with simulation confirming minimal effect on bias and statistical power. Scott underscores the practical and ethical importance of rigorously pre-specified, simulation-based futility rules and operationalizes the case for Bayesian predictive probability as a decision metric in interim monitoring. He reiterates that responsibility for defining futility belongs to trial designers, not left to ad hoc DSMB judgment, and calls for precise statistical planning in adaptive trial protocols.Key HighlightsTRACK: No pre-specified futility rule; DSMB stopped for futility using conditional power post hoc.Technical critique of conditional power as misguided at interim, supporting Bayesian predictive probability instead.VICTORY: Pre-specified futility threshold, with simulation confirming minimal operational bias and power reduction.Emphasizes pre-specified, simulation-based futility planning and predictive probability monitoring as standards for all trials.For more, visit us at https://www.berryconsultants.com/

In this episode of "In the Interim…", Dr. Scott Berry explores the origins of REMAP-CAP with Prof. Steve Webb, former chair of the REMAP-CAP International Trial Steering Committee. This episode examines how pandemic preparedness efforts after 2009 H1N1 shaped the design of an international, adaptive platform trial to be able to respond rapidly to new infectious threats. Steve and Scott explain the sequence of strategy meetings, the role of the PREPARE consortium in securing EU funding and subsequent federation across Australia and Canada. The discussion details REMAP-CAP’s technical foundations: a modular master protocol, domain architecture, Bayesian adaptive methods, and frequent interim analyses. When COVID-19 emerged, these core elements permitted immediate platform activation to combat the pandemic infection with assessment of treatments across multiple domains—including steroids, immune modulation, and anticoagulation—generating actionable evidence in weeks. The episode also addresses international data harmonization, multi-platform trial collaboration, and the capacity to adapt trial structure as infectious disease threats evolve.Key HighlightsResponse to H1N1 and feckless pandemic trialsInternational strategy meetings—origins of platform conceptPREPARE consortium and cross-continental fundingModular master protocol, factorial allocation, and domain-specific appendicesBayesian triggers and response adaptive randomizationPivot to COVID-19 and rapid data generationMulti-platform international collaborationFor more, visit us at https://www.berryconsultants.com/

In this episode of "In the Interim…", Dr. Scott Berry is joined by Dr. Will Meurer, professor of Emergency Medicine and Neurology at the University of Michigan, for an in-depth discussion of the ICECAP trial’s adaptive Bayesian design. The discussion breaks down the scientific rationale for hypothermia after cardiac arrest, critiques legacy studies, and explores the justification for including both shockable and non-shockable rhythm types. The episode provides a detailed account of ICECAP’s methodological strategies: a weighted mRS primary endpoint, Bayesian adaptive trial structure, response-adaptive randomization (governed by strict allocation guardrails), a unique Bayesian model for duration-response, and futility rules. The trial’s development is described in the context of the ADAPT-IT initiative, an FDA/NIH partnership, and the operational leadership of the MUSC Data Coordinating Center. Results are pending publication which will be highlighted in a future episode of “In the interim…”.Key HighlightsRationale for exploring duration of hypothermia after cardiac arrest with review of prior evidence.Enrollment of shockable and non-shockable populations to address clinical uncertainty.Primary endpoint: weighted mRS, independently developed for ICECAP.Bayesian adaptive design with response-adaptive randomization, interim analyses, and allocation guardrails.Management of missing data with multiple imputation from 30-day outcomes.For more, visit us at https://www.berryconsultants.com/

In this episode of "In the Interim…", Dr. Scott Berry examines the analytical challenges of comparing performance across eras in both sports and clinical research. Drawing from statistically robust family debates and published research, Scott details how overlapping competitors—such as athletes who played with both Babe Ruth, played with the next generation, who played with … all the way to playing with Aaron Judge—enable the estimation of temporal effects and allow for objective comparisons between generations. He translates this approach directly into platform clinical trials, demonstrating how overlapping trial arms or shared control groups make it possible to quantify and adjust for time trends. Scott distinguishes between observable, model-based comparisons and subjective judgments, rigorously addressing limitations such as interactions between treatments and era, and emphasizing the foundational importance of empirical overlap over speculative claims.Key HighlightsDeconstruction of time-machine thought experiments: analyzing how teams like the 1927 Yankees or athletes such as Johnny Weissmuller and Jesse Owens compare to present-day counterparts using statistical benchmarks.Technical explanation of connecting eras empirically through players or trial arms who span multiple time periods, thereby supporting quantitative estimation of temporal shifts.Detailed account of linear and hierarchical modeling strategies, with covariate adjustment for player age, period effects, and evolving population composition across baseball, hockey, and golf data.Translation of these statistical constructs to adaptive and platform clinical trials, exemplified by I-SPY 2, where overlapping treatment and control arms permit rigorous assessment of evolving treatment effects over a trial’s lifespan.Critical discussion of the rare but important possibility of treatment-by-era interactions, and the necessity of data-driven assessment rather than assumption.Consideration of how these methods inform not just debates about athletic greatness and Hall of Fame inclusion, but also robust interpretation of treatment effects in longitudinal clinical studies.For more, visit us at https://www.berryconsultants.com/

In this episode of "In the Interim…", Dr. Scott Berry and Dr. Nick Berry investigate how futility in clinical trials and stopping rules in sports illuminate very similar decision problems, albeit with very different consequences. Drawing from baseball’s 10-run rule, tournament cuts in golf, the discussion confronts traditional and Bayesian strategies for interim decisions. The episode explains why simulation, not historical trial review, provides the empirical backbone for futility boundaries in clinical trials, and details the mechanics and consequences of aggressive stopping criteria. Using the Biogen aducanumab Alzheimer’s trials, the conversation exposes how a futility rule based on 20% predictive probability halted trials even when meaningful probability of success remained. Scott and Nick address the influence of ethical considerations, cost, regulatory priorities, and statistical rigor, and contrast Bayesian predictive probability’s strengths over conditional power.Key HighlightsDissects sports futility rules (10-run rule, golf cuts, Bill James heuristic) and their application to clinical trial designArgues for prospective simulation to define adaptive futility thresholdsExplains how Bayesian predictive probability provides a more robust framework than conditional probability for interim adaptive decisionsDetails how aggressive futility criteria may prematurely stop trials and risk missing beneficial treatments, as in the aducanumab caseExplores the intersection of ethics, patient safety, operational efficiency, regulatory standards, and trial cost

In this episode of "In the Interim…" Dr. Scott Berry is joined by Professors Victoria Cornelius, Danny McAuley, and Anthony Gordon, for a technical review of the PANTHER trial—an international, Phase 2 adaptive platform evaluating pharmacologic interventions for ARDS. The trial is open-label and does not employ blinding, as discussed in the episode. The primary endpoint is 28-day organ support-free days (death as -1, survivors 0–28 days), analyzed with a Bayesian proportional odds model. PANTHER uses stratification by hyper- and hypoinflammatory subphenotypes, with fixed, equal randomization within each stratum. Analyses for treatments are separated by stratum, reflecting the potential of differential treatment effects. Quarterly interim analyses allow early stopping by stratum for efficacy or futility. Content includes explicit discussion of infrastructure: rapid device deployment, centralized data for trial and future biological discovery, and governance challenges in multinational collaboration. Funding is provided by NIHR (UK), US Department of Defense, CIHR (Canada), NHMRC and MRFF (Australia), HRB (Ireland), and additional support from Germany and Japan. PANTHER is positioned to streamline Phase 2 critical care drug testing and facilitate graduation to larger platforms such as REMAP-CAP, with potential to expedite pharmaceutical evaluation and accelerate ARDS therapeutic development.Key HighlightsReal-time phenotyping (Randox device) to stratify ARDS patients.Separate Bayesian analyses by phenotype stratum.Open-label, fixed randomization within stratum.28-day organ support-free days as a composite endpoint.Quarterly interim analyses enable early dropping or graduation of arms by strata.Central data resource and biosample collection for future research.Operational, funding, and device logistics for global trial deployment.Transition of Phase 2 results to established Phase 3 platforms (e.g., REMAP-CAP).For more, visit us at https://www.berryconsultants.com/

In this episode of "In the Interim...", Dr. Scott Berry hosts Dr. Stephen Senn, award-winning statistician and author, for a discussion on advanced challenges in adaptive and platform trial methodology. Senn draws on experience in academic, pharmaceutical, and regulatory settings to address the recent draft guidance on Bayesian statistics from the FDA and multiple controversies in clinical trial design.Key HighlightsEmphasizes understanding data origin and regression to the mean as essential for trial interpretation, above adherence to Bayesian or frequentist frameworks.Details methodological considerations for time adjustments and model complexity, highlighting that model specification and parameter handling are critical regardless of statistical school.Identifies the limitations of non-concurrent controls in platform trials, focusing on evolving background therapy, site participation, and protocol changes that reduce validity of historical or pooled control data.Analyzes blinding difficulties in trials with multiple treatments and administration modes, using “veiled” blinding as a case and noting the implications for placebo response comparability.Clarifies that operational efficiencies are the principal advantage of adaptive and platform trials, while purported statistical efficiencies can be exaggerated.Stresses the importance of presenting interim analyses transparently to DSMBs when using complex models for time or covariate adjustment, to ensure oversight and interpretation remain rigorous.For more, visit us at https://www.berryconsultants.com/

In this episode of "In the Interim…", Dr. Scott Berry interviews Professors Steven Tong and Josh Davis about the SNAP platform trial for Staphylococcus aureus bacteremia. The discussion covers SNAP’s rationale, large-scale adaptive design, methodology, and operational execution at approximately 150 hospitals in 13 countries. Key statistical questions, domain results, pediatric-adult analysis, and global implementation strategy are explored in depth. Listeners will find clear examples of how adaptive platform trials can efficiently address clinically relevant questions in infectious disease, while highlighting the nuances of trial design, statistical thresholds, and network collaboration.Key HighlightsHigh and unchanging mortality for Staphylococcus aureus bacteremia—over one million deaths annually.SNAP leverages silo-based structure (MSSA, MRSA, PSSA) and factorial domains for simultaneous, efficient investigation of treatments.Cefazolin shown non-inferior to flucloxacillin for MSSA with lower related acute kidney injury.In PSSA, penicillin demonstrated significantly less toxicity and favorable mortality signal over flucloxacillin; mortality difference did not meet the statistical superiority threshold.Futility reached in the adjunctive clindamycin domain for effect on 90-day mortality.Both adults and children enrolled, with pediatric results using statistical borrowing from adults in line with FDA Bayesian guidance.Ongoing platform expansion includes bacteriophage therapy, antiplatelet domains, and evaluation of diagnostic strategies.Statistical leadership: Dr. Anna McGlothlin (Berry Consultants), Dr. Julie Marsh (statistics lead).For more, visit us at https://www.berryconsultants.com/

In Episode 51 of "In the Interim…", Dr. Scott Berry interviews writer, producer, and performer Shaun Cassidy to examine the practical elements of storytelling that matter in scientific and statistical communication. Cassidy draws on his experience in television, music, and live performance—including his role as writer and Executive Producer of New Amsterdam—to present clear parallels between audience engagement in show business and in clinical research. The conversation prioritizes improving narrative precision, emotional resonance, and authenticity when conveying complex topics to varied audiences.Key HighlightsCassidy demonstrates that audiences retain emotional impact over factual content, asserting that “people don’t remember what you say, but how you made them feel.”Emphasis on narrative specificity: personal, concrete details foster stronger audience connection than generalized statements, countering assumptions about broad relatability.Effective communication relies on reactive delivery—improvised response to audience cues—rather than rigid, memorized scripts; Cassidy notes this principle applies across disciplines.Role of authenticity and vulnerability: openly stating discomfort or introversion facilitates greater audience trust and personal connection, especially in technical or scientific fields.Anecdotes from Cassidy’s work in television, music, and teaching illustrate the central role of storytelling structure and audience feedback, with parallels drawn to professional scientific presentations.Alan Alda’s illustration of improv for scientists is discussed as an example of bridging technical expertise with adaptive communication skills.For more, visit us at https://www.berryconsultants.com/

In this episode of "In the Interim…", Dr. Scott Berry marks the podcast’s one-year anniversary, sharing listener metrics, watch data, and regional engagement. He then delivers a step-by-step analysis of the FDA meeting process, detailing the progression from initial sponsor meeting requests and question submission to briefing book preparation, feedback cycles, and in-person logistics for a Type C meeting at the White Oak facility. Drawing from more than 25 years of trial design and regulatory experience, Scott offers precise guidance on technical preparation, sponsor responsibilities, and common errors in sponsor-FDA dialog, emphasizing what works and what wastes time inside the one-hour meeting constraint. His practical approach focuses on clarity, respect for process, and actionable advice.Key HighlightsSlightly over 30,000 people tuned in during the first year across 45 episodes; about 10,000 via audio, 20,000 via video with a global worldwide reach.FDA meeting workflow: request, submit four to eight questions, draft briefing book, receive written feedback, strict one-hour in-person discussion controlled by sponsor.Advice on briefing book content, avoiding new materials at the meeting, even what not to bring through the White Oak facility.Sponsor pitfalls: disingenuous patient advocacy, asking impossible questions, taking adversarial stance in statistical discussion.For more, visit us at https://www.berryconsultants.com/

In this episode of "In the Interim…", Dr. Scott Berry speaks with Dr. Michael Harhay, Associate Professor at the University of Pennsylvania and Director of the Center for Clinical Trials Innovation. The conversation explores Dr. Harhay’s progression through neuroscience, philosophy, epidemiology, and statistics, examining how this academic path shapes his work in clinical trial methodology. They discuss the Center’s role in addressing unresolved methodological questions arising from pragmatic, health system-based trials, including challenges with cluster and factorial randomized designs. The episode focuses on statistical and conceptual issues in endpoint selection for critical care, such as the analysis of informatively truncated outcomes, composite endpoints including organ support-free days, and the application of the win ratio. The increasing use of Bayesian methods in trial design is addressed.Key HighlightsDr. Harhay’s academic background and transition into clinical trial methodology at Penn.The mission of the Center for Clinical Trials Innovation to support methodologic research and training, particularly among statisticians participating in multi-center health system trials.Discussion of hospital-level and provider-level randomization strategies in cluster and factorial designs within health systems.Ongoing challenges in analysis of composite and informatively truncated endpoints, especially in critical care, exemplified by ventilator-free and organ support-free days.Evaluation of analytic strategies including survival average causal effect, composite endpoints, and the win ratio, with emphasis on the need for clinical rather than purely statistical weighting of outcomes.Consideration of the conceptual strengths of Bayesian methods and their integration into modern trial design and decision analysis.For more, visit us at https://www.berryconsultants.com/

In this episode of "In the Interim…", Dr. Scott Berry is joined by Dr. Tanya Simuni, Arthur C. Nielsen Jr. Professor of Neurology and Director of the Parkinson’s Disease and Movement Disorders Center at Northwestern University, and Dr. Barbara Wendelberger, Senior Statistical Scientist at Berry Consultants. The conversation focuses on the Path to Prevention (P2P) platform trial—an international, multi-arm prevention study in Parkinson’s disease targeting participants defined by biological markers, specifically alpha-synuclein pathology, prior to clinical diagnosis. The discussion covers the PPMI cohort, trial operational and statistical structure, the rationale behind biomarker-driven inclusion, and the use of Bayesian platform trial design.Key Highlights:Parkinson’s disease pathobiology and risk: genotype-phenotype variability, multi-system involvement, and the central roles of age, environment, and genetics.Michael J. Fox Foundation’s PPMI cohort: 4,000+ participants, prospective longitudinal biomarker and clinical data, high participant retention, enabling study of early Parkinson’s.P2P platform structure: multi-arm design, two-stage randomization with shared placebo group, integration of non-randomized PPMI cohort in Bayesian analysis for improved inference.Inclusion criteria: prodromal population biologically defined by CSF alpha-synuclein seed amplification and dopaminergic imaging (DAT-SPECT), highlighting regulatory nuances.Dual primary endpoints: biomarker (DAT-SPECT) and clinical (MDS-UPDRS Part III), 24-36 months follow-up.Commitment to public data sharing in line with the Michael J. Fox Foundation’s open science philosophy.For more, visit us at https://www.berryconsultants.com/

In this episode of "In the Interim…", host Dr. Scott Berry and frequent co-host Dr. Kert Viele, Senior Statistical Scientist at Berry Consultants, analyze the potential shift in FDA regulatory policy from requiring two independent trials to accepting a single trial as sufficient for “substantial evidence” in drug approvals. Reflecting on the statutory and regulatory definitions originating with the 1962 Federal Food, Drug, and Cosmetic Act and 21 CFR 314.126, they dissect current and emerging interpretations, referencing recent statements by Dr. Martin Makary and coverage described in a STAT article. The conversation focuses on the scientific and statistical foundations of the two-trial threshold, challenges with dichotomous results, and how pooled evidence might increase efficiency and rigor. They discuss statistical implications including alpha thresholds, sample size effects, program power, and the consequences for clinical labeling. The episode also introduces Bayesian approaches as a method for integrating totality of evidence. Attention is given to both population breadth and the possible risks of a narrowed evidentiary base under a single-trial standard.Key HighlightsRegulatory and historical context of “substantial evidence” since 1962 and current FDA directives.Industry practice: simultaneous Phase III trials, statistical power, and evidentiary replication.Criticism of binary, trial-level significance thresholds; merits of pooling or meta-analysis.Potential efficiency gains and tradeoffs with a more stringent alpha requirement for single trials.Strategic and operational effects on trial design, sample size, and label indications.Bayesian statistical approaches for full evidence integration, discussed as an analytical viewpoint.