Oncology clinical trial disruption during the COVID-19 pandemic: a COVID-19 and cancer outcomes study

Background

COVID-19 disproportionately impacted patients with cancer as a result of direct infection, and delays in diagnosis and therapy. Oncological clinical trials are resource-intensive endeavors that could be particularly susceptible to disruption by the pandemic, but few studies have evaluated the impact of the pandemic on clinical trial conduct.

Patients and methods

This prospective, multicenter study assesses the impact of the pandemic on therapeutic clinical trials at two large academic centers in the Northeastern United States between December 2019 and June 2021. The primary objective was to assess the enrollment on, accrual to, and activation of oncology therapeutic clinical trials during the pandemic using an institution-wide cohort of (i) new patient accruals to oncological trials, (ii) a manually curated cohort of patients with cancer, and (ii) a dataset of new trial activations.

Results

The institution-wide cohort included 4756 new patients enrolled to clinical trials from December 2019 to June 2021. A major decrease in the numbers of new patient accruals (−46%) was seen early in the pandemic, followed by a progressive recovery and return to higher-than-normal levels (+2.6%). A similar pattern (from −23.6% to +30.4%) was observed among 467 newly activated trials from June 2019 to June 2021. A more pronounced decline in new accruals was seen among academically sponsored trials (versus industry sponsored trials) (P < 0.05). In the manually curated cohort, which included 2361 patients with cancer, non-white patients tended to be more likely taken off trial in the early pandemic period (adjusted odds ratio: 2.60; 95% confidence interval 1.00-6.63), and substantial pandemic-related deviations were recorded.

Conclusions

Substantial disruptions in clinical trial activities were observed early during the pandemic, with a gradual recovery during ensuing time periods, both from an enrollment and an activation standpoint. The observed decline was more prominent among academically sponsored trials, and racial disparities were seen among people taken off trial.

On the robustness of model-based algorithms for photoacoustic tomography: Comparison between time and frequency domains

For photoacoustic image reconstruction, certain parameters such as sensor positions and speed of sound have a major impact on the reconstruction process and must be carefully determined before data acquisition. Uncertainties in these parameters can lead to errors produced by a modeling mismatch, hindering the reconstruction process and severely affecting the resulting image quality. Therefore, in this work, we study how modeling errors arising from uncertainty in sensor locations affect the images obtained by matrix model-based reconstruction algorithms based on time domain and frequency domain models of the photoacoustic problem. The effects on the reconstruction performance with respect to the uncertainty in the knowledge of the sensors location are compared and analyzed both in a qualitative and quantitative fashion for both time and frequency models. Ultimately, our study shows that the frequency domain approach is more sensitive to this kind of modeling errors. These conclusions are supported by numerical experiments and a theoretical sensitivity analysis of the mathematical operator for the direct problem.

Standardisierter Computer-basiert-organisierter Report des EEG (SCORE) – Eine strukturierende Form der EEG-Befundung

Eine 2013 von der „International Federation of Clinical Neurophysiology“ gegründete Taskforce hat eine international konsensfähige EEG-Terminologie entwickelt. Im Folgenden soll das Resultat – die 2. Version des Standardized Computer-based Organized Reporting of EEG (SCORE) - vorgestellt werden. Die Terminologie wurde im Rahmen eines Softwarepaketes (SCORE-EEG) in der klinischen Praxis an über 12.000 EEGs getestet. Die Auswahl der Begriffe ist kontextabhängig: die initiale Auswahl bestimmt, welche weiteren Auswahlmöglichkeiten zur Verfügung stehen. Im Verlauf wird automatisch ein Befund erstellt und dessen Einzelmerkmale in eine Datenbank eingespeist. SCORE verfügt über Module spezifisch für die Befundung epileptischer Anfälle, sowie charakteristischer neonataler und intensivmedizinische EEG-Merkmale. SCORE ist nicht nur ein nützliches Werkzeug im ambulanten, klinischen und wissenschaftlichen Setting, es erleichtert auch Qualitätssicherung, Datenaustausch und die EEG-Aus und Weiterbildung.

Psychiatric and behavioral side effects of anti-epileptic drugs in adolescents and children with epilepsy

PURPOSE

The objective of the study was to compare the psychiatric and behavioral side effect (PBSE) profiles of both older and newer antiepileptic drugs (AEDs) in children and adolescent patients with epilepsy.

METHOD

We used logistic regression analysis to test the correlation between 83 non-AED/patient related potential predictor variables and the rate of PBSE. We then compared for each AED the rate of PBSEs and the rate of PBSEs that led to intolerability (IPBSE) while controlling for non-AED predictors of PBSEs.

RESULTS

922 patients (≤18 years old) were included in our study. PBSEs and IPBSEs occurred in 13.8% and 11.2% of patients, respectively. Overall, a history of psychiatric condition, absence seizures, intractable epilepsy, and frontal lobe epilepsy were significantly associated with increased PBSE rates. Levetiracetam (LEV) had the greatest PBSE rate (16.2%). This was significantly higher compared to other AEDs. LEV was also significantly associated with a high rate of IPBSEs (13.4%) and dose-decrease rates due to IPBSE (6.7%). Zonisamide (ZNS) was associated with significantly higher cessation rate due to IPBSE (9.1%) compared to other AEDs.

CONCLUSION

Patients with a history of psychiatric condition, absence seizures, intractable epilepsy, or frontal lobe epilepsy are more likely to develop PBSE. PBSEs appear to occur more frequently in adolescent and children patients taking LEV compared to other AEDs. LEV-attributed PBSEs are more likely to be associated with intolerability and subsequent decrease in dose. The rate of ZNS-attributed IPBSEs is more likely to be associated with complete cessation of AED.

A solvent additive to enhance the efficiency and the thermal stability of polymer:fullerene solar cells

A novel bisazide molecule to be used in polymer–fullerene bulk heterojunction (BHJ) solar cells with two distinct functionalities is reported here.

The Third Injection Technique Workshop in Athens (TITAN)

The first Injection Technique workshop brought together endocrinologists and injection experts from around the world in Strasbourg in 1997. From its work came groundbreaking recommendations which advanced best practices in areas such as the use of a skin fold when injecting. The second Injection Technique workshop, with an expanded format including nurses and diabetes educators, took place in Barcelona in 2000. The initial stimulus to use shorter injecting needles can be said to date from this meeting. The third Injection Technique workshop was held in Athens in September 2009 and involved 127 experts from across the globe. After a comprehensive review of all publications since 2000 as well as several unpublished studies, the attendees divided into smaller groups to debate and draft new injecting recommendations based on the new data and their collective experience. This paper summarizes all the formal presentations given at this practical consensus workshop.

New injection recommendations for patients with diabetes

AIM

Injections administered by patients are one of the mainstays of diabetes management. Proper injection technique is vital to avoiding intramuscular injections, ensuring appropriate delivery to the subcutaneous tissues and avoiding common complications such as lipohypertrophy. Yet few formal guidelines have been published summarizing all that is known about best practice. We propose new injection guidelines which are thoroughly evidence-based, written and vetted by a large group of international injection experts.

METHODS

A systematic literature study was conducted for all peer-reviewed studies and publications which bear on injections in diabetes. An international group of experts met regularly over a two-year period to review this literature and draft the recommendations. These were then presented for review and revision to 127 experts from 27 countries at the TITAN workshop in September, 2009.

RESULTS

Of 292 articles reviewed, 157 were found to meet the criteria of relevance to the recommendations. Each recommendation was graded by the weight it should have in daily practice and by its degree of support in the medical literature. The topics covered include The Role of the Professional, Psychological Challenges, Education, Site Care, Storage, Suspension and Priming, Injecting Process, Proper Use of Pens and Syringes, Insulin analogues, Human and Pre-mixed Insulins, GLP-1 analogs, Needle Length, Skin Folds, Lipohypertrophy, Rotation, Bleeding and Bruising, Pregnancy, Safety and Disposal.

CONCLUSION

These injecting recommendations provide practical guidance and fill an important gap in diabetes management. If followed, they should help ensure comfortable, effective and largely complication-free injections.

Strategies to maximize retention of a sample of young adolescents in a longitudinal evaluation of Healthy & Alive!

The authors implemented strategies to maximize cohort retention to avert loss of statistical power and minimize bias in a longitudinal evaluation of a middle school HIV/STD prevention intervention. A retention rate of 80% of the baseline sample (n = 2,975) at six months and 73% at 18 months was achieved despite high reported rates of student mobility and a major system reorganization in one urban district. The strategies increased retention but did not eliminate differences in demographic characteristics and behaviors between the groups of retained and lost students. Results confirm the need to implement retention strategies early and to maintain them throughout data collection. Information from a tracking data base can be used to prioritize students for follow-up to reduce bias from sample loss.

Increased expression of glomerular AT1 receptors in rats with myocardial infarction

Rats with congestive heart failure demonstrate striking intrarenal vasoconstriction that contributes to reduced renal excretory function. We previously demonstrated that inhibition of angiotensin action reverses intrarenal vasoconstriction in rats 4-6 wk after coronary artery ligation. In the present study we tested the hypothesis that abnormalities in the expression and regulation of glomerular angiotensin receptors contribute to the intrarenal vasoconstriction. Because glomerular angiotensin type 1 (AT1) receptors normally downregulate in response to high local ANG II concentrations, we anticipated that glomerular AT1-receptor expression would be reduced in rats after myocardial infarction (MI). To our surprise, the density of glomerular AT1 receptors was nearly double (97% increase, P < 0.002) that of controls, indicating an acquired abnormality in angiotensin receptor regulation. This was specific for renal glomeruli, because the density of angiotensin receptors on renal vasculature was decreased in rats after MI compared with normal controls. Glomerular AT1-receptor expression was downregulated by an acute pharmacological infusion of ANG II and upregulated by acute angiotensin-converting enzyme inhibition to a similar extent in MI and control rats. Renal cortical mRNA expression showed an increase in the renin mRNA-to-actin ratio and angiotensinogen-to-actin ratio, indicating stimulation of the intrarenal angiotensin system in rats after MI. The data indicate a specific dysregulation of AT1 receptors in glomeruli but not blood vessels after MI.

Blinded reading of radiographs increases the frequency of errors in vertebral fracture detection

We examined the effect of blinding X-rays to film sequence and patient identity on vertebral fracture detection. A sample of 50 postmenopausal women with low bone density and two sets of spine X-rays 3.6 years apart was selected; based on prior morphometric studies, about half of the women had experienced new fractures after the initial film. New morphometric and semiquantitative radiologist readings were each performed twice: blinded and unblinded. For morphometry, incident fractures were defined as vertebral height decreases of more than 15% compared with the initial film. The incidence was slightly higher when blinded versus unblinded (5.6 vs. 5.3% of all vertebrae for morphometry, and 9.7 vs. 8.7% for the radiologist), but these differences were not significant. The error rate was investigated by examining the frequency of "fracture reversals"-vertebrae identified as fractured on the initial film but not on the later film. Agreement between blinded and unblinded readings was generally greater than 80% for fractures but less than 10% for "fracture reversals," suggesting that reversals are not true events but random errors. The number of reversals was higher when the radiologist was blinded (2.1% of all vertebrae vs. 0.8% when unblinded; p = 0.07). The number of vertebrae with increases greater than 15% in size over time was also greater when morphometry readings were blinded versus unblinded: 0.8 versus 0% (p < 0.05). Although these errors are small, they are similar in magnitude to the annual fracture incidence in many populations. These data show that blinding X-rays to sequence offers no advantages, increases the frequency of errors, and may inflate incidence rates. We conclude that the assessment of X-rays for vertebral fractures in clinical trials should not be performed with the evaluator blinded to the sequence of the X-rays.

Quantitative evaluation of the effect of low-intensity exercise on insulin secretion in man

We studied insulin secretion rates (ISR) during low-intensity exercise (40% peak aerobic capacity [VO2]) in 12 normal subjects to assess the contribution of altered insulin secretion to the reduction in peripheral insulin concentrations associated with exercise. ISR were calculated by a previously validated method of two-compartment analysis of peripheral C-peptide concentrations using individual parameters derived following a bolus injection of biosynthetic human C-peptide. In addition, the effect of low-intensity exercise on kinetic parameters of C-peptide was evaluated. The results showed that low-intensity exercise did not significantly affect C-peptide kinetics. Peripheral insulin concentrations and ISR decreased to a similar degree throughout exercise. There was a mean maximum decrease in serum insulin concentrations from 42 +/- 5.4 pmol/L basally to 24 +/- 2.6 pmol/L, constituting a 51% +/- 5.9% decrease (P < .001), and ISR decreased from 85.7 +/- 11.9 pmol/min to a nadir of 45.6 +/- 10.6 pmol/min (P < .001), a 48% +/- 8.4% decline. Plasma glucose and glucagon concentrations did not change significantly either during or after exercise, although there was a matched twofold increase in glucose utilization and disposal rates. We suggest that the reduction in peripheral insulin concentrations during exercise is due to reduced insulin secretion.

Comparison of the Clearview Chlamydia, the PACE 2 assay, and culture for detection of Chlamydia trachomatis from cervical specimens in a low-prevalence population

The Clearview Chlamydia assay (Wampole Laboratories, Cranbury, N.J.), the PACE 2 DNA probe assay (GenProbe, San Diego, Calif.), and culture were compared for their abilities to detect Chlamydia trachomatis from cervical specimens in a population with a low prevalence (3.9%) of chlamydial infections. A consensus reference method was used. The consensus reference method defined a positive specimen as one with a positive culture result or positive by both of the two nonculture methods. Of the 940 specimens tested, 37 were positive; 36 were positive by culture, 28 were positive by the PACE 2 assay, and 27 were positive by the Clearview assay, giving sensitivities of 97.3, 75.5, and 72.9%, respectively, and specificities of 100, 97.1, and 98.9%, respectively. There was a direct correlation between the number of inclusion-forming units detected by culture and the ability of the two nonculture methods to detect the positive specimens.

Evaluation of the rapid CLEARVIEW Chlamydia test for direct detection of chlamydiae from cervical specimens

The CLEARVIEW Chlamydia test (Unipath, Mountain View, Calif.), a 30-min immunoassay, was compared to a standard tissue culture technique for the direct detection of chlamydiae from 677 cervical specimens obtained from 667 patients. For data analysis, 15 specimens were eliminated because of toxicity in the culture and 14 were eliminated because of failure of the extracted specimen to migrate in the CLEARVIEW test, one of the latter group being culture positive. Of the remaining 648 specimens, 40 were culture positive, of which 38 were detected by the CLEARVIEW test, and 12 specimens were positive only by the CLEARVIEW test. Therefore, the CLEARVIEW in comparison with culture was easier to perform, more rapid, and in this low prevalence (6.2%) population had a 95.0% sensitivity, 98.0% specificity, and 76.0% positive and 99.7% negative predictive values.

Glyburide enhances the responsiveness of the beta-cell to glucose but does not correct the abnormal patterns of insulin secretion in noninsulin-dependent diabetes mellitus

Eleven patients with noninsulin-dependent diabetes mellitus were studied before and after 6-10 weeks of glyburide therapy. Patients were studied during a 24-h period on a mixed diet comprising 30 Cal/kg divided into three meals. The following day a hyperglycemic clamp study was performed, with glucose levels clamped at 300 mg/dL (16.7 mmol/L) for a 3-h period. Insulin secretion rates were calculated by deconvolution of peripheral C-peptide concentrations using individual C-peptide clearance kinetics derived after bolus injection of biosynthetic human C-peptide. After 6-10 weeks on glyburide, the identical studies were repeated. In response to glyburide, the fasting plasma glucose level decreased from 12.3 +/- 1.2 to 6.8 +/- 0.9 mmol/L. Although the mean glucose over the 24 h of the meal study decreased from 12.7 +/- 1.4 to 10.8 +/- 1.2 mmol/L, postprandial hyperglycemia persisted on therapy, and after breakfast, glucose levels exceeded 10 mmol/L and did not return to fasting levels for the remainder of the day. Fasting serum insulin, plasma C-peptide, and the insulin secretion rate were not different before (152 +/- 48 pmol/L, 0.82 +/- 0.16 pmol/mL, and 196 +/- 34 pmol/min, respectively) and after (186 +/- 28 pmol/L, 0.91 +/- 0.11 pmol/mL, and 216 +/- 23 pmol/min, respectively) glyburide treatment despite lowering of the glucose level. However, average insulin and C-peptide concentrations over the 24-h period increased from 366 +/- 97 pmol/L and 1.35 +/- 0.19 pmol/mL to 434 +/- 76 pmol/L and 1.65 +/- 0.15 pmol/mL, respectively. The total amount of insulin secreted over the 24-h period rose from 447 +/- 58 nmol before therapy to 561 +/- 55 nmol while receiving glyburide. Insulin secretion was demonstrated to be pulsatile in all subjects, with periodicity ranging from 2-2.5 h. The number of insulin secretory pulses was not altered by glyburide, whereas pulse amplitude was enhanced after lunch and dinner, suggesting that the increased insulin secretion is characterized by increased amplitude of the individual pulses. In response to a hyperglycemic clamp at 300 mg/dL (16.7 mmol/L), insulin secretion rose more than 2-fold, from 47 +/- 9 nmol over the 3-h period before treatment to 103 +/- 21 nmol after glyburide therapy. We conclude that the predominant mechanism of action of glyburide in patients receiving therapy for 6-10 weeks is to increase the responsiveness of the beta-cell to glucose.(ABSTRACT TRUNCATED AT 400 WORDS)

Quantitative study of insulin secretion and clearance in normal and obese subjects

The secretion and hepatic extraction of insulin were compared in 14 normal volunteers and 15 obese subjects using a previously validated mathematical model of insulin secretion and rate constants for C-peptide derived from analysis of individual decay curves after intravenous bolus injections of biosynthetic human C-peptide. Insulin secretion rates were substantially higher than normal in the obese subjects after an overnight fast (86.7 +/- 7.1 vs. 50.9 +/- 4.8 pmol/m2 per min, P less than 0.001, mean +/- SEM), over a 24-h period on a mixed diet (279.6 +/- 24.2 vs. 145.8 +/- 8.8 nmol/m2 per 24 h, P less than 0.001), and during a hyperglycemic intravenous glucose infusion (102.2 +/- 10.8 vs. 57.2 +/- 2.8 nmol/m2 per 180 min, P less than 0.001). Linear regression analysis revealed a highly significant relationship between insulin secretion and body mass index. Basal hepatic insulin extraction was not significantly different in the normal and obese subjects (53.1 +/- 3.8 vs. 51.6 +/- 4.0%). In the normal subjects, fasting insulin did not correlate with basal hepatic insulin extraction, but a significant negative correlation between fasting insulin and hepatic insulin extraction was seen in obesity (r = -0.63, P less than 0.02). This finding reflected a higher extraction in the six obese subjects with fasting insulin levels within the range of the normal subjects than in the nine subjects with elevated fasting insulin concentrations (61 +/- 3 vs. 45 +/- 6%, P less than 0.05). During the hyperglycemic clamp, the insulin secretion rate increased to an average maximum of 6.2-fold over baseline in the normal subjects and 5.8-fold in the obese subjects. Over the same time, the peripheral insulin concentration increased 14.1-fold over baseline in the normals and 16.6-fold over baseline in the obese, indicating a reduction in the clearance of endogenously secreted insulin. Although the fall in insulin clearance tended to be greater in the obese subjects, the differences between the two groups were not statistically significant. Thus, under basal, fasting conditions and during ingestion of a mixed diet, the hyperinsulinemia of obesity results predominantly from increased insulin secretion. In patients with more marked basal hyperinsulinemia and during intense stimulation of insulin secretion, a reduction in insulin clearance may contribute to the greater increase in peripheral insulin concentrations that are characteristic of the obese state.+

Echocardiographic diagnosis of dilatation of the ascending aorta using right parasternal scanning

With the ultrasound transducer positioned at the second or third right intercostal space, the ascending aorta was visualized in 8 patients in whom dilatation of the ascending aorta had been demonstrated radiographically. The diameter of the ascending aorta by right parasternal scan, with the transducer held perpendicular to the chest wall, measured 4.2-6 cm. The aortic root diameter (at aortic valve level) recorded by conventional left parasternal scan was normal or only slightly increased in 5 cases, but in 3 others it approached the value obtained by right parasternal scan. Aortography performed in 3 patients demonstrated marked dilatation of the ascending aorta.

The effects of splenectomy and glucocorticoids on survival and hepatic uptake of damaged red cells in the mouse

We have studied the effects of splenectomy and glucocorticoids on the survival and sequestration of Heinz body-containing red blood cells (RBC-HZB). Mice were injected with phenylhydrazine damaged 51Cr labeled isologous red blood cells (RBCs). The spleen removed 36% and the liver 19% of the injected dose after 120 hrs. Red cell survival (T 1/2) fell from 180 hrs for undamaged red cells to 16 hrs for RBC-HZB. Splenectomy resulted in an increase in hepatic uptake of damaged RBCs (36% of the injected dose) and a modest improvement in red cell survival (T 1/2 54 hrs). Treatment of non-splenectomized mice with glucocorticoids reduced the splenic uptake to 16% and the hepatic uptake to 14% of the injected dose. The reduction of splenic upatke was associated with a decrease in splenic mass rather than a decrease in uptake per unit weight of splenic tissue, while reduction in hepatic uptake was associated with both a decrease in hepatic mass and uptake per unit weight. A marked decrease was observed in hepatic uptake and in phagocytosis by Kupffer cells in glucocorticoid-treated splenectomized mice. These data suggest that increased hepatic uptake may decrease the effectiveness of splenectomy in RBC-HZB hemolytic anemia and that glucocorticoids may decrease the hepatic uptake by reducing phagocytosis by Kupffer cells.