xml: <clinical_study>
    <!-- This xml conforms to an XML Schema at:
      https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
    <required_header>
      <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
      <link_text>Link to the current ClinicalTrials.gov record.</link_text>
      <url>https://clinicaltrials.gov/ct2/show/NCT05982912</url>
    </required_header>
    <id_info>
      <org_study_id>RMB-22-0398</org_study_id>
      <nct_id>NCT05982912</nct_id>
    </id_info>
    <brief_title>VOC in Breath Samples for the Diagnosis of IPA</brief_title>
    <official_title>The Identification of Volatile Organic Compunds Profiles Predictive of Invasive Pulmonary Aspergillosis in Breath Samples</official_title>
    <sponsors>
      <lead_sponsor>
        <agency>Rambam Health Care Campus</agency>
        <agency_class>Other</agency_class>
      </lead_sponsor>
    </sponsors>
    <source>Rambam Health Care Campus</source>
    <oversight_info>
      <has_dmc>No</has_dmc>
      <is_fda_regulated_drug>No</is_fda_regulated_drug>
      <is_fda_regulated_device>No</is_fda_regulated_device>
    </oversight_info>
    <brief_summary>
      <textblock>
        The diagnosis of invasive pulmonary aspergillosis (IPA) bears grave implications for the&#xD;
        prognosis and treatment plan of the immunosuppressed patient. Thus far, such diagnosis in the&#xD;
        immunosuppressed patient, such as patients with acute myeloid leukemia (AML), relied heavily&#xD;
        on chest computed tomography (CT) and bronchoalveolar lavage (BAL), an invasive approach&#xD;
        bearing many caveats. Volatile organic compounds (VOC) are compounds that could be detected&#xD;
        in exhaled air, and have shown some potential in the non-invasive diagnosis of various&#xD;
        conditions, including IPA.&#xD;
  &#xD;
        In this prospective longitudinal study we aim to compare the VOC profiles of patients&#xD;
        diagnosed with AML (baseline) to the profile of the same patient diagnosed with IPA later on,&#xD;
        and to the post recovery profile in the same patient. This approach should resolve many of&#xD;
        the issues plaguing prior attempts at VOC based IPA diagnosis, mainly the lack of properly&#xD;
        designed controls.&#xD;
  &#xD;
        Samples will be collected from consenting patients using Tedlar bags, and analyzed using&#xD;
        thermal desorption gas chromatography mass spectrometry (TD-GC-MS). VOCs detected will be&#xD;
        digitally analyzed to construct different classification models, with predictive performances&#xD;
        compared to the clinical diagnosis using the accepted methods will be assessed by binary&#xD;
        logistic regression.&#xD;
      </textblock>
    </brief_summary>
    <detailed_description>
      <textblock>
        BACKGROUND The diagnosis of invasive pulmonary aspergillosis (IPA) bears grave implications&#xD;
        for the prognosis and treatment plan of the immunosuppressed patient. The omnipresence of&#xD;
        Aspergillus spp in the environment, and by extension - the ubiquity of such isolates in the&#xD;
        respiratory system of healthy subjects, poses a great diagnostic challenge. Namely, the&#xD;
        differentiation of IPA from non-invasive colonization of the respiratory tract, may be&#xD;
        challenging. The vast increase in prevalence of patients who are immunosuppressed, including&#xD;
        malignancies and oncological treatments, hematopoietic stem cells and solid organ&#xD;
        transplantations, and immunomodulatory medications, accentuates this dilemma.(1)&#xD;
        Particularly, patients with acute myelogenous leukemia (AML) are at high risk of developing&#xD;
        IPA, with 5-15% of such patients developing IPA during the first 3 months after AML&#xD;
        diagnosis.(1-3) As up to 5% of patients with AML may have IPA at presentation, patients&#xD;
        admitted to Rambam Medical Center (RMC) with a new diagnosis of AML routinely undergo chest&#xD;
        computerized tomography (CT), which serves as screening for the presence of IPA at diagnosis&#xD;
        and a baseline for further reference should IPA be suspected later on.(3) Diagnosis of&#xD;
        probable or proven IPA in an AML patient requires suggestive imaging findings along with&#xD;
        microbiologic evidence. While in some cases the diagnosis can be made using biomarkers&#xD;
        (mainly the d-galactomannan antigen and or Aspergillus spp polymerase chain reaction) in&#xD;
        peripheral blood, the sensitivity of these assays is low and often this minimally invasive&#xD;
        approach does not yield sufficient diagnostic certainty. In such cases, bronchoscopy with&#xD;
        bronchoalveolar lavage is usually performed. This invasive procedure is particularly&#xD;
        hazardous in patients with suspected IPA, the vast majority of whom are very frail due to&#xD;
        their underlying illness.(4) These considerations have led the quest for additional,&#xD;
        non-invasive modalities in the diagnosis of IPA. (5) One such approach has been volatile&#xD;
        organic compounds (VOC) analysis in exhaled air samples. Characterized by low vapor pressure&#xD;
        at room temperature, VOC profile analysis of exhaled air is an emerging field of diagnostics,&#xD;
        with the potential of non-invasive screening and diagnosis of various diseases, including&#xD;
        neoplasms,(6) infections(7) and inflammatory processes.(8) Previous studies have identified&#xD;
        potential VOC markers of metabolically active Aspergillus spp,(9) with one small prospective&#xD;
        study in humans(10) showing encouraging diagnostic performance for VOC based IPA&#xD;
        identification. However, these attempts have been hampered by several pitfalls. Firstly, VOC&#xD;
        profiles of in vitro Aspergillus spp seem to have little relation with VOCs found in breath&#xD;
        analysis of colonized patients.(5) Secondly, exhaled VOCs tend to differ greatly between&#xD;
        individuals, making the absence of temporal controls (i.e., VOC profile changes in the same&#xD;
        individual before and after IPA development) a crucial caveat.(10) Thirdly, to our knowledge&#xD;
        no longitudinal studies have assessed the response of VOC profiles to IPA treatment.&#xD;
  &#xD;
        In this prospective longitudinal study we aim to overcome these hurdles taking advantage of&#xD;
        two key characteristics of hematologic patients treated in RMC. First, patients with newly&#xD;
        diagnosed AML have a relatively high prevalence of IPA. Second, a chest CT is performed at&#xD;
        the diagnosis of AML in all patients. Thus, collecting breath samples from patients with&#xD;
        normal baseline CT will serve as negative controls, allowing for the comparison of VOC&#xD;
        profiles before and after the development of IPA in the same patient. Further sampling after&#xD;
        the patient has recovered from IPA will provide additional longitudinal control.&#xD;
  &#xD;
        GOALS The identification of VOC profiles predictive of IPA in breath samples&#xD;
  &#xD;
        METHODS&#xD;
  &#xD;
        Study design:&#xD;
  &#xD;
        This is a single center, non randomized, prospective cohort study. Breath samples from&#xD;
        consenting patients will be analyzed for VOC profiles at the time of initial CT screening for&#xD;
        IPA. In addition, samples will also be collected at the time of diagnosis of any possible,&#xD;
        probable or confirmed IPA (defined according to the EORTC criteria (4) as detailed below).&#xD;
  &#xD;
        Setting and participants:&#xD;
  &#xD;
        Patients newly diagnosed with AML initiating treatment in the RMC hematology department will&#xD;
        be approached. Inclusion period will be from October 1, 2022, until March 31, 2025.&#xD;
  &#xD;
        Inclusion criteria:&#xD;
  &#xD;
        New diagnosis of acute myeloid leukemia AND/OR planned hematopoietic stem cells&#xD;
        transplantation (HCT) Chest CT performed within 30 days from sampling 18 years of age or&#xD;
        older The ability to provide tidal breath samples totalling 10L directly into a Tedlar bag&#xD;
  &#xD;
        Exclusion criteria:&#xD;
  &#xD;
        Any condition impairing the patient's ability to provide informed consent&#xD;
  &#xD;
        Sample collection:&#xD;
  &#xD;
        Breath samples will be collected in one of our hematological department's 23 dedicated&#xD;
        hospitalization rooms - positively pressurized and climate controlled with E-pure&#xD;
        high-efficiency particulate air (HEPA) filters (ADS-Laminaire, Israel). Patients will be&#xD;
        required to abstain from teeth brushing, dental wash, eating, drinking or smoking in the 6&#xD;
        hours prior to sample collection. After being seated for 10 minutes (to avoid exercise&#xD;
        induced isoprene concentration increase (11) ), the patient will be asked to fill 10L of&#xD;
        tidal breath into a tedlar bag (SKC, South Korea). Simultaneously, an identical tedlar bag&#xD;
        shall be filled with ambient air.&#xD;
  &#xD;
        Upon each sample collection, the following data will be recorded:&#xD;
  &#xD;
        Patient's characteristics, including age, hemato-oncological diagnosis, time from initial&#xD;
        diagnosis, current treatment, time from HCT if applicable, background diagnoses Current&#xD;
        pharmacological treatment, including all antibiotics and antifungals prescribed the preceding&#xD;
        month.&#xD;
  &#xD;
        Current diagnostic tests, including all cultures, serology assays, nucleic acid amplification&#xD;
        studies, complete blood count and chemistry, voriconazole plasma level and chest imaging&#xD;
        performed during the past month.&#xD;
  &#xD;
        Sample handling and VOC extraction:&#xD;
  &#xD;
        All tedlar bags will be stored at 4℃ following collection. Adsorption onto 2 parallel thermal&#xD;
        desorption tubes shall be accomplished via Gilian LFS-113 Low Flow Personal Air Sampling Pump&#xD;
        (SRA instruments, Milano, Italy), performed within 72 hours from sampling and stored under&#xD;
        ambient conditions. These samples will be labeled (coded) and transformed to the&#xD;
        Environmental Chemistry Laboratory (Kasali Institute of Chemistry, Hebrew University of&#xD;
        Jerusalem, Israel)&#xD;
  &#xD;
        Analytics:&#xD;
  &#xD;
        Thermal desorption will be accomplished at 290 for 20 minutes using analytical grade&#xD;
        (99.999%) helium gas as carrier. Injection to tandem gas chromatography mass spectroscopy&#xD;
        (GC-MS) shall be performed at similar inlet temperatures not exceeding the flow of 40 mL/min.&#xD;
        The initial GC temperature program will mimic previously reported (10) protocols: 40˚C for 3&#xD;
        minutes, raised to 70˚C at a rate of 5˚C per minute and held for 3 minutes, raised to 203˚C&#xD;
        at 7˚C per minute and held for 4 minutes, raised rapidly to 270˚C and held for 5 minutes. A&#xD;
        triple quad mass spectrometer (Agilent Technologies, Santa Clara, CA) shall be connected in&#xD;
        tandem, with a range of mass measurement of 20-400 m/z.&#xD;
  &#xD;
        The diagnosis of Invasive Pulmonary Aspergillosis will be defined according to the updated&#xD;
        EORTC criteria (4) as either one of the following:&#xD;
  &#xD;
        Confirmed IPA defined as a respiratory biopsy specimen with positive culture of Aspergillus&#xD;
        spp or histopathologic demonstration of tissue invasion by hyphae.&#xD;
  &#xD;
        &quot;Probable IPA&quot;, defined (1) as compatible radiographic features on chest CT (Dense,&#xD;
        well-circumscribed lesion(s) with or without a halo sign, air-crescent sign or a cavity) and&#xD;
        any of the following: Evidence of Aspergillus spp upon cytology, direct microscopy or culture&#xD;
        from any respiratory specimen, including sputum, broncho-alveolar lavage (BAL) fluid or&#xD;
        bronchial brush Positive D-galactomannan antigen detected in plasma, serum, or BAL fluid&#xD;
        Positive polymerase chain reaction (PCR) for Aspergillus spp detected in plasma, serum, or&#xD;
        BAL fluid &quot;Possible IPA&quot;, defined (1) as compatible radiographic features on chest CT (Dense,&#xD;
        well-circumscribed lesion(s) with or without a halo sign, air-crescent sign or a cavity)&#xD;
        without corroboratory laboratory findings.&#xD;
  &#xD;
        Additional information regarding the probability of IPA diagnosis will be collected by two&#xD;
        independent observers (I.G. and A.S.) reviewing the full electronic medical record (EMR) at&#xD;
        the end of the study period, assigning a single probability score 1-10 (1 being very low&#xD;
        probability of IPA, 10 corresponding to almost certain IPA) in view of the full clinica&#xD;
        course of the disease.&#xD;
  &#xD;
        Additional variables and data sources: For all cohort patients, epidemiological and clinical&#xD;
        information will be extracted from the hospital's electronic medical records (EMR) system&#xD;
        used in our hospital retrieved with the assistance of the MD-clone software. We will need to&#xD;
        obtain the personal information of patients in order to access their data recorded in the&#xD;
        daily follow up in their medical chart as some data is not coded. All data shall be later&#xD;
        coded and stripped off any personal identifiers including name, surname, date of birth, ID&#xD;
        number, and address. All data shall be stored on a designated hard disk at the hands of the&#xD;
        primary investigator. Data sources will include the patient's file on the &quot;prometheus&quot; EMR&#xD;
        registry as well as retrieved data using MD-clone software. Collected data will include:&#xD;
        demographics (age, sex), background diagnoses, length of stay and transfer to other units,&#xD;
        laboratory results, vital signs recorded and the oxygenation method used as documented in the&#xD;
        daily follow-up.&#xD;
  &#xD;
        Sample collection schedule: The first sample of consenting patients included in this study&#xD;
        will be collected within 7 days from baseline chest CT. Subsequently, following any clinical&#xD;
        suspicion of IPA by the treating physician - a suspicion that invariably leads to a chest CT&#xD;
        being performed, samples will be collected within 7 days from chest CT. Additional samples&#xD;
        will be collected within 7 days from the discontinuation of antifungal treatment by the&#xD;
        treating physician. The sampling schedule, are visualized in figure 1.&#xD;
  &#xD;
        Figure 1 - Sampling strategy. This study's intervention is limited to sampling underlined in&#xD;
        bold red - all other steps are part of the usual management of AML patients and are in no way&#xD;
        affected by the participation in this study. AML - Acute Myeloid Leukemia; Dx - Diagnosis; CT&#xD;
        - Computerized Tomography; IPA - Invasive Pulmonary Aspergillosis; Tx - Treatment; d/c -&#xD;
        discontinued; GGO - Ground Glass Opacities.&#xD;
  &#xD;
        Data handling and statistical analysis:&#xD;
  &#xD;
        Clinical data shall be analyzed using descriptive statistics, parametric and nonparametric&#xD;
        tests as appropriate. All statistical analysis shall be performed using R software version&#xD;
        4.0.0 (&quot;Arbor day&quot;) or later. All identifiable data, including patient's baseline&#xD;
        characteristics, laboratory and imaging results and previous diagnoses and treatment records,&#xD;
        shall be stored by the primary investigator on a designated RAS encrypted solid phase memory&#xD;
        device for the duration of the study. Patient's names, ID numbers, address and date of birth&#xD;
        will not be stored.&#xD;
  &#xD;
        Mass spectroscopy outputs will be reviewed using the MassHunter workstation and software&#xD;
        (Agilent Technologies, Santa Clara, CA). Partial least squares discrimination analysis will&#xD;
        be preformed using the SIMCA software version 14.0 or later (MKS Umetrics, Sweden). For each&#xD;
        m/z range, a logistic regression model will be constructed, allowing for the calculation of&#xD;
        the variable importance for projection (VIP). For all VIPs ≥1 the corresponding ion profile&#xD;
        will be selected as a potential target. These will be compared with previously implicated&#xD;
        metabolites indicative of IPA, (10,11) as well as our existing database, as summarized in&#xD;
        APPENDIX A. Such identification is crucial since the same m/z value can correspond to&#xD;
        different metabolites, as different substances may have the same germplasm charge ratio.&#xD;
        Next, all identified substances will be confirmed against the National Institute of Standards&#xD;
        and Technology (NIST) 11 Mass Spectral Library (Scientific Instrument Services, Ringoes, New&#xD;
        Jersey) and a pure chemical standard. Finally, the digital matrix composed of the selected&#xD;
        characteristic VOCs will be imported into python (version 3.10.5 or later) to construct&#xD;
        different classification models, with predictive performances assessed by binary logistic&#xD;
        regression. The correlations between exhaled breath VOC expression levels and levels of serum&#xD;
        and BAL d-gallactomannan and IPA diagnostic certainty (confirmed, probable or possible, as&#xD;
        defined below) will be accomplished using Person's r.&#xD;
  &#xD;
        Sample size and power:&#xD;
  &#xD;
        In this prospective longitudinal study patients with high probability of developing IPA&#xD;
        (i.e., patients diagnosed with acute leukemia) will be enrolled at diagnosis. Since our&#xD;
        center performs baseline chest CT screening to identify potential IPA at baseline, VOC&#xD;
        collected after normal radiography can serve as ample controls. At least 15% of such patients&#xD;
        go on to develop IPA in the ensuing months,(3) limiting the sample size needed at&#xD;
        recruitment. Based on previously reported adherence to follow-up,(12) we expect drop out rate&#xD;
        to be low, allowing for the detection of previously elusive post treatment changes in VOC&#xD;
        profiles.&#xD;
  &#xD;
        For the purpose of these calculations we assumed the previously reported VOC assays&#xD;
        sensitivity (compared to microbiology or antigen testing in respiratory secretions, BAL or&#xD;
        patient serum) of 80-95% each.(10) Recent retrospective surveys have identified the incidence&#xD;
        of IPA to be 5% at initial screening CT and additional 10% within the initial&#xD;
        hospitalization.(3) This translates into an estimated sample size of 124 patients, calculated&#xD;
        under the assumption of the accepted significance (alpha = 0.05) and power (beta = 0.8).&#xD;
        Allowing for an estimated 70% enrolment and the additional 15% exclusion rate, the total&#xD;
        estimated sample size is 208 patients. Projecting the average annual incidence of 90 new&#xD;
        cases of acute leukemia treated in our hospital, this sampling goal should be easily reached&#xD;
        within the prespecified 30 months recruitment period. We thus expect the number of&#xD;
        participants to be 300.&#xD;
  &#xD;
        ETHICAL CONSIDERATIONS The development and amelioration of noninvasive techniques for IPA&#xD;
        identification has been the stated goal of various professional societies for over two&#xD;
        decades. (1,4) The patients proposed diagnostic tool bears minimal to no inconvenience to the&#xD;
        participants, and we deem potential side effects and danger to be negligible in this entirely&#xD;
        non-invasive modality.&#xD;
  &#xD;
        Following data extraction, all data shall be stripped of any identification including name,&#xD;
        surname, ID number, case number, date of birth and address - all destroyed when initial data&#xD;
        extraction is completed. Data shall be stored securely on a RAS encrypted, designated SD&#xD;
        device at the hands of the PI, minimizing the probability of this study affecting data&#xD;
        privacy or medical confidentiality of the patients included. In view of the direct effect the&#xD;
        results of this inquiry may have on the management and the prognosis of the severely ill, we&#xD;
        find the benefits of this study to outweigh any potential risks.&#xD;
  &#xD;
        Funding No external funding was provided for this study thus far.&#xD;
  &#xD;
        Bibliography&#xD;
  &#xD;
          1. Blot SI, Taccone FS, Van den Abeele A-M, Bulpa P, Meersseman W, Brusselaers N, et al. A&#xD;
             clinical algorithm to diagnose invasive pulmonary aspergillosis in critically ill&#xD;
             patients. Am J Respir Crit Care Med. 2012 Jul 1;186(1):56-64.&#xD;
  &#xD;
          2. Souza L, Nouér SA, Morales H, Simões B, Solza C, Queiroz-Telles F, et al. Epidemiology&#xD;
             of invasive fungal disease in haematologic patients. Mycoses. 2021 Mar;64(3):252-6.&#xD;
  &#xD;
          3. Bitterman R, Hardak E, Raines M, Stern A, Zuckerman T, Ofran Y, et al. Baseline Chest&#xD;
             Computed Tomography for Early Diagnosis of Invasive Pulmonary Aspergillosis in&#xD;
             Hemato-oncological Patients: A Prospective Cohort Study. Clin Infect Dis. 2019 Oct&#xD;
             30;69(10):1805-8.&#xD;
  &#xD;
          4. Donnelly JP, Chen SC, Kauffman CA, Steinbach WJ, Baddley JW, Verweij PE, et al. Revision&#xD;
             and update of the consensus definitions of invasive fungal disease from the european&#xD;
             organization for research and treatment of cancer and the mycoses study group education&#xD;
             and research consortium. Clin Infect Dis. 2020 Sep 12;71(6):1367-76.&#xD;
  &#xD;
          5. Savelieff MG, Pappalardo L. Novel cutting-edge metabolite-based diagnostic tools for&#xD;
             aspergillosis. PLoS Pathog. 2017 Sep 7;13(9):e1006486.&#xD;
  &#xD;
          6. Tsou P-H, Lin Z-L, Pan Y-C, Yang H-C, Chang C-J, Liang S-K, et al. Exploring Volatile&#xD;
             Organic Compounds in Breath for High-Accuracy Prediction of Lung Cancer. Cancers&#xD;
             (Basel). 2021 Mar 21;13(6).&#xD;
  &#xD;
          7. Kamal F, Kumar S, Edwards MR, Veselkov K, Belluomo I, Kebadze T, et al. Virus-induced&#xD;
             Volatile Organic Compounds Are Detectable in Exhaled Breath during Pulmonary Infection.&#xD;
             Am J Respir Crit Care Med. 2021 Nov 1;204(9):1075-85.&#xD;
  &#xD;
          8. Castro-Rodriguez JA, Cifuentes L, Martinez FD. Predicting asthma using clinical indexes.&#xD;
             Front Pediatr. 2019 Jul 31;7:320.&#xD;
  &#xD;
          9. Das S, Pal M. Review-Non-Invasive Monitoring of Human Health by Exhaled Breath Analysis:&#xD;
             A Comprehensive Review. J Electrochem Soc. 2020 Feb 3;167(3):037562.&#xD;
  &#xD;
         10. Koo S, Thomas HR, Daniels SD, Lynch RC, Fortier SM, Shea MM, et al. A breath fungal&#xD;
             secondary metabolite signature to diagnose invasive aspergillosis. Clin Infect Dis. 2014&#xD;
             Dec 15;59(12):1733-40.&#xD;
  &#xD;
         11. Li Z-T, Zeng P-Y, Chen Z-M, Guan W-J, Wang T, Lin Y, et al. Exhaled volatile organic&#xD;
             compounds for identifying patients with chronic pulmonary aspergillosis. Front Med&#xD;
             (Lausanne). 2021 Sep 23;8:720119.&#xD;
  &#xD;
         12. Hardak E, Fuchs E, Leskes H, Geffen Y, Zuckerman T, Oren I. Diagnostic role of&#xD;
             polymerase chain reaction in bronchoalveolar lavage fluid for invasive pulmonary&#xD;
             aspergillosis in immunocompromised patients - A retrospective cohort study. Int J Infect&#xD;
             Dis. 2019 Jun;83:20-5.&#xD;
      </textblock>
    </detailed_description>
    <overall_status>Recruiting</overall_status>
    <start_date type="Actual">March 3, 2022</start_date>
    <completion_date type="Anticipated">December 2025</completion_date>
    <primary_completion_date type="Anticipated">July 2025</primary_completion_date>
    <study_type>Observational</study_type>
    <has_expanded_access>No</has_expanded_access>
    <study_design_info>
      <observational_model>Cohort</observational_model>
      <time_perspective>Prospective</time_perspective>
    </study_design_info>
    <primary_outcome>
      <measure>Invasive Pulmonary Aspergillosis</measure>
      <time_frame>within 2 years from inrollment</time_frame>
      <description>The diagnosis of Invasive Pulmonary Aspergillosis will be defined according to the updated EORTC criteria</description>
    </primary_outcome>
    <number_of_groups>1</number_of_groups>
    <enrollment type="Anticipated">200</enrollment>
    <condition>Invasive Pulmonary Aspergillosis</condition>
    <condition>Breath Samples</condition>
    <condition>Volatile Organic Compounds</condition>
    <arm_group>
      <arm_group_label>Patients that developed Invasive Pulmonary Aspergillosis</arm_group_label>
      <description>All patients sampled who later on developed IPA</description>
    </arm_group>
    <intervention>
      <intervention_type>Diagnostic Test</intervention_type>
      <intervention_name>breath sampling</intervention_name>
      <description>We collect a breath sample of exhaled air and analyse the VOC profile in this sample</description>
      <arm_group_label>Patients that developed Invasive Pulmonary Aspergillosis</arm_group_label>
    </intervention>
    <eligibility>
      <study_pop>
        <textblock>
          Patients newly diagnosed with AML initiating treatment in the RMC hematology department&#xD;
          will be approached.&#xD;
        </textblock>
      </study_pop>
      <sampling_method>Non-Probability Sample</sampling_method>
      <criteria>
        <textblock>
          Inclusion Criteria:&#xD;
  &#xD;
            -  New diagnosis of acute myeloid leukemia AND/OR planned hematopoietic stem cells&#xD;
               transplantation (HCT)&#xD;
  &#xD;
            -  Chest CT performed within 30 days from sampling&#xD;
  &#xD;
            -  18 years of age or older&#xD;
  &#xD;
            -  The ability to provide tidal breath samples totalling 10L directly into a Tedlar bag&#xD;
  &#xD;
          Exclusion Criteria:&#xD;
  &#xD;
            -  Any condition impairing the patient's ability to provide informed consent&#xD;
        </textblock>
      </criteria>
      <gender>All</gender>
      <minimum_age>18 Years</minimum_age>
      <maximum_age>18 Years</maximum_age>
      <healthy_volunteers>No</healthy_volunteers>
    </eligibility>
    <overall_contact>
      <last_name>Ivan GUR, MD</last_name>
      <phone>0542555655</phone>
      <email>ostyly@gmail.com</email>
    </overall_contact>
    <location>
      <facility>
        <name>Rambam Healthcare Campus</name>
        <address>
          <city>Haifa</city>
          <zip>9619002</zip>
          <country>Israel</country>
        </address>
      </facility>
      <status>Recruiting</status>
      <contact>
        <last_name>Ivan GUR, MD</last_name>
        <phone>0542555655</phone>
        <email>ostyly@gmail.com</email>
      </contact>
    </location>
    <location_countries>
      <country>Israel</country>
    </location_countries>
    <verification_date>August 2023</verification_date>
    <study_first_submitted>August 1, 2023</study_first_submitted>
    <study_first_submitted_qc>August 1, 2023</study_first_submitted_qc>
    <study_first_posted type="Actual">August 9, 2023</study_first_posted>
    <last_update_submitted>August 1, 2023</last_update_submitted>
    <last_update_submitted_qc>August 1, 2023</last_update_submitted_qc>
    <last_update_posted type="Actual">August 9, 2023</last_update_posted>
    <responsible_party>
      <responsible_party_type>Sponsor</responsible_party_type>
    </responsible_party>
    <condition_browse>
      <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
      <mesh_term>Aspergillosis</mesh_term>
      <mesh_term>Pulmonary Aspergillosis</mesh_term>
      <mesh_term>Invasive Pulmonary Aspergillosis</mesh_term>
    </condition_browse>
    <patient_data>
      <sharing_ipd>Yes</sharing_ipd>
      <ipd_description>VOC profiles including time of collection, as well as hamatological and clinical data, shall be shared with no identifying personal information upon resonable request</ipd_description>
      <ipd_info_type>Study Protocol</ipd_info_type>
      <ipd_info_type>Statistical Analysis Plan (SAP)</ipd_info_type>
      <ipd_info_type>Informed Consent Form (ICF)</ipd_info_type>
      <ipd_info_type>Clinical Study Report (CSR)</ipd_info_type>
      <ipd_info_type>Analytic Code</ipd_info_type>
      <ipd_time_frame>starting Dec 2025, indefinetely</ipd_time_frame>
      <ipd_access_criteria>upon resonable request at ostyly@gmail.com</ipd_access_criteria>
    </patient_data>
    <!-- Results have not yet been posted for this study                                          -->
  </clinical_study>
  
  
text: download date: ClinicalTrials.gov processed this data on September 20, 2023
  link text: Link to the current ClinicalTrials.gov record.
  url: https://clinicaltrials.gov/ct2/show/NCT05982912
  org study id: RMB-22-0398
  nct id: NCT05982912
  lead sponsor: 
  has dmc: No
  is fda regulated drug: No
  is fda regulated device: No
  The diagnosis of invasive pulmonary aspergillosis (IPA) bears grave implications for the
        prognosis and treatment plan of the immunosuppressed patient. Thus far, such diagnosis in the
        immunosuppressed patient, such as patients with acute myeloid leukemia (AML), relied heavily
        on chest computed tomography (CT) and bronchoalveolar lavage (BAL), an invasive approach
        bearing many caveats. Volatile organic compounds (VOC) are compounds that could be detected
        in exhaled air, and have shown some potential in the non-invasive diagnosis of various
        conditions, including IPA.
  
        In this prospective longitudinal study we aim to compare the VOC profiles of patients
        diagnosed with AML (baseline) to the profile of the same patient diagnosed with IPA later on,
        and to the post recovery profile in the same patient. This approach should resolve many of
        the issues plaguing prior attempts at VOC based IPA diagnosis, mainly the lack of properly
        designed controls.
  
        Samples will be collected from consenting patients using Tedlar bags, and analyzed using
        thermal desorption gas chromatography mass spectrometry (TD-GC-MS). VOCs detected will be
        digitally analyzed to construct different classification models, with predictive performances
        compared to the clinical diagnosis using the accepted methods will be assessed by binary
        logistic regression.
  BACKGROUND The diagnosis of invasive pulmonary aspergillosis (IPA) bears grave implications
        for the prognosis and treatment plan of the immunosuppressed patient. The omnipresence of
        Aspergillus spp in the environment, and by extension - the ubiquity of such isolates in the
        respiratory system of healthy subjects, poses a great diagnostic challenge. Namely, the
        differentiation of IPA from non-invasive colonization of the respiratory tract, may be
        challenging. The vast increase in prevalence of patients who are immunosuppressed, including
        malignancies and oncological treatments, hematopoietic stem cells and solid organ
        transplantations, and immunomodulatory medications, accentuates this dilemma.(1)
        Particularly, patients with acute myelogenous leukemia (AML) are at high risk of developing
        IPA, with 5-15% of such patients developing IPA during the first 3 months after AML
        diagnosis.(1-3) As up to 5% of patients with AML may have IPA at presentation, patients
        admitted to Rambam Medical Center (RMC) with a new diagnosis of AML routinely undergo chest
        computerized tomography (CT), which serves as screening for the presence of IPA at diagnosis
        and a baseline for further reference should IPA be suspected later on.(3) Diagnosis of
        probable or proven IPA in an AML patient requires suggestive imaging findings along with
        microbiologic evidence. While in some cases the diagnosis can be made using biomarkers
        (mainly the d-galactomannan antigen and or Aspergillus spp polymerase chain reaction) in
        peripheral blood, the sensitivity of these assays is low and often this minimally invasive
        approach does not yield sufficient diagnostic certainty. In such cases, bronchoscopy with
        bronchoalveolar lavage is usually performed. This invasive procedure is particularly
        hazardous in patients with suspected IPA, the vast majority of whom are very frail due to
        their underlying illness.(4) These considerations have led the quest for additional,
        non-invasive modalities in the diagnosis of IPA. (5) One such approach has been volatile
        organic compounds (VOC) analysis in exhaled air samples. Characterized by low vapor pressure
        at room temperature, VOC profile analysis of exhaled air is an emerging field of diagnostics,
        with the potential of non-invasive screening and diagnosis of various diseases, including
        neoplasms,(6) infections(7) and inflammatory processes.(8) Previous studies have identified
        potential VOC markers of metabolically active Aspergillus spp,(9) with one small prospective
        study in humans(10) showing encouraging diagnostic performance for VOC based IPA
        identification. However, these attempts have been hampered by several pitfalls. Firstly, VOC
        profiles of in vitro Aspergillus spp seem to have little relation with VOCs found in breath
        analysis of colonized patients.(5) Secondly, exhaled VOCs tend to differ greatly between
        individuals, making the absence of temporal controls (i.e., VOC profile changes in the same
        individual before and after IPA development) a crucial caveat.(10) Thirdly, to our knowledge
        no longitudinal studies have assessed the response of VOC profiles to IPA treatment.
  
        In this prospective longitudinal study we aim to overcome these hurdles taking advantage of
        two key characteristics of hematologic patients treated in RMC. First, patients with newly
        diagnosed AML have a relatively high prevalence of IPA. Second, a chest CT is performed at
        the diagnosis of AML in all patients. Thus, collecting breath samples from patients with
        normal baseline CT will serve as negative controls, allowing for the comparison of VOC
        profiles before and after the development of IPA in the same patient. Further sampling after
        the patient has recovered from IPA will provide additional longitudinal control.
  
        GOALS The identification of VOC profiles predictive of IPA in breath samples
  
        METHODS
  
        Study design:
  
        This is a single center, non randomized, prospective cohort study. Breath samples from
        consenting patients will be analyzed for VOC profiles at the time of initial CT screening for
        IPA. In addition, samples will also be collected at the time of diagnosis of any possible,
        probable or confirmed IPA (defined according to the EORTC criteria (4) as detailed below).
  
        Setting and participants:
  
        Patients newly diagnosed with AML initiating treatment in the RMC hematology department will
        be approached. Inclusion period will be from October 1, 2022, until March 31, 2025.
  
        Inclusion criteria:
  
        New diagnosis of acute myeloid leukemia AND/OR planned hematopoietic stem cells
        transplantation (HCT) Chest CT performed within 30 days from sampling 18 years of age or
        older The ability to provide tidal breath samples totalling 10L directly into a Tedlar bag
  
        Exclusion criteria:
  
        Any condition impairing the patient's ability to provide informed consent
  
        Sample collection:
  
        Breath samples will be collected in one of our hematological department's 23 dedicated
        hospitalization rooms - positively pressurized and climate controlled with E-pure
        high-efficiency particulate air (HEPA) filters (ADS-Laminaire, Israel). Patients will be
        required to abstain from teeth brushing, dental wash, eating, drinking or smoking in the 6
        hours prior to sample collection. After being seated for 10 minutes (to avoid exercise
        induced isoprene concentration increase (11) ), the patient will be asked to fill 10L of
        tidal breath into a tedlar bag (SKC, South Korea). Simultaneously, an identical tedlar bag
        shall be filled with ambient air.
  
        Upon each sample collection, the following data will be recorded:
  
        Patient's characteristics, including age, hemato-oncological diagnosis, time from initial
        diagnosis, current treatment, time from HCT if applicable, background diagnoses Current
        pharmacological treatment, including all antibiotics and antifungals prescribed the preceding
        month.
  
        Current diagnostic tests, including all cultures, serology assays, nucleic acid amplification
        studies, complete blood count and chemistry, voriconazole plasma level and chest imaging
        performed during the past month.
  
        Sample handling and VOC extraction:
  
        All tedlar bags will be stored at 4℃ following collection. Adsorption onto 2 parallel thermal
        desorption tubes shall be accomplished via Gilian LFS-113 Low Flow Personal Air Sampling Pump
        (SRA instruments, Milano, Italy), performed within 72 hours from sampling and stored under
        ambient conditions. These samples will be labeled (coded) and transformed to the
        Environmental Chemistry Laboratory (Kasali Institute of Chemistry, Hebrew University of
        Jerusalem, Israel)
  
        Analytics:
  
        Thermal desorption will be accomplished at 290 for 20 minutes using analytical grade
        (99.999%) helium gas as carrier. Injection to tandem gas chromatography mass spectroscopy
        (GC-MS) shall be performed at similar inlet temperatures not exceeding the flow of 40 mL/min.
        The initial GC temperature program will mimic previously reported (10) protocols: 40˚C for 3
        minutes, raised to 70˚C at a rate of 5˚C per minute and held for 3 minutes, raised to 203˚C
        at 7˚C per minute and held for 4 minutes, raised rapidly to 270˚C and held for 5 minutes. A
        triple quad mass spectrometer (Agilent Technologies, Santa Clara, CA) shall be connected in
        tandem, with a range of mass measurement of 20-400 m/z.
  
        The diagnosis of Invasive Pulmonary Aspergillosis will be defined according to the updated
        EORTC criteria (4) as either one of the following:
  
        Confirmed IPA defined as a respiratory biopsy specimen with positive culture of Aspergillus
        spp or histopathologic demonstration of tissue invasion by hyphae.
  
        "Probable IPA", defined (1) as compatible radiographic features on chest CT (Dense,
        well-circumscribed lesion(s) with or without a halo sign, air-crescent sign or a cavity) and
        any of the following: Evidence of Aspergillus spp upon cytology, direct microscopy or culture
        from any respiratory specimen, including sputum, broncho-alveolar lavage (BAL) fluid or
        bronchial brush Positive D-galactomannan antigen detected in plasma, serum, or BAL fluid
        Positive polymerase chain reaction (PCR) for Aspergillus spp detected in plasma, serum, or
        BAL fluid "Possible IPA", defined (1) as compatible radiographic features on chest CT (Dense,
        well-circumscribed lesion(s) with or without a halo sign, air-crescent sign or a cavity)
        without corroboratory laboratory findings.
  
        Additional information regarding the probability of IPA diagnosis will be collected by two
        independent observers (I.G. and A.S.) reviewing the full electronic medical record (EMR) at
        the end of the study period, assigning a single probability score 1-10 (1 being very low
        probability of IPA, 10 corresponding to almost certain IPA) in view of the full clinica
        course of the disease.
  
        Additional variables and data sources: For all cohort patients, epidemiological and clinical
        information will be extracted from the hospital's electronic medical records (EMR) system
        used in our hospital retrieved with the assistance of the MD-clone software. We will need to
        obtain the personal information of patients in order to access their data recorded in the
        daily follow up in their medical chart as some data is not coded. All data shall be later
        coded and stripped off any personal identifiers including name, surname, date of birth, ID
        number, and address. All data shall be stored on a designated hard disk at the hands of the
        primary investigator. Data sources will include the patient's file on the "prometheus" EMR
        registry as well as retrieved data using MD-clone software. Collected data will include:
        demographics (age, sex), background diagnoses, length of stay and transfer to other units,
        laboratory results, vital signs recorded and the oxygenation method used as documented in the
        daily follow-up.
  
        Sample collection schedule: The first sample of consenting patients included in this study
        will be collected within 7 days from baseline chest CT. Subsequently, following any clinical
        suspicion of IPA by the treating physician - a suspicion that invariably leads to a chest CT
        being performed, samples will be collected within 7 days from chest CT. Additional samples
        will be collected within 7 days from the discontinuation of antifungal treatment by the
        treating physician. The sampling schedule, are visualized in figure 1.
  
        Figure 1 - Sampling strategy. This study's intervention is limited to sampling underlined in
        bold red - all other steps are part of the usual management of AML patients and are in no way
        affected by the participation in this study. AML - Acute Myeloid Leukemia; Dx - Diagnosis; CT
        - Computerized Tomography; IPA - Invasive Pulmonary Aspergillosis; Tx - Treatment; d/c -
        discontinued; GGO - Ground Glass Opacities.
  
        Data handling and statistical analysis:
  
        Clinical data shall be analyzed using descriptive statistics, parametric and nonparametric
        tests as appropriate. All statistical analysis shall be performed using R software version
        4.0.0 ("Arbor day") or later. All identifiable data, including patient's baseline
        characteristics, laboratory and imaging results and previous diagnoses and treatment records,
        shall be stored by the primary investigator on a designated RAS encrypted solid phase memory
        device for the duration of the study. Patient's names, ID numbers, address and date of birth
        will not be stored.
  
        Mass spectroscopy outputs will be reviewed using the MassHunter workstation and software
        (Agilent Technologies, Santa Clara, CA). Partial least squares discrimination analysis will
        be preformed using the SIMCA software version 14.0 or later (MKS Umetrics, Sweden). For each
        m/z range, a logistic regression model will be constructed, allowing for the calculation of
        the variable importance for projection (VIP). For all VIPs ≥1 the corresponding ion profile
        will be selected as a potential target. These will be compared with previously implicated
        metabolites indicative of IPA, (10,11) as well as our existing database, as summarized in
        APPENDIX A. Such identification is crucial since the same m/z value can correspond to
        different metabolites, as different substances may have the same germplasm charge ratio.
        Next, all identified substances will be confirmed against the National Institute of Standards
        and Technology (NIST) 11 Mass Spectral Library (Scientific Instrument Services, Ringoes, New
        Jersey) and a pure chemical standard. Finally, the digital matrix composed of the selected
        characteristic VOCs will be imported into python (version 3.10.5 or later) to construct
        different classification models, with predictive performances assessed by binary logistic
        regression. The correlations between exhaled breath VOC expression levels and levels of serum
        and BAL d-gallactomannan and IPA diagnostic certainty (confirmed, probable or possible, as
        defined below) will be accomplished using Person's r.
  
        Sample size and power:
  
        In this prospective longitudinal study patients with high probability of developing IPA
        (i.e., patients diagnosed with acute leukemia) will be enrolled at diagnosis. Since our
        center performs baseline chest CT screening to identify potential IPA at baseline, VOC
        collected after normal radiography can serve as ample controls. At least 15% of such patients
        go on to develop IPA in the ensuing months,(3) limiting the sample size needed at
        recruitment. Based on previously reported adherence to follow-up,(12) we expect drop out rate
        to be low, allowing for the detection of previously elusive post treatment changes in VOC
        profiles.
  
        For the purpose of these calculations we assumed the previously reported VOC assays
        sensitivity (compared to microbiology or antigen testing in respiratory secretions, BAL or
        patient serum) of 80-95% each.(10) Recent retrospective surveys have identified the incidence
        of IPA to be 5% at initial screening CT and additional 10% within the initial
        hospitalization.(3) This translates into an estimated sample size of 124 patients, calculated
        under the assumption of the accepted significance (alpha = 0.05) and power (beta = 0.8).
        Allowing for an estimated 70% enrolment and the additional 15% exclusion rate, the total
        estimated sample size is 208 patients. Projecting the average annual incidence of 90 new
        cases of acute leukemia treated in our hospital, this sampling goal should be easily reached
        within the prespecified 30 months recruitment period. We thus expect the number of
        participants to be 300.
  
        ETHICAL CONSIDERATIONS The development and amelioration of noninvasive techniques for IPA
        identification has been the stated goal of various professional societies for over two
        decades. (1,4) The patients proposed diagnostic tool bears minimal to no inconvenience to the
        participants, and we deem potential side effects and danger to be negligible in this entirely
        non-invasive modality.
  
        Following data extraction, all data shall be stripped of any identification including name,
        surname, ID number, case number, date of birth and address - all destroyed when initial data
        extraction is completed. Data shall be stored securely on a RAS encrypted, designated SD
        device at the hands of the PI, minimizing the probability of this study affecting data
        privacy or medical confidentiality of the patients included. In view of the direct effect the
        results of this inquiry may have on the management and the prognosis of the severely ill, we
        find the benefits of this study to outweigh any potential risks.
  
        Funding No external funding was provided for this study thus far.
  
        Bibliography
  
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             clinical algorithm to diagnose invasive pulmonary aspergillosis in critically ill
             patients. Am J Respir Crit Care Med. 2012 Jul 1;186(1):56-64.
  
          2. Souza L, Nouér SA, Morales H, Simões B, Solza C, Queiroz-Telles F, et al. Epidemiology
             of invasive fungal disease in haematologic patients. Mycoses. 2021 Mar;64(3):252-6.
  
          3. Bitterman R, Hardak E, Raines M, Stern A, Zuckerman T, Ofran Y, et al. Baseline Chest
             Computed Tomography for Early Diagnosis of Invasive Pulmonary Aspergillosis in
             Hemato-oncological Patients: A Prospective Cohort Study. Clin Infect Dis. 2019 Oct
             30;69(10):1805-8.
  
          4. Donnelly JP, Chen SC, Kauffman CA, Steinbach WJ, Baddley JW, Verweij PE, et al. Revision
             and update of the consensus definitions of invasive fungal disease from the european
             organization for research and treatment of cancer and the mycoses study group education
             and research consortium. Clin Infect Dis. 2020 Sep 12;71(6):1367-76.
  
          5. Savelieff MG, Pappalardo L. Novel cutting-edge metabolite-based diagnostic tools for
             aspergillosis. PLoS Pathog. 2017 Sep 7;13(9):e1006486.
  
          6. Tsou P-H, Lin Z-L, Pan Y-C, Yang H-C, Chang C-J, Liang S-K, et al. Exploring Volatile
             Organic Compounds in Breath for High-Accuracy Prediction of Lung Cancer. Cancers
             (Basel). 2021 Mar 21;13(6).
  
          7. Kamal F, Kumar S, Edwards MR, Veselkov K, Belluomo I, Kebadze T, et al. Virus-induced
             Volatile Organic Compounds Are Detectable in Exhaled Breath during Pulmonary Infection.
             Am J Respir Crit Care Med. 2021 Nov 1;204(9):1075-85.
  
          8. Castro-Rodriguez JA, Cifuentes L, Martinez FD. Predicting asthma using clinical indexes.
             Front Pediatr. 2019 Jul 31;7:320.
  
          9. Das S, Pal M. Review-Non-Invasive Monitoring of Human Health by Exhaled Breath Analysis:
             A Comprehensive Review. J Electrochem Soc. 2020 Feb 3;167(3):037562.
  
         10. Koo S, Thomas HR, Daniels SD, Lynch RC, Fortier SM, Shea MM, et al. A breath fungal
             secondary metabolite signature to diagnose invasive aspergillosis. Clin Infect Dis. 2014
             Dec 15;59(12):1733-40.
  
         11. Li Z-T, Zeng P-Y, Chen Z-M, Guan W-J, Wang T, Lin Y, et al. Exhaled volatile organic
             compounds for identifying patients with chronic pulmonary aspergillosis. Front Med
             (Lausanne). 2021 Sep 23;8:720119.
  
         12. Hardak E, Fuchs E, Leskes H, Geffen Y, Zuckerman T, Oren I. Diagnostic role of
             polymerase chain reaction in bronchoalveolar lavage fluid for invasive pulmonary
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             Dis. 2019 Jun;83:20-5.
  observational model: Cohort
  time perspective: Prospective
  measure: Invasive Pulmonary Aspergillosis
  time frame: within 2 years from inrollment
  description: The diagnosis of Invasive Pulmonary Aspergillosis will be defined according to the updated EORTC criteria
  arm group label: Patients that developed Invasive Pulmonary Aspergillosis
  description: All patients sampled who later on developed IPA
  intervention type: Diagnostic Test
  intervention name: breath sampling
  description: We collect a breath sample of exhaled air and analyse the VOC profile in this sample
  arm group label: Patients that developed Invasive Pulmonary Aspergillosis
  study pop: 
  sampling method: Non-Probability Sample
  criteria: 
  gender: All
  minimum age: 18 Years
  maximum age: 18 Years
  healthy volunteers: No
  last name: Ivan GUR, MD
  phone: 0542555655
  email: ostyly@gmail.com
  facility: 
  status: Recruiting
  contact: 
  country: Israel
  responsible party type: Sponsor
  mesh term: Aspergillosis
  mesh term: Pulmonary Aspergillosis
  mesh term: Invasive Pulmonary Aspergillosis
  sharing ipd: Yes
  ipd description: VOC profiles including time of collection, as well as hamatological and clinical data, shall be shared with no identifying personal information upon resonable request
  ipd info type: Study Protocol
  ipd info type: Statistical Analysis Plan (SAP)
  ipd info type: Informed Consent Form (ICF)
  ipd info type: Clinical Study Report (CSR)
  ipd info type: Analytic Code
  ipd time frame: starting Dec 2025, indefinetely
  ipd access criteria: upon resonable request at ostyly@gmail.com