Large scale clinical trials: lessons from the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has presented substantial new challenges to clinical and research teams. Our objective was to analyse the experience of investigators and research delivery staff regarding the research response to COVID-19 in order to identify these challenges as well as solutions for future pandemic planning.

METHODS

We conducted a survey of diverse research staff involved in delivery of COVID-19 clinical trials across the UK. This was delivered online across centres linked to the NIHR Respiratory Translational Research Collaboration. Responses were analysed using a formal thematic analysis approach to identify common themes and recommendations.

RESULTS

83 survey participants from ten teaching hospitals provided 922 individual question responses. Respondents were involved in a range of research delivery roles but the largest cohort (60%) was study investigators. A wide range of research experiences were captured, including early and late phase trials. Responses were coded into overarching themes. Among common observations, complex protocols without adaptation to a pandemic were noted to have hampered recruitment. Recommendations included the need to develop and test pandemic-specific protocols, and make use of innovations in information technology. Research competition needs to be avoided and drug selection processes should be explicitly transparent.

CONCLUSIONS

Delivery of clinical trials, particularly earlier phase trials, in a pandemic clinical environment is highly challenging, and was reactive rather than anticipatory. Future pandemic studies should be designed and tested in advance, making use of pragmatic study designs as far as possible and planning for integration between early and later phase trials and regulatory frameworks.

729 “I Don’t Feel Like I’m Learning How to Be A Doctor:” The Impact of Disruptions Due to Covid-19 On Professional Identity Formation in UK Medical Students

Introduction

Professional identity formation (PIF) is a priority of medical training. Covid-19 caused disruption to medical education. We ask how this disruption impacted PIF through the lens of the activities performed – or not performed – by medical students during the first wave of the covid-19 pandemic, and perceptions of conflicts between activities.

Method

A pragmatic survey was distributed in spring 2020. Thematic analysis was performed of qualitative responses to two open questions. A social constructivist approach linked participants’ comments to PIF theory.

Results

We analysed 928 responses. Three themes surrounding students’ activities during covid-19 and their impact on identity were constructed:

Conflict arose at the intersections between these themes. Students noted lack of clinical exposure was detrimental, implicitly recognising that aspects of PIF require the clinical environment. Participants were keen to volunteer but struggled with balancing academic work. Participants worried about risk to their households and the wider community and wanted their skills to add value in the clinical environment. Volunteers felt frustrated when they were unable to perform tasks aligning with their identity as a future doctor. An exception was participants who worked as interim FY1s, aligned with the role of an FY1.

Conclusions

Medical students feel a duty to help during crises. Conflict arises when different aspects of their identity demand different actions. Care must be taken to nurture PIF during periods of disruption.

967 COVID READY Study: Cross-Sectional Survey of Medical Students Volunteering During the Coronavirus Pandemic (COVID-19) In the United Kingdom

Introduction

We aimed to identify the willingness, attitudes, and practice of medical students towards volunteering in a clinical capacity during the COVID-19 pandemic.

Method

We distributed a cross-sectional survey from 2/5/2020 to 14/6/2020 to all medical students at UK medical schools.

Results

A total of 1145 medical students from 36 medical schools completed the questionnaire. 82.7% of students were willing to volunteer, but only 34.3% had volunteered. The strongest predictors of willingness to volunteer on multiple linear regression were the beliefs that volunteering to work would benefit their medical education (estimate=0.35±0.03, adjusted P < 0.001) and that they would have a positive impact (estimate=0.33±0.03, adjusted P < 0.001). The majority of students were willing to take up a clinical role and were confident in having the necessary skills, but there was a discrepancy between the role’s students were comfortable performing and those they were assigned. Thematic analysis of the issue’s students would face when volunteering identified five themes: safety, professional practice, pressure to volunteer, finances and logistics, and education.

Conclusions

This study identifies areas for consideration from those responsible for workforce planning, healthcare provision, and student safety. We provide recommendations to facilitate a volunteering process that is safer for students, staff, and patients.

P78 MedEd Collaborative: a new research collaborative to promote medical education research

Introduction

In response to the disruption to medical education caused by COVID-19, there is a need for wide-scale robust medical education research and the generation of research capacity for the future. Trainee research collaboratives have demonstrated they can nurture the research skills of students and trainees while delivering high quality research outputs. However, we have been unable to identify a permanent medical education research collaborative for trainees and students.

Methods

We started the MedEd Collaborative in September 2020 to fill this gap, consisting of a trainee- and student-led medical education research collaborative supported by senior medical education experts and clinicians.

Results

Our vision is to increase engagement of students and trainees in high-quality medical education research that informs practice. The MedEd Collaborative will engage students and trainees in medical education research by completing at least one national multicentre study per year, the first being the COVID Ready 2 study. This is a national cross-sectional survey of the educational impact of medical student volunteering during the COVID-19 pandemic.

Conclusions

We anticipate the MedEd collaborative will: increase exposure to medical education research, thereby increasing the number of medical students and trainees aiming to pursue an academic medical education career; provide training in medical education research methodologies, such as qualitative analysis; improve the quality of medical education research outputs from students and trainees; encourage collaboration between medical schools and deaneries; and provide support to other trainee research collaboratives that aim to explore education research in their own specialties.

P39 Cross sectional survey of medical student volunteering and education during the coronavirus pandemic in the United Kingdom

Introduction

COVID-19 led to global disruption of healthcare and many students volunteered to provide clinical support. Volunteering to work was a unique medical education opportunity; however, it is unknown whether this was a positive learning experience.

Methods

The COVID Ready 2 study is a national cross-sectional study of all medical students at UK medical schools. We will compare opinions of those who did and did not volunteer to determine the educational benefit and issues they faced. We will use thematic analysis to identify themes in qualitative responses, in addition to quantitative analysis.

Results

The primary objective is to explore the effect of volunteering during the pandemic on medical education in comparison to those who did not volunteer. Our secondary objectives are to identify: whether students would be willing to assume similar roles in a non-pandemic setting; if students found the experience more or less beneficial than traditional hospital placements and reasons for this; what the perceived benefits and disadvantages of volunteering were; the difference in perceived preparedness between students who did and did not volunteer for foundation training year one and the next academic year; training received by volunteers; and to explore issues associated with volunteering, including safety issues and issues with role and competence.

Conclusions

We anticipate this study will help identify volunteer structures that have been beneficial for students, so that similar infrastructures can be used in the future; and help determine whether formal voluntary roles should be introduced into the non-pandemic medical curriculum.

Phenotype analysis of male transgenic mice overexpressing mutant IGFBP-2 lacking the Cardin-Weintraub sequence motif: Reduced expression of synaptic markers and myelin basic protein in the brain and a lower degree of anxiety-like behaviour

Brain growth and function are regulated by insulin-like growth factors I and II (IGF-I and IGF-II) but also by IGF-binding proteins (IGFBPs), including IGFBP-2. In addition to modulating IGF activities, IGFBP-2 interacts with a number of components of the extracellular matrix and cell membrane via a Cardin-Weintraub sequence or heparin binding domain (HBD1). The nature and the signalling elicited by these interactions are not fully understood. Here, we examined transgenic mice (H1d-hBP2) overexpressing a mutant human IGFBP-2 that lacks a specific heparin binding domain (HBD1) known as the Cardin-Weintraub sequence. H1d-hBP2 transgenic mice have the genetic background of FVB mice and are characterized by severe deficits in brain growth throughout their lifetime (p<0.05). In tissue lysates from brain hemispheres of 12-21day old male mice, protein levels of the GTPase dynamin-I were significantly reduced (p<0.01). Weight reductions were also found in distinct brain regions in two different age groups (12 and 80weeks). In the younger group, impaired weights were observed in the hippocampus (-34%; p<0.001), cerebellum (-25%; p<0.0001), olfactory bulb (-31%; p<0.05) and prefrontal cortex (-29%; p<0.05). At an age of 12weeks expression of myelin basic protein was reduced (p<0.01) in H1d-BP-2 mice in the cerebellum but not in the hippocampus. At 80weeks of age, weight reductions were similarly present in the cerebellum (-28%; p<0.001) and hippocampus (-31; p<0.05). When mice were challenged in the elevated plus maze, aged but not younger H1d-hBP2 mice displayed significantly less anxiety-like behaviour, which was also observed in a second transgenic mouse model overexpressing mouse IGFBP-2 lacking HBD1 (H1d-mBP2). These in vivo studies provide, for the first time, evidence for a specific role of IGFBP-2 in brain functions associated with anxiety and risk behaviour. These activities of IGFBP-2 could be mediated by the Cardin-Weintraub/HBD1 sequence and are altered in mice expressing IGFBP-2 lacking the HBD1.

Extreme value statistics for river quality simulations

Various methods have been proposed to assess intermittent pollution loads and impacts on rivers in urban areas. Although the variables to describe the impact are mainly the same, the standards show significant differences in the assessment of permitted concentration level, duration and return period. The probability of an event is derived using either frequencies of occurrence or predefined extreme value distributions. Both methods have drawbacks. To bypass these, an a posteriori estimation of the statistical distribution of data based on the peak-over-threshold method is proposed. The method is exemplarily demonstrated using a semi-virtual case study.

The HSG procedure for modelling integrated urban wastewater systems

Whilst the importance of integrated modelling of urban wastewater systems is ever increasing, there is still no concise procedure regarding how to carry out such modelling studies. After briefly discussing some earlier approaches, the guideline for integrated modelling developed by the Central European Simulation Research Group (HSG - Hochschulgruppe) is presented. This contribution suggests a six-step standardised procedure to integrated modelling. This commences with an analysis of the system and definition of objectives and criteria, covers selection of modelling approaches, analysis of data availability, calibration and validation and also includes the steps of scenario analysis and reporting. Recent research findings as well as experience gained from several application projects from Central Europe have been integrated in this guideline.

Has arteriography gotten a bad name? Current accuracy and morbidity of diagnostic contrast arteriography for aortoiliac and lower extremity arterial disease

Recently, contrast arteriography has been challenged as the diagnostic test of choice for lower extremity arterial disease because of its associated morbidity and questionable accuracy in identifying suitable distal outflow arteries. The purpose of this report was to analyze our experience to determine if these concerns were justified. We reviewed 500 consecutive contrast arteriograms performed at our hospital for aortoiliac and lower extremity arterial disease between November 1994 and November 1998. Arteriograms performed in conjunction with therapeutic procedures such as balloon angioplasty, stent placement, and thrombolysis were excluded, leaving 244 diagnostic cases for analysis. Forty-six percent (112) of patients had diabetes mellitus, 14% (34) had an elevated baseline serum creatinine (> or =1.5 mg/dL), and an additional 7% (17) were dialysis dependent. Radiologists limited contrast volume by imaging only the symptomatic extremity when appropriate and using digital subtraction techniques as indicated. Our results showed that diagnostic contrast arteriography is associated with an acceptably low morbidity, has an accuracy that is unlikely to be surpassed by other modalities, and remains the diagnostic test of choice for lower extremity arterial disease.

Predictors of outcome when reoperating for early infrainguinal bypass occlusion

The purpose of this study is to identify factors that predict outcome after intervention for early (<30 days) infrainguinal graft thrombosis. We reviewed the medical records, arteriograms, and follow-up studies of patients who underwent infrainguinal bypass for limb salvage between 8/91 and 9/98 and whose graft failed <30 days from the index procedure. Five factors were analyzed: (1) conduit: single segment saphenous vein versus alternative vein or composite conduit (20 vs. 13 patients); (2) repair modality: construction of a new graft at the time of the initial take-back procedure versus local revision and/or thrombectomy alone (12 vs. 21 patients); (3) run-off: good run-off versus poor run-off (20 vs. 13 patients); (4) operative findings: the presence of a correctable problem versus noncorrectable problem (20 vs. 13 patients); and (5) surgical history: previous versus no previous ipsilateral bypass (16 vs. 17 patients). These variables are statistically significant risk factors that can be used in combination to predict outcome. Unless a focal lesion clearly responsible for graft occlusion is found, complete graft replacement should be considered even if the new bypass must be prosthetic. The costs and morbidity of repeated procedures argue for primary amputation when adverse risk factors exist.

Carotid endarterectomy in octogenarians: comparison with patient characteristics and outcomes in younger patients

OBJECTIVES

Carotid endarterectomy has been shown to be of clear benefit to selected patients. However, recent trials of carotid endarterectomy versus best medical therapy have excluded octogenarians, and some authors have suggested that carotid endarterectomy would have an unfavorable cost-benefit relationship in octogenarians. We compared patients and results for carotid endarterectomy in octogenarians and younger patients.

METHODS

We reviewed the results for 582 primary carotid endarterectomies (90 in octogenarians and 492 in younger patients) performed in 528 patients between February 1, 1985, and January 31, 1998 (all data were collected prospectively for the most recent 301 carotid endarterectomies). Conventional surgical technique was used with general anesthesia, selective shunting, and selective patching. Main outcome measures were perioperative and late ipsilateral stroke and death.

RESULTS

The two groups were similar with respect to indications for carotid endarterectomy and patient characteristics, except that octogenarians were more likely to have histories of congestive heart failure or hypertension and less likely to have histories of smoking or chronic lung disease. Carotid endarterectomy was performed for asymptomatic disease in 27% of the octogenarians and 33% of the younger patients (P =.31). Stenosis was >/=80% in 90% of the octogenarians and 78% of the younger patients (P =.014). Perioperative strokes, all of which were ipsilateral, occurred in one octogenarian (1.1%) and eight younger patients (1.6%, P = 1.00). No octogenarians and two younger patients died within 30 days of surgery (P = 1.00). Length of stay and direct costs associated with carotid endarterectomy were similar for octogenarians and younger patients. Late strokes occurred in two octogenarians (one ipsilateral) and four younger patients (two ipsilateral). Life table estimates of freedom from ipsilateral stroke at 2 years were 98% and 97% for octogenarians and younger patients, respectively (log-rank P =.69), and life table estimates of patient survival at 4 years were 81% and 89% for octogenarians and younger patients, respectively (P =.11). Octogenarians represented an increasing fraction of the carotid endarterectomies performed during the study period.

CONCLUSIONS

Octogenarians selected for carotid endarterectomy were similar to younger patients with respect to indications for carotid endarterectomy and comorbidities. Early mortality, early and late neurologic outcome, complications, and resource utilization were similar for the two groups, and more than 75% of octogenarians survived 4 years after undergoing carotid endarterectomy. Cost-benefit analyses for carotid endarterectomy, which are highly sensitive to expected patient survival, might not be pertinent to individual patient situations. Intellectually intact octogenarians without unusually severe comorbidities are good candidates for and should be offered the benefits of carotid endarterectomy.

Prosthetic patch remnants to treat infected arterial grafts

PURPOSE

Our previous experience with the traditional management of infected prosthetic arterial grafts, which included graft excision and vein patch repair of the involved artery, was complicated by a high incidence of vein patch rupture. This study assessed the treatment of infected prosthetic grafts with subtotal graft excision and oversewing of small graft remnants.

METHODS

During the last 20 years, we treated 53 wounds involving 45 infected prosthetic grafts in 42 patients by means of subtotal graft excision and oversewing of a residual 2- to 3-mm graft remnant (patch) at an intact arterial anastomosis. This technique was selectively used to maintain patency of small-diameter arteries (41 common femoral, five deep femoral, three axillary, two iliac, and two popliteal), which were critical for limb salvage or amputation healing. This strategy avoided difficult dissection of the underlying artery in scarred wounds and obviated the placement of a new patch in an infected field. Graft remnants were polytetrafluoroethylene in 51 cases and Dacron in two cases. Of the 45 grafts, 31 were occluded and 14 were patent. All infected tissue was widely debrided, wet-to-dry dressing changes were performed three times daily, and appropriate intravenous antibiotics were administered for at least 1 week. Secondary bypass grafting procedures were performed as needed to achieve limb salvage. The follow-up period in surviving patients averaged 32 months (range, 1 to 218 months).

RESULTS

No complications were directly attributable to prosthetic patch remnants in 92% of cases (49 of 53 cases). Six of 42 patients (14%) died during hospitalization (three of cardiac complications and three of sepsis with multiple organ failure). Two infected pseudoaneurysms developed 8 and 34 months after surgery, and two wounds failed to heal. Sixteen secondary bypass grafting procedures were necessary to achieve limb salvage. Patch oversewing led to limb salvage without the need for secondary revascularization in 26 other cases and to the successful healing of 10 amputated limbs when secondary revascularization was not possible.

CONCLUSION

Prosthetic patch remnants are a useful adjunct that simplify management of infected prosthetic grafts, are associated with a low incidence of wound complications, and help maintain patency of essential collaterals to achieve limb salvage or heal an amputation.

Amitriptyline increases GABA-stimulated 36Cl- influx by recombinant (alpha 1 gamma 2) GABAA receptors

WSS-1 cells expressing (alpha 1 gamma 2)GABAA receptors show an augmented 36Cl- response to GABA in the presence of amitriptyline that is increased by flumazenil, unlike augmentation by diazepam which is blocked by flumazenil. This amitriptyline effect is opposite to the inhibition of GABA-stimulated 36Cl influx manifested in membrane vesicles prepared from drug-naive rats or submissive rats (a model of depression) but is similar to that seen in tissue from amitriptyline-treated rats or dominant rats. The results suggest a novel mechanism of antidepressant drug action having a delayed onset.

Endovascular versus surgical treatment for thrombosed hemodialysis grafts: A prospective, randomized study

PURPOSE

The objective of this study was to compare clinical outcome and costs for two widely used treatment strategies for hemodialysis graft thrombosis.

METHODS

During a 4-year period, 80 patients with thrombosed dialysis grafts were randomly assigned to surgical thrombectomy with or without graft revision (SURG) or thrombolytic therapy with urokinase with the pulse-spray technique (ENDO), with adjunctive percutaneous transluminal angioplasty as indicated. All the procedures were performed in an endovascular operating suite with fistulography. The clinical and cost data were tabulated, and the outcome was analyzed with the life-table method.

RESULTS

Fifty-six women and 24 men ranged in age from 33 to 90 years (mean, 63.7 years). The patients had undergone a mean of 2.8 prior access procedures in the ipsilateral extremity. All the grafts were upper extremity expanded polytetrafluoroethylene grafts. Lesions that were presumed to be the primary cause of graft thrombosis were identified in 73 of 80 grafts, and 60 of these were at the venous anastomosis. The procedure time averaged 99 minutes for the patients in the SURG group and 113 minutes for the patients in the ENDO group (P =.12). Eleven patients in the ENDO group crossed over to surgical revision as compared with two patients in the SURG group who required adjunctive percutaneous transluminal angioplasty (P =.005). The mean cost of treatment (including room and supply costs but not professional fees) was significantly higher for the ENDO group than for the SURG group ($2945 vs $1512; P <.001). There were no procedure-related complications in either group. At a median follow-up time of 24 months, there was no difference in primary or assisted primary patency between groups, which averaged 6 and 7 months, respectively.

CONCLUSION

Although thrombolytic therapy combined with endovascular treatment can extend the life of dialysis grafts with results similar to surgical revision, there is a high rate of technical failure necessitating surgery and a substantially higher cost for thrombolysis.

Superior vena cava syndrome. Experience with endovascular stents and surgical therapy

Superior vena cava (SVC) syndrome is a serious complication of benign and malignant diseases. Benign causes may be increasing because of the increased use of central venous cannulation. Modern surgical therapy is durable with a few complications. Traditional treatment for SVC obstruction from malignant causes has consisted of anticoagulation, radiation, chemotherapy, and occasionally surgery. Endovascular techniques present a new treatment option for these patients, and uses a combination of thrombolysis, angioplasty, and intravascular stents. Short-term results are excellent with relatively rapid patient recovery. Further research is needed to elucidate the long-term results of endovascular treatment and to find its role in benign and malignant disease.