Clinical Research in Hepatology in the COVID-19 Pandemic and Post-Pandemic Era: Challenges and the Need for Innovation

Clinical trials reimagined

Clinical trials have been a central driver of change and have provided the evidence base necessary to advance new therapies for liver diseases. This review provides a perspective on the status of trials in hepatology and a vantage point into the emerging capabilities and external forces that will shape the conduct of clinical trials in the future. The adaptations to clinical trial operations in response to the disruptions by the COVID-19 pandemic and opportunities for innovation in hepatology trials are emphasized. Future trials in hepatology will be driven by unmet therapeutic needs and fueled by technological advances incorporating digital capabilities with expanded participant-derived data collection, computing, and analytics. Their design will embrace innovative trial designs adapted to these advances and that emphasize broader and more inclusive participant engagement. Their conduct will be further shaped by evolving regulatory needs and the emergence of new stakeholders in the clinical trials ecosystem. The evolution of clinical trials will offer unique opportunities to advance new therapeutics that will ultimately improve the lives of patients with liver diseases.

COVID-19 and severity of liver diseases: Possible crosstalk and clinical implications

COVID-19-infected individuals and those who recovered from the infection have been demonstrated to have elevated liver enzymes or abnormal liver biochemistries, particularly with preexisting liver diseases, liver metabolic disorders, viral hepatitis, and other hepatic comorbidities. However, possible crosstalk and intricate interplay between COVID-19 and liver disease severity are still elusive, and the available data are murky and confined. Similarly, the syndemic of other blood-borne infectious diseases, chemical-induced liver injuries, and chronic hepatic diseases continued to take lives while showing signs of worsening due to the COVID-19 crisis. Moreover, the pandemic is not over yet and is transitioning to becoming an epidemic in recent years; hence, monitoring liver function tests (LFTs) and assessing hepatic consequences of COVID-19 in patients with or without liver illnesses would be of paramount interest. This pragmatic review explores the correlations between COVID-19 and liver disease severity based on abnormal liver biochemistries and other possible mechanisms in individuals of all ages from the emergence of the COVID-19 pandemic to the post-pandemic period. The review also alludes to clinical perspectives of such interactions to curb overlapping hepatic diseases in people who recovered from the infection or living with long COVID-19.

The role transition of radiotherapy for the treatment of liver cancer in the COVID-19 era

The uncontrollable COVID-19 crises in the SARS-CoV-2 high-prevalence areas have greatly disrupted the routine treatment of liver cancer and triggered a role transformation of radiotherapy for liver cancer. The weight of radiotherapy in the treatment algorithm for liver cancer has been enlarged by the COVID-19 pandemic, which is helpful for the optimal risk-benefit profile.

Barreras y facilitadores para la investigación en ciencias de la salud durante la crisis del COVID-19: una revisión de alcance

Objetivo:

La pandemia ocasionada por el Covid-19 ha significado un gran desafío para la investigación en salud por la necesidad de dar una respuesta oportuna y efectiva a esta situación de crisis. Es importante proveer una visión panorámica sobre las principales barreras y facilitadores encontrados en la conducción de estudios en ciencias de la salud durante la crisis del Covid-19, así como también de las iniciativas en investigación sugeridas por autoridades en salud de investigación a nivel global, regional o local.

Materiales y métodos:

Se desarrolló una revisión sistemática de alcance. Se hizo una búsqueda de la literatura en Medline, Cochrane library, Lilacs y Google Scholar. Se incluyeron estudios de investigación originales, artículos de revisión, de opinión y editoriales disponibles en texto completo, publicados entre enero de 2020 y mayo de 2021 en español, inglés o portugués. Se hizo selección de los documentos y extracción de los datos por dos autores de manera independiente. Las barreras y facilitadores identificados fueron descritos y organizados en cuatro categorías a partir de la literatura: socioculturales, administrativos, organizacionales y metodológicos. Asimismo, se incluyeron documentos y comunicados oficiales de autoridades en salud e investigación a nivel global, regional y local. Los resultados se presentan de manera narrativa y en tablas.

Resultados:

Se seleccionaron 26 documentos para el análisis y síntesis de la información. Las barreras mencionadas más frecuentemente en la literatura incluyen las dificultades en cuanto al acceso a los participantes, a los trámites asociados a los comités de ética; así como el riesgo biológico para los investigadores y la falta de coordinación inter e intrainstitucional. Por su parte, los facilitadores identificados incluyen la adopción de soluciones virtuales, el trabajo cooperativo entre los actores de la investigación y la flexibilidad en el proceso de obtención del consentimiento informado. Frente a las iniciativas difundidas por las autoridades en salud e investigación, se identificaron cuatro estrategias relacionadas con la priorización de preguntas de investigación, el fomento de la cooperación y la inclusión en la investigación, la lucha contra la infodemia y el fortalecimiento de la calidad metodológica de los estudios.

Conclusiones:

Para la investigación en el contexto de la pandemia representa un desafío continuar con la cooperación e interoperabilidad entre las instituciones, los países y las disciplinas, con el fin de facilitar los procesos investigativos en el futuro; del mismo modo, cobra importancia mantener la ciencia abierta y la financiación de estudios cooperativos cuando surjan otras prioridades. Asimismo, es evidente la necesidad de desarrollar y sostener mecanismos que gestionen la información de manera eficiente para la toma de decisiones. Se requiere evaluar de manera continua los efectos que ha dejado esta pandemia en la práctica de la investigación en ciencias de la salud para comprender de manera integral lo que debemos aprender como sociedad a partir de las crisis.

Hyperthermia ablation combined with transarterial chemoembolization versus monotherapy for hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND AND AIMS

The existing evidence has indicated that hyperthermia ablation (HA) and HA combined with transarterial chemoembolization (HATACE) are the optimal alternative to surgical resection for patients with hepatocellular carcinoma (HCC) in the COVID-19 crisis. However, the evidence for decision-making is lacking in terms of comparison between HA and HATACE. Herein, a comprehensive evaluation was performed to compare the efficacy and safety of HATACE with monotherapy.

MATERIALS AND METHODS

Worldwide studies were collected to evaluate the HATACE regimen for HCC due to the practical need for global extrapolation of applicative population. Meta-analyses were performed using the RevMan 5.3 software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark).

RESULTS

Thirty-six studies involving a large sample of 5036 patients were included finally. Compared with HA alone, HATACE produced the advantage of 5-year overall survival (OS) rate (OR:1.90; 95%CI:1.46,2.46; p < 0.05) without increasing toxicity (p ≥ 0.05). Compared with TACE alone, HATACE was associated with superior 5-year OS rate (OR:3.54; 95%CI:1.96,6.37; p < 0.05) and significantly reduced the incidences of severe liver damage (OR:0.32; 95%CI:0.11,0.96; p < 0.05) and ascites (OR:0.42; 95%CI:0.20,0.88; p < 0.05). Subgroup analysis results of small (≤3 cm) HCC revealed that there were no significant differences between the HATACE group and HA monotherapy group in regard to the OS rates (p ≥ 0.05).

CONCLUSIONS

Compared with TACE alone, HATACE was more effective and safe for HCC. Compared with HA alone, HATACE was more effective for non-small-sized (>3 cm) HCC with comparable safety. However, the survival benefit of adjuvant TACE in HATACE regimen was not found for the patients with small (≤3 cm) HCC.

IT-Enabled Sustainable Innovation and the Global Digital Divides

This article investigates the impact of information and communication technologies (ICTs), human capital, institutional settings, socio-economic, and environmental parameters on sustainable innovation (SI) using archival data for 127 economies from 2008 to 2017. We developed an econometrics research framework for investigating factors influencing SI on a global scale. We found that ICT variables, such as ICT access and ICT broadband network, positively influence sustainable innovation in conjunction with the socio-economic and political parameters. Despite differences among economies in terms of ICTs, socio-economic development, and educational attainment, ICTs are the significant drivers of sustainable innovation and economic growth. We observed a growing digital divide among nations within the context of the knowledge-based economy and the expansion of digital commerce, particularly in the least developed countries and Africa, a phenomenon impeding sustainable innovation growth. To the best of our knowledge, this is the first study that empirically investigates the global digital divide from sustainable innovation perspectives. The results of this study suggest that to tackle the digital divide issues, policymakers and educational institutes need to perform constructive educational reform in higher education curricula, particularly concerning STEM programs, which should reflect the necessary skills and competencies for deploying emergent technologies. In addition, ICT should be considered part of a country’s critical infrastructure, particularly investment in the broadband networks regarded as the backbone of today’s innovation.

The effect of COVID-19 on liver transplantation: impact, practice patterns, therapeutics, and next steps

PURPOSE OF REVIEW

To assess the impact of coronavirus disease 2019 (COVID-19) and the pandemic on liver transplant candidates, recipients, and donors, and review guidelines and recommendations for integrating COVID-19 therapies into current practice.

RECENT FINDINGS

COVID-19 has high morbidity and mortality for transplant candidates; interestingly, posttransplant comorbidities play a larger role than immunosuppression status. COVID-19 therapies and vaccinations are well tolerated in pre and postliver transplant patients with few exceptions, although further research is needed regarding effectiveness in this patient population. Provider practice patterns should evolve to minimize contagion during the current pandemic and prepare for an increase in liver disease due to after-shocks of missed diagnosis and progression of liver disease.

SUMMARY

COVID-19 has spurred new research and technologies to ensure the safety of liver transplant candidates, recipients, and donors, and most COVID-19 therapies are safe in this patient population. Further work needs to be done regarding the use of COVID-19 positive organs and the efficacy of vaccines in the transplant population.

COVID-19 and liver disease: mechanistic and clinical perspectives

Our understanding of the hepatic consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and its resultant coronavirus disease 2019 (COVID-19) has evolved rapidly since the onset of the pandemic. In this Review, we discuss the hepatotropism of SARS-CoV-2, including the differential expression of viral receptors on liver cell types, and we describe the liver histology features present in patients with COVID-19. We also provide an overview of the pattern and relevance of abnormal liver biochemistry during COVID-19 and present the possible underlying direct and indirect mechanisms for liver injury. Furthermore, large international cohorts have been able to characterize the disease course of COVID-19 in patients with pre-existing chronic liver disease. Patients with cirrhosis have particularly high rates of hepatic decompensation and death following SARS-CoV-2 infection and we outline hypotheses to explain these findings, including the possible role of cirrhosis-associated immune dysfunction. This finding contrasts with outcome data in pharmacologically immunosuppressed patients after liver transplantation who seem to have comparatively better outcomes from COVID-19 than those with advanced liver disease. Finally, we discuss the approach to SARS-CoV-2 vaccination in patients with cirrhosis and after liver transplantation and predict how changes in social behaviours and clinical care pathways during the pandemic might lead to increased liver disease incidence and severity.

Clinical significance of serum transforming growth factor-β1 and procollagen type I N-propeptide in post-tuberculosis tracheobronchial stenosis

Non-invasive strategies for monitoring post-tuberculosis (TB) tracheobronchial stenosis (PTTS) are clinically important but currently lacking. Transforming growth factor-β1 (TGF-β1) and procollagen type I N-propeptide (PINP) have been identified as markers of fibrosis. The present study aimed to investigate the clinical significance of serum TGF-β1 and PINP in PTTS. Serum samples were collected from 119 patients with tracheobronchial TB after the condition was treated for at least 6 months (59 patients with airway stenosis and 60 patients with no stenosis). Serum TGF-β1 and PINP levels were measured using ELISA and compared between the groups. Relationships between serum TGF-β1 and PINP levels and clinical characteristics, interventional bronchoscopy and outcomes of airway stenosis were analysed. The correlation between TGF-β1 and PINP, and their diagnostic efficacy for airway stenosis were also analysed. The TGF-β1 and PINP levels in the airway stenosis group were higher than those in the non-stenosis group. Furthermore, airway stenosis with atelectasis or mucus plugging was associated with higher TGF-β1 levels, and airway stenosis with atelectasis, mucus plugging, right main bronchus stenosis or severe airway tracheal stenosis was associated with higher PINP levels. In addition, TGF-β1 and PINP levels increased after interventional bronchoscopy therapy and airway stenosis with recurrent stenosis was associated with higher baseline levels of both markers. Finally, TGF-β1 levels were positively correlated with PINP levels in patients with airway stenosis. The area under the receiver operating characteristic curve of TGF-β1 and PINP for distinguishing airway stenosis from non-stenosis cases was 0.824 (95% CI: 0.748-0.900) and 0.863 (95% CI: 0.796-0.930), respectively. Therefore, TGF-β1 and PINP are potential biomarkers that may be useful for diagnosing and monitoring PTTS.

Going Remote-Demonstration and Evaluation of Remote Technology Delivery and Usability Assessment With Older Adults: Survey Study

BACKGROUND

The COVID-19 pandemic necessitated "going remote" with the delivery, support, and assessment of a study intervention targeting older adults enrolled in a clinical trial. While remotely delivering and assessing technology is not new, there are few methods available in the literature that are proven to be effective with diverse populations, and none for older adults specifically. Older adults comprise a diverse population, including in terms of their experience with and access to technology, making this a challenging endeavor.

OBJECTIVE

Our objective was to remotely deliver and conduct usability testing for a mobile health (mHealth) technology intervention for older adult participants enrolled in a clinical trial of the technology. This paper describes the methodology used, its successes, and its limitations.

METHODS

We developed a conceptual model for remote operations, called the Framework for Agile and Remote Operations (FAR Ops), that combined the general requirements for spaceflight operations with Agile project management processes to quickly respond to this challenge. Using this framework, we iteratively created care packages that differed in their contents based on participant needs and were sent to study participants to deliver the study intervention-a medication management app-and assess its usability. Usability data were collected using the System Usability Scale (SUS) and a novel usability questionnaire developed to collect more in-depth data.

RESULTS

In the first 6 months of the project, we successfully delivered 21 care packages. We successfully designed and deployed a minimum viable product in less than 6 weeks, generally maintained a 2-week sprint cycle, and achieved a 40% to 50% return rate for both usability assessment instruments. We hypothesize that lack of engagement due to the pandemic and our use of asynchronous communication channels contributed to the return rate of usability assessments being lower than desired. We also provide general recommendations for performing remote usability testing with diverse populations based on the results of our work, including implementing screen sharing capabilities when possible, and determining participant preference for phone or email communications.

CONCLUSIONS

The FAR Ops model allowed our team to adopt remote operations for our mHealth trial in response to interruptions from the COVID-19 pandemic. This approach can be useful for other research or practice-based projects under similar circumstances or to improve efficiency, cost, effectiveness, and participant diversity in general. In addition to offering a replicable approach, this paper tells the often-untold story of practical challenges faced by mHealth projects and practical strategies used to address them.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04121858; https://clinicaltrials.gov/ct2/show/NCT04121858.

Longitudinal changes of laboratory measurements after discharged from hospital in 268 COVID-19 pneumonia patients

BACKGROUND AND OBJECTIVE

Monitoring recovery process of coronavirus disease 2019 (COVID-19) patients released from hospital is crucial for exploring residual effects of COVID-19 and beneficial for clinical care. In this study, a comprehensive analysis was carried out to clarify residual effects of COVID-19 on hospital discharged patients.

METHODS

Two hundred sixty-eight cases with laboratory measured data at hospital discharge record and five follow-up visits were retrospectively collected to carry out statistical data analysis comprehensively, which includes multiple statistical methods (e.g., chi-square, T-test and regression) used in this study.

RESULTS

Study found that 13 of 21 hematologic parameters in laboratory measured dataset and volume ratio of right lung lesions on CT images highly associated with COVID-19. Moderate patients had statistically significant lower neutrophils than mild and severe patients after hospital discharge, which is probably caused by more efforts on severe patients and slightly neglection of moderate patients. COVID-19 has residual effects on neutrophil-to-lymphocyte ratio (NLR) of patients who have hypertension or chronic obstructive pulmonary disease (COPD). After released from hospital, female showed better performance in T lymphocytes subset cells, especially T helper lymphocyte% (16% higher than male). According to this sex-based differentiation of COVID-19, male should be recommended to take clinical test more frequently to monitor recovery of immune system. Patients over 60 years old showed unstable recovery process of immune cells (e.g., CD45 + lymphocyte) within 75 days after discharge requiring longer clinical care. Additionally, right lung was vulnerable to COVID-19 and required more time to recover than left lung.

CONCLUSIONS

Criterion of hospital discharge and strategy of clinical care should be flexible in different cases due to residual effects of COVID-19, which depend on several impact factors. Revealing remaining effects of COVID-19 is an effective way to eliminate disorder of mental health caused by COVID-19 infection.

Lessons learned from the implementation of a video health coaching technology intervention to improve self-care of family caregivers of adults with heart failure

Individuals with heart failure (HF) typically live in the community and are cared for at home by family caregivers. These caregivers often lack supportive services and the time to access those services when available. Technology can play a role in conveniently bringing needed support to these caregivers. The purpose of this article is to describe the implementation of a virtual health coaching intervention with caregivers of HF patients ("Virtual Caregiver Coach for You"-ViCCY). A randomized controlled trial is currently in progress to test the efficacy of the intervention to improve self-care. In this trial, 250 caregivers will be randomly assigned to receive health information via a tablet computer (hereafter, tablet) plus 10 live health coaching sessions delivered virtually (intervention group; n = 125) or health information via a tablet only (control group; n = 125). Each tablet has specific health information websites preloaded. To inform others embarking on similar technology projects, here we highlight the technology challenges encountered with the first 15 caregivers who received the ViCCY intervention and the solutions used to overcome those challenges. Several adaptations to the implementation of ViCCY were needed to address hardware, software, and network connectivity challenges. Even with a well-designed research implementation plan, it is important to re-examine strategies at every step to solve implementation barriers and maximize fidelity to the intervention. Researcher and interventionist flexibility in adapting to new strategies is essential when implementing a technology-based virtual health coaching intervention.

Frontiers of Robotic Gastroscopy: A Comprehensive Review of Robotic Gastroscopes and Technologies

Simple Summary

With the rapid advancements of medical technologies and patients’ higher expectations for precision diagnostic and surgical outcomes, gastroscopy has been increasingly adopted for the detection and treatment of pathologies in the upper digestive tract. Correspondingly, robotic gastroscopes with advanced functionalities, e.g., disposable, dextrous and not invasive solutions, have been developed in the last years. This article extensively reviews these novel devices and describes their functionalities and performance. In addition, the implementation of artificial intelligence technology into robotic gastroscopes, combined with remote telehealth endoscopy services, are discussed. The aim of this paper is to provide a clear and comprehensive view of contemporary robotic gastroscopes and ancillary technologies to support medical practitioners in their future clinical practice but also to inspire and drive new engineering developments.

Abstract

Upper gastrointestinal (UGI) tract pathology is common worldwide. With recent advancements in robotics, innovative diagnostic and treatment devices have been developed and several translational attempts made. This review paper aims to provide a highly pictorial critical review of robotic gastroscopes, so that clinicians and researchers can obtain a swift and comprehensive overview of key technologies and challenges. Therefore, the paper presents robotic gastroscopes, either commercial or at a progressed technology readiness level. Among them, we show tethered and wireless gastroscopes, as well as devices aimed for UGI surgery. The technological features of these instruments, as well as their clinical adoption and performance, are described and compared. Although the existing endoscopic devices have thus far provided substantial improvements in the effectiveness of diagnosis and treatment, there are certain aspects that represent unwavering predicaments of the current gastroenterology practice. A detailed list includes difficulties and risks, such as transmission of communicable diseases (e.g., COVID-19) due to the doctor–patient proximity, unchanged learning curves, variable detection rates, procedure-related adverse events, endoscopists’ and nurses’ burnouts, limited human and/or material resources, and patients’ preferences to choose non-invasive options that further interfere with the successful implementation and adoption of routine screening. The combination of robotics and artificial intelligence, as well as remote telehealth endoscopy services, are also discussed, as viable solutions to improve existing platforms for diagnosis and treatment are emerging.