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Randomized, Embedded, Multifactorial Adaptive Platform Trial for Community- Acquired Pneumonia (REMAP-CAP)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Know the risks and potential benefits of clinical studies and talk to your health care provider before participating. Read our disclaimer for details.
 
ClinicalTrials.gov Identifier: NCT02735707
Recruitment Status : Recruiting
First Posted : April 13, 2016
Last Update Posted : July 21, 2020
Sponsor:
Collaborators:
Australian and New Zealand Intensive Care Research Centre
Medical Research Institute of New Zealand
Unity Health
Berry Consultants
Global Coalition for Adaptive Research
University of Pittsburgh Medical Center
Information provided by (Responsible Party):
MJM Bonten, UMC Utrecht

Tracking Information
First Submitted Date  ICMJE December 11, 2015
First Posted Date  ICMJE April 13, 2016
Last Update Posted Date July 21, 2020
Actual Study Start Date  ICMJE April 11, 2016
Estimated Primary Completion Date December 2021   (Final data collection date for primary outcome measure)
Current Primary Outcome Measures  ICMJE
 (submitted: July 17, 2020)
  • All-cause mortality [ Time Frame: Day 90 ]
  • Days alive and not receiving organ support in ICU [ Time Frame: Day 21 ]
    Primary end-point for patients with suspected or proven COVID-19 pandemic infection
Original Primary Outcome Measures  ICMJE
 (submitted: April 6, 2016)
Mortality (%) measured at day 60 after randomization of the patients included in this trial. [ Time Frame: 60 days ]
Mortality (%) measured at day 60 after randomization of the patients included in this trial for all different interventions.
Change History
Current Secondary Outcome Measures  ICMJE
 (submitted: April 15, 2020)
  • ICU Mortality [ Time Frame: Day 90 ]
  • ICU length of stay [ Time Frame: Day 90 ]
  • Hospital length of stay [ Time Frame: Day 90 ]
  • Ventilator free days [ Time Frame: Day 28 ]
  • Organ failure free days [ Time Frame: Day 28 ]
  • All-cause mortality [ Time Frame: 6 months ]
  • Health-related Quality of life assessment [ Time Frame: 6 months ]
    EQ5D-5L and WHODAS 2.0 (not completed in all regions)
  • Proportion of intubated patients who receive a tracheostomy [ Time Frame: Day 28 ]
  • Destination at time of hospital discharge [ Time Frame: Free text Day 90 ]
    Characterised as home, rehabilitation hospital, nursing home or long-term care facility, or another acute hospital
  • Readmission to the index ICU during the index hospitalization [ Time Frame: Day 90 ]
  • World Health Organisation 8-point ordinal scale outcome [ Time Frame: Hospital discharge ]
Original Secondary Outcome Measures  ICMJE
 (submitted: April 6, 2016)
  • ICU length of stay of the patients included in this trial. [ Time Frame: Through study completion, average of 6 days ]
    ICU length of stay of the patients included in this trial, measured in number of days for all interventions
  • Hospital length of stay of the patients included in this trial. [ Time Frame: Through study completion, average of 10 days ]
    Hospital length of stay of the patients included in this trial, measured in number of days for all interventions.
  • Ventilator free days. [ Time Frame: Day 30 ]
    Measure the number of ventilator free days of the patients included in this trial at day 30.
  • Ventilator free days. [ Time Frame: Day 60 ]
    Measure the number of ventilator free days of the patients included in this trial at day 60.
  • Organ failure free days. [ Time Frame: Day 30 ]
    Measure the number of organ failure free days of the patients included in this trial at day 30.
  • Organ failure free days. [ Time Frame: Day 60 ]
    Measure the number of organ failure free days of the patients included in this trial at day 60.
Current Other Pre-specified Outcome Measures
 (submitted: March 25, 2020)
  • Occurrence of multi-resistant organism colonisation/infection [ Time Frame: Day 90, censored at hospital discharge ]
    Antibiotic Domain specific outcome
  • Occurrence clostridium difficile [ Time Frame: Day 90, censored at hospital discharge ]
    Antibiotic Domain specific outcome
  • Occurrence of serious ventricular arrhythmia (including ventricular fibrillation) or sudden unexpected death [ Time Frame: Day 90, censored at hospital discharge ]
    Macrolide Duration domain specific outcome, and COVID-19 Antiviral Domain specific outcome.
  • Change from baseline influenza virus levels in upper and lower respiratory tract specimens [ Time Frame: Day 3, up to Day 7 ]
    Antiviral Domain specific outcome. Only required at selected sites.
  • Serial detection of SARS-CoV-2 in upper or lower respiratory tract specimens (using only specimens collected for routine clinical testing) [ Time Frame: Day 90, censored at hospital discharge ]
    COVID-19 Antiviral Domain and COVID-19 Immune Modulation Domain specific endpoint
Original Other Pre-specified Outcome Measures Not Provided
 
Descriptive Information
Brief Title  ICMJE Randomized, Embedded, Multifactorial Adaptive Platform Trial for Community- Acquired Pneumonia
Official Title  ICMJE Randomized, Embedded, Multifactorial Adaptive Platform Trial for Community- Acquired Pneumonia
Brief Summary

REMAP-CAP is a randomised, embedded, multifactorial, adaptive platform trial for community-acquired pneumonia.

The purpose of this study is to evaluate the effect of a range of interventions to improve outcome of patients admitted to intensive care with community-acquired pneumonia.

In addition, REMAP-CAP provides and adaptive research platform for evaluation of multiple treatment modalities in the event of a respiratory pandemic resulting in critical illness.

REMAP-COVID is a sub-platform of REMAP-CAP that evaluates treatments specific to COVID-19.

Detailed Description

Community-acquired pneumonia (CAP) that is of sufficient severity to require admission to an intensive care unit (ICU) is associated with substantial mortality.

Patients with pneumonia who are being treated in an ICU will receive therapy that consists of many different treatments, as many as 20 or 30. These treatments act together to treat both the infection and its effects on the body. When treating a patient, doctors choose from many different treatments, most of which are known or believed to be safe and effective. However, doctors don't always know which treatment option is the better one, as individuals or groups of individuals may respond differently. This study aims to help doctors understand which treatments work best.

This clinical study has been designed in a way that allows the information from patients already in the study to help new patients joining the study. Most studies aren't able to do that. REMAP-CAP has been designed to:

  • Evaluate multiple treatment strategies, at the same time, in the same patient.
  • Reach platform conclusions when sufficient data is accrued, rather than when a pre-specified sample size is reached
  • Utilise data that is already accrued to increase the likelihood that patients within the trial are randomised to treatments that are more likely to be beneficial
  • New questions can be substituted into the trial as initial questions are answered, meaning that the trial can be perpetual or open-ended
  • Interactions between interventions in different domains can be evaluated

It is reasonable to presume that any pandemic respiratory infection of major significance to public health will manifest as life-threatening respiratory infection including Severe Acute Respiratory illness and severe Community Acquired Pneumonia (CAP) with concomitant admission to hospital, and for some patients, admission to an Intensive Care Unit (ICU). Previous pandemics and more localized outbreaks of respiratory emerging infections have resulted in severe CAP and ICU admission.

Previous pandemics and outbreaks of emerging infectious diseases have outlined the urgent need for evidence, preferably from Randomized Controlled Trials (RCTs), to guide best treatment. However, there are substantial challenges associated with being able to organize such trials when the time of onset of a pandemic and its exact nature are unpredictable. As an adaptive platform trial that enrolls patients during the interpandemic period, REMAP-CAP is ideally positioned to adapt, in the event of a respiratory pandemic, to evaluate existing treatments as well as novel approaches.

Study Type  ICMJE Interventional
Study Phase  ICMJE Phase 4
Study Design  ICMJE Allocation: Randomized
Intervention Model: Factorial Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Condition  ICMJE Community-acquired Pneumonia, Influenza, COVID-19
Intervention  ICMJE
  • Drug: Fixed-duration Hydrocortisone
    50mg of intravenous hydrocortisone will be administered every 6 hours for up to 7 days.
  • Drug: Shock-dependent hydrocortisone
    Patient will receive 50mg IV hydrocortisone every 6 hours while the patient is in septic shock
  • Drug: Ceftriaxone
    The duration and dose of empiric antibiotics will be determined by the treating clinician and local guidelines or practice.
  • Drug: Moxifloxacin or Levofloxacin
    The duration and dose of empiric antibiotics will be determined by the treating clinician and local guidelines or practice.
  • Drug: Piperacillin-tazobactam
    The duration and dose of empiric antibiotics will be determined by the treating clinician and local guidelines or practice.
  • Drug: Ceftaroline

    The duration and dose of empiric antibiotics will be determined by the treating clinician and local guidelines or practice.

    Ceftaroline is not available at commencement

  • Drug: Amoxicillin-clavulanate
    The duration and dose of empiric antibiotics will be determined by the treating clinician and local guidelines or practice.
  • Drug: Macrolide administered for 3-5 days

    Standard course of macrolide therapy, discontinued between study day 3 and the end of study day 5.

    The dosing of and route of administration is not protocolised, the following guidance is provided:

    • Initial IV administration of a macrolide is strongly preferred
    • The preferred IV macrolide is azithromycin, but IV clarithromycin may be substituted.
    • The preferred enteral macrolide is azithromycin, but enteral clarithromycin or roxithromycin may be substituted.
    Other Name: Standard course macrolide
  • Drug: Macrolide administered for up to 14 days

    Extended course of macrolide therapy discontinued at the end of study day 14 or hospital discharge (whichever occurs first).

    The dosing of and route of administration is not protocolised, the following guidance is provided:

    • Initial IV administration of a macrolide is strongly preferred
    • The preferred IV macrolide is azithromycin, but IV clarithromycin may be substituted.
    • The preferred enteral macrolide is azithromycin, but enteral clarithromycin or roxithromycin may be substituted.
    Other Name: Extended course macrolide
  • Drug: Five-days oseltamivir
    Oseltamivir administered enterally twice daily for 5 days or until hospital discharge (whichever occurs first)
  • Drug: Ten-days oseltamivir
    Oseltamivir administered enterally twice daily for 10 days or until hospital discharge (whichever occurs first)
  • Drug: Lopinavir/ritonavir
    Lopinavir/ritonavir 400/100mg administered enterally, or 5ml 80/20mg per mL solution suspension via gastric tube, every 12 hours. Administered for a minimum of 5 days, including if discharged from ICU prior to end of study day 5. For patients discharged from ICU between study day 6 and study day 14, lopinavir/ritonavir is ceased at ICU discharge. Lopinavir/ritonavir is ceased at the end of study day 14 if the patient remains in ICU.
    Other Name: Kaletra
  • Drug: Hydroxychloroquine
    Loading dose of 800mg hydroxychloroquine administered enterally every 6 hours until 2 doses have been administered. Subsequently, 400mg hydroxychloroquine will be administered enterally every 12 hours for 12 doses or ICU discharge (whichever occurs first).
  • Drug: Hydroxychloroquine + lopinavir/ritonavir

    Lopinavir/ritonavir 400/100mg administered enterally, or 5ml 80/20mg per mL solution suspension via gastric tube, every 12 hours. Administered for a minimum of 5 days, including if discharged from ICU prior to end of study day 5. For patients discharged from ICU between study day 6 and study day 14, lopinavir/ritonavir is ceased at ICU discharge. Lopinavir/ritonavir is ceased at the end of study day 14 if the patient remains in ICU.

    Loading dose of 800mg hydroxychloroquine administered enterally every 6 hours until 2 doses have been administered. Subsequently, 400mg hydroxychloroquine will be administered enterally every 12 hours for 12 doses or ICU discharge (whichever occurs first).

  • Drug: Interferon-β1a
    IFN-β1a 10 μg will be administered as an intravenous bolus injection via a central or peripheral line. IFN-β1a will be administered once daily for 6 days or until ICU discharge, whichever occurs first.
    Other Name: IFN-β1a
  • Drug: Anakinra

    A loading dose of 300mg anakinra will be administered as a bolus via central or peripheral line. This is followed by maintenance doses of 100mg of anakinra administered very 6 hours.

    In patients with renal impairment, anakinra will be administered on alternate days.

    Other Name: Interleukin-1 receptor antagonist (IL-1Ra)
  • Drug: Fixed-duration higher dose Hydrocortisone
    100mg of intravenous hydrocortisone will be administered every 6 hours for up to 7 days.
  • Drug: Tocilizumab

    Tocilizumab will be administered as a single dose of 8mg/kg estimated or measured body weight, with a maximum total dose of 800mg.

    Tocilizumab will be administered as an IV infusion via central or peripheral line over a one-hour period.

  • Drug: Sarilumab
    Sarilumab will be administered as a single dose of 400mg, via IV infusion through peripheral or central line over a one-hour period.
  • Drug: Vitamin C
    Vitamin C 50mg/kg administered IV every 6 hours for 16 doses
  • Drug: Therapeutic anticoagulation
    Patients will be administered either low molecular weight heparin or unfractionated heparin to achieve systemic anticoagulation. Either agent may be used and the same patient may be switched between UFH and LMWH at the discretion of the treating clinician.
  • Drug: Simvastatin
    Simvastatin 80mg administered once daily via enteral route, while the patient remains in hospital up to 28 days after randomisation
  • Drug: Convalescent plasma
    Patients will recieve at least one and no more than two units of ABO compatible convalescent plasma within 48 hours of randomisation.
  • Other: Protocolised mechanical ventilation strategy
    See Domain Specific Appendix for a complete description of protoclised invasive mechanical ventilation strategy.
Study Arms  ICMJE
  • Active Comparator: Corticosteroid Domain: fixed-duration Hydrocortisone
    The patient will receive IV Hydrocortisone 50 mg every 6 hours for up to 7 days.
    Intervention: Drug: Fixed-duration Hydrocortisone
  • No Intervention: Corticosteroid Domain:No systemic corticosteroid (no placebo)
    The patient will receive no systemic corticosteroid for the treatment of CAP or its direct complications, up until study day 28.
  • Active Comparator: Corticosteroid Domain: shock dependant Hydrocortisone
    The patient will receive hydrocortisone (50mg IV every 6 hours) while the patient is in septic shock.
    Intervention: Drug: Shock-dependent hydrocortisone
  • Active Comparator: Antibiotic Domain: Ceftriaxone + Macrolide
    Ceftriaxone and site preferred macrolide will be administered for empiric antibiotic therapy
    Intervention: Drug: Ceftriaxone
  • Active Comparator: Antibiotic Domain: Moxifloxacin or Levofloxacin
    Moxifloxacin or levofloxacin will be administered for empiric antibiotic therapy
    Intervention: Drug: Moxifloxacin or Levofloxacin
  • Active Comparator: Antibiotic Domain: Piperacillin-tazobactam + Macrolide
    Piperacillin-tazobactam and site preferred macrolide will be administered for empiric antibiotic therapy
    Intervention: Drug: Piperacillin-tazobactam
  • Active Comparator: Antibiotic Domain: Ceftaroline + Macrolide
    Ceftaroline and site preferred macrolide will be administered for empiric antibiotic therapy
    Intervention: Drug: Ceftaroline
  • Active Comparator: Antibiotic Domain: Amoxicillin-clavulanate + Macrolide
    Amoxicillin-clavunate and site preferred macrolide will be administered for empiric antibiotic therapy
    Intervention: Drug: Amoxicillin-clavulanate
  • Active Comparator: Macrolide Duration Domain: Standard course macrolide
    The patient will receive macrolide therapy for 3-5 days. This arm is nested within the Antibiotic Domain.
    Intervention: Drug: Macrolide administered for 3-5 days
  • Active Comparator: Macrolide Duration Domain: Extended course macrolide
    The patient will receive macrolide therapy for up to 14 days. This arm is nested within the Antibiotic Domain.
    Intervention: Drug: Macrolide administered for up to 14 days
  • No Intervention: No antiviral agent active against influenza (no placebo)
    The patient will receive no antiviral agent active against influenza, including oseltamivir.
  • Active Comparator: Five-day course of Oseltamivir
    The patient will receive a five-day course of oseltamivir.
    Intervention: Drug: Five-days oseltamivir
  • Active Comparator: 10-day course of oseltamivir
    The patient will receive a ten-day course of oseltamivir.
    Intervention: Drug: Ten-days oseltamivir
  • No Intervention: No antiviral for COVID-19
    The patient will receive no antiviral agent intended to be active against SARS-CoV-2 infection.
  • Active Comparator: Lopinavir/ritonavir for COVID-19
    Patients will receive lopinavir/ritonavir (kaletra) 400/100mg enterally every 12 hours intended to be active against SARS-CoV-2 infection.
    Intervention: Drug: Lopinavir/ritonavir
  • Active Comparator: Hydroxychloroquine for COVID-19
    Patients will receive hydroxychloroquine intended to be active against SARS-CoV-2 infection.
    Intervention: Drug: Hydroxychloroquine
  • Active Comparator: Hydroxychloroquine + lopinavir/ritonavir for COVID-19
    Patients will receive both hydroxychloroquine and lopinavir/ritonavir intended to be active against SARS-CoV-2 infection.
    Intervention: Drug: Hydroxychloroquine + lopinavir/ritonavir
  • No Intervention: No immune modulation for COVID-19
    Patients will not receive any immune modulating therapy intended to be active against COVID-19.
  • Active Comparator: Interferon-β1a for COVID-19
    Patients will receive Interferon-β1a intended to be active against COVID-19.
    Intervention: Drug: Interferon-β1a
  • Active Comparator: Anakinra (interleukin-1 receptor antagonist) for COVID-19
    Patients will receive anakinra intended to be active against COVID-19.
    Intervention: Drug: Anakinra
  • Active Comparator: Fixed-duration higher dose Hydrocortisone
    The patient will receive IV Hydrocortisone 100mg every 6 hours for up to 7 days.
    Intervention: Drug: Fixed-duration higher dose Hydrocortisone
  • Active Comparator: Tocilizumab
    Patients will receive Tocilizumab intended to be active against COVID-19
    Intervention: Drug: Tocilizumab
  • Active Comparator: Sarilumab
    Patients will receive Sarilumab intended to be active against COVID-19
    Intervention: Drug: Sarilumab
  • No Intervention: No Vitamin C
    Patients will not receive vitamin c (no placebo)
  • Active Comparator: Vitamin C
    Patients will receive IV Vitamin C (50mg/kg every 6 hours for 16 doses)
    Intervention: Drug: Vitamin C
  • No Intervention: Standard Care Thromboprophylaxis
    Patients will receive local standard care thromboprophylaxis for 14 days.
  • Active Comparator: Therapeutic Anticoagulation
    Therapeutic anticoagulation with IV unfractionated heparin or subcutaneous low molecular weight heparin.
    Intervention: Drug: Therapeutic anticoagulation
  • No Intervention: No simvastatin
    Patients will not receive simvastatin for up to 28 days while the patient remains in hospital.
  • Active Comparator: Simvastatin
    Patients will receive simvastatin (80mg enterally once daily) for up to 28 days while the patient remains in hospital.
    Intervention: Drug: Simvastatin
  • No Intervention: No immunoglobulin against SARS-CoV-2
    Patients will not receive any preparation of immunoglobulin intended to neutralise SARS-CoV-2 during the index hospitalisation.
  • Active Comparator: Convalescent plasma
    Patients will receive at least one, and not more than two, units of convalescent plasma within 48 hours of randomisation.
    Intervention: Drug: Convalescent plasma
  • No Intervention: Clinician-preferred invasive ventilation
    Patients will receive invasive mechanical ventilation as determined by the treating clinician.
  • Active Comparator: Protocolised invasive mechanical ventilation strategy
    Patient will receive a protocolised invasive mechanical ventilation strategy
    Intervention: Other: Protocolised mechanical ventilation strategy
Publications *

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruitment Information
Recruitment Status  ICMJE Recruiting
Estimated Enrollment  ICMJE
 (submitted: April 15, 2020)
7100
Original Estimated Enrollment  ICMJE
 (submitted: April 6, 2016)
4000
Estimated Study Completion Date  ICMJE December 2023
Estimated Primary Completion Date December 2021   (Final data collection date for primary outcome measure)
Eligibility Criteria  ICMJE

REMAP-CAP PLATFORM INCLUSION CRITERIA:

  1. Adult patient admitted to an ICU for severe CAP within 48 hours of hospital admission with:

    1. symptoms or signs or both that are consistent with lower respiratory tract infection AND
    2. Radiological evidence of new onset consolidation (in patients with pre-existing radiological changes, evidence of new infiltrate)
  2. Up to 48 hours after ICU admission, receiving organ support with one or more of:

    1. Non-invasive or Invasive ventilatory support;
    2. Receiving infusion of vasopressor or inotropes or both

PLATFORM EXCLUSION CRITERIA:

  1. Healthcare-associated pneumonia:

    1. Prior to this illness, is known to have been an inpatient in any healthcare facility within the last 30 days
    2. Resident of a nursing home or long term care facility
  2. Death is deemed to be imminent and inevitable during the next 24 hours AND one or more of the patient, substitute decision maker or attending physician are not committed to full active treatment
  3. Previous participation in this REMAP within the last 90 days

REMAP-COVID PLATFORM INCLUSION CRITERIA

1. Adult patients (≥ 18 years) admitted to hospital with acute illness due to suspected or proven pandemic infection.

REMAP-COVID PLATFORM EXCLUSION CRITERIA

  1. Death is deemed to be imminent and inevitable during the next 24 hours AND one or more of the patient, substitute decision maker or attending physician are not committed to full active treatment
  2. Patient is expected to be discharged from hospital today or tomorrow
  3. More than 14 days have elapsed while admitted to hospital with symptoms of an acute illness due to suspected or proven pandemic infection.
  4. Previous participation in this REMAP within the last 90 days

DOMAIN-SPECIFIC ELIGIBLE CRITERIA:

Each domain may have additional eligibility criteria. Refer to the study website for more information (www.remapcap.org).

Sex/Gender  ICMJE
Sexes Eligible for Study: All
Ages  ICMJE 18 Years and older   (Adult, Older Adult)
Accepts Healthy Volunteers  ICMJE No
Contacts  ICMJE
Contact: Cameron Green info@remapcap.org
Contact: Wilma Van Bentum-Puijk, MSc +31 (0) 88 755 5555 prepare_icu@umcutrecht.nl
Listed Location Countries  ICMJE Australia,   Belgium,   Canada,   Croatia,   Germany,   Hungary,   Ireland,   Netherlands,   New Zealand,   Portugal,   Romania,   Spain,   United Kingdom,   United States
Removed Location Countries France
 
Administrative Information
NCT Number  ICMJE NCT02735707
Other Study ID Numbers  ICMJE U1111-1189-1653
2015-002340-14 ( EudraCT Number )
602525 ( Other Grant/Funding Number: European Union, FP7-HEALTH-2013-INNOVATION-1, PREPARE )
16/631 ( Other Grant/Funding Number: Platform Trial Optimising Interventions in Severe Community Acquired Pneumonia Health Research Council, New Zealand) )
APP1101719 ( Other Grant/Funding Number: OPTIMISE-CAP, The National Health and Medical Research Council, Australia )
158584 ( Other Grant/Funding Number: Canadian Institute of Health Research, Strategy for Patient-Oriented Research (CIHR- )
Has Data Monitoring Committee Yes
U.S. FDA-regulated Product
Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
IPD Sharing Statement  ICMJE
Plan to Share IPD: Yes
Responsible Party MJM Bonten, UMC Utrecht
Study Sponsor  ICMJE MJM Bonten
Collaborators  ICMJE
  • Australian and New Zealand Intensive Care Research Centre
  • Medical Research Institute of New Zealand
  • Unity Health
  • Berry Consultants
  • Global Coalition for Adaptive Research
  • University of Pittsburgh Medical Center
Investigators  ICMJE
Study Chair: Steve Webb, Prof Monash University, Study Chair REMAP-CAP Australia
Study Chair: Colin McArthur, Dr Medical Research Institute of New Zealand, Study Chair REMAP-CAP New Zealand
Study Chair: Marc Bonten, Prof UMC Utrecht, Study Chair REMAP-CAP Europe
Study Chair: Lennie Derde, MD UMC Utrecht, Coordinating Investigator REMAP-CAP Europe
Study Chair: Marshall Marshall, Prof Unity Health Toronto
Study Chair: Angus Derek, Prof University of Pittsburgh Medical Center
PRS Account UMC Utrecht
Verification Date July 2020

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP