Remote Monitoring and Data Collection for Decentralized Clinical Trials

Importance

Less than 5% of patients with cancer enroll in a clinical trial, partly due to financial and logistic burdens, especially among underserved populations. The COVID-19 pandemic marked a substantial shift in the adoption of decentralized trial operations by pharmaceutical companies.

Objective

To assess the current global state of adoption of decentralized trial technologies, understand factors that may be driving or preventing adoption, and highlight aspirations and direction for industry to enable more patient-centric trials.

Design, Setting, and Participants

The Bloomberg New Economy International Cancer Coalition, composed of patient advocacy, industry, government regulator, and academic medical center representatives, developed a survey directed to global biopharmaceutical companies of the coalition from October 1 through December 31, 2022, with a focus on registrational clinical trials. The data for this survey study were analyzed between January 1 and 31, 2023.

Exposure

Adoption of decentralized clinical trial technologies.

Main Outcomes and Measures

The survey measured (1) outcomes of different remote monitoring and data collection technologies on patient centricity, (2) adoption of these technologies in oncology and all therapeutic areas, and (3) barriers and facilitators to adoption using descriptive statistics.

Results

All 8 invited coalition companies completed the survey, representing 33% of the oncology market by revenues in 2021. Across nearly all technologies, adoption in oncology trials lags that of all trials. In the current state, electronic diaries and electronic clinical outcome assessments are the most used technology, with a mean (SD) of 56% (19%) and 51% (29%) adoption for all trials and oncology trials, respectively, whereas visits within local physician networks is the least adopted at a mean (SD) of 12% (18%) and 7% (9%), respectively. Looking forward, the difference between the current and aspired adoption rate in 5 years for oncology is large, with respondents expecting a 40% or greater absolute adoption increase in 8 of the 11 technologies surveyed. Furthermore, digitally enabled recruitment, local imaging capabilities, and local physician networks were identified as technologies that could be most effective for improving patient centricity in the long term.

Conclusions and Relevance

These findings may help to galvanize momentum toward greater adoption of enabling technologies to support a new paradigm of trials that are more accessible, less burdensome, and more inclusive.

WITHDRAWAL

Withdrawal: This content is part of a Special Issue and will be available in the full issue publication Summer 2022.

Vaccine mandates: A transplant recipient's perspective

COVID-19 vaccination mandates: A patient’s view from the transplant trenches (see Kates et al. and Hippen, pages 371 and 381).

Understanding patient experiences and challenges to osteoporosis care delivered virtually by telemedicine: a mixed methods study

This study sought to understand patient experiences, benefits, and challenges to osteoporosis care delivered virtually by telemedicine. Telemedicine bridges the access gap to specialized osteoporosis care in remote areas. Improving coordination of investigations, access to allied health members, and future initiatives may improve osteoporosis-related morbidity and mortality in this population.

INTRODUCTION

There is limited research on the role of telemedicine (TM) in the management of osteoporosis (OP). We previously reported that OP patients assessed by TM had a higher prevalence of fragility fractures, co-morbidities, and need for allied health resources than those serviced by the outpatient clinic. The purpose of this study is to understand the experiences, benefits, and challenges associated with receiving OP care by TM from the patient perspective.

METHODS

We adopted a convergent, mixed methods study design whereby both a quantitative component (mailed survey) and qualitative component (30-min telephone interviews) were conducted simultaneously. In addition to reporting survey data, thematic analysis was applied to interview data.

RESULTS

Participants were comfortable with virtual technology and perceived that their quality of care by TM was comparable to in-person visits. Expressed benefits included the convenience of timely care close to home, reduced burden of travel and costs, and enhanced sense of confidence with being assessed by an osteoporosis specialist. Perceived barriers included poor follow-up with allied health professionals in the TM program (e.g., physiotherapist) and coordination of tests and investigations. Many participants indicated interest in an OP self-management program, with content focusing on diet and lifestyle factors.

CONCLUSION

The TM program bridges the access gap for those living with OP in underserviced and remote areas. However, we identified the need to improve the existing processes to better coordinate access to allied health team members and arrangements for investigations. Participants also expressed interest for a virtual osteoporosis self-management program.

Effect of early mobilization on sedation practices in the neurosciences intensive care unit: a preimplementation and postimplementation evaluation

INTRODUCTION

The use of sedation and analgesia protocols, daily interruption of sedation, and early mobilization (EM) have been shown to decrease duration of mechanical ventilation and hospital length of stay (LOS).

METHODS

A retrospective chart review was conducted during a 6-month premobilization (pre-EM) and 6-month postmobilization (post-EM) period. Patients older than 18 years who were admitted to the neurosciences intensive care unit (ICU) and mechanically ventilated for at least 24 hours without documentation of withdrawal of life support or brain death were included.

RESULTS

Thirty-one pre-EM and 37 post-EM patients were included. Baseline demographics were similar with the exception of more ischemic stroke patients in the pre-EM group (P < .05). In the pre-EM and post-EM groups, patients received similar cumulative doses of propofol, dexmedetomidine, and benzodiazepines but higher median (interquartile range) doses of opioids (50.0 [13.8-165.0] vs 173.3 [41.2-463.2] μg of fentanyl equivalents [P < .05]) in the post-EM group. Neurosciences ICU LOS was 10 (6-19) and 13 (8-18) days, respectively (P = .188).

CONCLUSIONS

After implementation of an EM program, an increase in opioid use and no significant change in other sedatives were observed. Despite an increase in the amount of physical therapy and occupational therapy provided to patients, there was no change in hospital and ICU LOS or duration of mechanical ventilation.

The role of law in public health preparedness: opportunities and challenges

We report the results of a study designed to assess and evaluate how the law shapes the public health system's preparedness activities. Based on 144 qualitative interviews conducted in nine states, we used a model that compared the objective legal environment with how practitioners perceived the laws. Most local public health and emergency management professionals relied on what they perceived the legal environment to be rather than on an adequate understanding of the objective legal requirements. Major reasons for the gap include the lack of legal training for local practitioners and the difficulty of obtaining clarification and consistent legal advice regarding public health preparedness. Narrowing the gap would most likely improve preparedness outcomes. We conclude that there are serious deficiencies in legal preparedness that can undermine effective responses to public health emergencies. Correcting the lack of legal knowledge, coupled with eliminating delays in resolving legal issues and questions during public health emergencies, could have measurable consequences on reducing morbidity and mortality.

Bacterial Biofilms and implantable prosthetic devices

Erectile dysfunction afflicts millions of men. A group of patients with advanced degeneration of their erectile tissue do not respond to pharmacological therapy, and surgical prosthetic reconstruction represents an attractive and highly satisfying alternative. Yet many men are unwilling to take this step due to fear of infection. Implanted prosthetic devices are at risk for infection because they provide a platform for the development of a bacterial biofilm, an organized bacterial colony that grows on the surface of the implanted material. The biofilm is resistant to all efforts to eradicate it short of removal of the foreign material. Bacteria may attach to the surface of the foreign material by surface charge attraction, hydrophilic/hydrophobic interactions, and by specific attachment by fimbrae. Growth, colonization, and maturation follow bacterial attachment. A mature biofilm is composed of three layers: a linking film binding the biofilm to the surface; a base film made up of a compact layer of bacteria; and a surface film from which free-floating bacteria can arise and spread. The majority of the surface layer is made up of exopolysaccharide matrix. Bacteria deep within the biofilm matrix live in a protected environment; diffusion of antibiotics is difficult, low oxygen tension leads to a lower bacterial metabolic rate rendering the bacteria functionally resistant to high levels of antibiotics. Effective strategies to reduce prosthetic infection levels must rely on the prevention of biofilm formation through surface modification. Possible mechanisms include the addition of antimicrobials to the surface of the device, or chemical modifications, which reduces bacterial attachment.

The brain tumor of George Gershwin and the legs of Cole Porter

George Gershwin died in 1937 of a glioblastoma of the right temporal lobe. He had been in psychoanalytical care for some time and was hospitalized a few weeks before his death, when he was thought to have a functional illness. The controversies about George Gershwin's death, duration of neurologic symptoms, and problems in diagnosis are discussed. Cole Porter fell off a horse he was riding in 1937 and sustained multiple open fractures of both legs. There probably was some nerve injury in the right leg, at least, from this fall. Despite intensive pain, many hospitalizations, and 33 operations on his legs, Porter continued to write music and lyrics until his amputation in 1958. After the amputation, all creative activities ceased. The explanations for this are discussed.

Bilateral persistent trigeminal arteries associated with cerebral aneurysms and aortic arch vessel anomaly

We present the case of a patient with headache who, on computed tomography, was found to have subarachnoid hemorrhage. Angiography revealed bilateral persistent trigeminal arteries, anterior communicating artery and left pericallosal artery aneurysms, and an absent left vertebral artery. An anomalous right subclavian artery, originating at a common trunk with the left subclavian artery, was also present. To our knowledge, this is the fifth case of bilateral persistent trigeminal arteries and the sixth case of bilateral persistent carotid-basilar anastomosis of any type reported in the literature. A mechanism for the pathogenesis of multiple cerebrovascular anomalies is briefly discussed.

Diffuse vaginal adenosis associated with imperforate hymen

A case of imperforate hymen associated with adenosis of the proximal surface of the obstructing membrane and of the vaginal wall is reported. The histogenesis of vaginal adenosis coexisting with congenital obstructive lesions is discussed, and the importance of careful follow-up of the patients with this type of anomaly is emphasized.

Neurological complications of anticoagulation therapy: a neurologist's review

Anticoagulant-induced bleeding may involve the brain, spinal cord, or peripheral nerves. It may occur with either coumarin or heparin anticoagulants, in the absence of trauma, and while prothrombin times, clotting times, or partial thromboplastin times are in accepted therapeutic ranges. Bleeding involving the brain occurs usually as a subdural hematoma, with intracerebral or subarachnoid hemorrhages occurring less frequently. There may be diagnostic problems in the recognition of these anticoagulant-related subdural hematomas. The spinal cord involvement usually appears in the form of an extradural hematoma. This condition can progress rapidly, and prompt recognition of its presence, localization with myelography, and laminectomy for surgical evacuation are necessary. The peripheral nerve most frequently compressed is the femoral nerve, due to bleeding into the iliacus muscle. Other nerves can be involved, and surgical evacuation may be necessary at times.

Salpingitis in ovarian endometriosis

A histologic study of 87 cases of ovarian endometriosis with salpingectomy revealed 29 cases (33%) in which the removed fallopian tubes showed chronic salpingitis. Tubal obstruction could be demonstrated in only one of these patients. Tubo-ovarian adhesions were found in 15 patients (17%) and in only 7 of these in association with salpingitis. Although the patients in the present series did not consult their physicians because of infertility, but rather for other symptoms related to pelvic endometriosis, the finding of chronic salpingitis in 33% of the cases suggests that salpingitis may play a role in the infertility associated with endometriosis, possibly through altered tubal secretion.

Auditory prompting in assessing availability of responses in recall

A measurement procedure was described for assessing response-availability in a quantitatively continuous fashion, based upon the use of auditory prompts and the assumption that the greater the amplitude of prompting required the less available is the response. Experimental data showed the signal-to-noise ratio of auditory prompts required for recall was inversely related to the number of practice trials. Those items which Ss never correctly anticipated during training required a higher prompting level than those which had been anticipated at least once. Successive recall opportunities without prompting did not improve the level of recall.