Biospecimen Repositories in Low- and Middle-Income Countries: Insights From an American University of Beirut and Memorial Sloan Kettering Collaboration

PURPOSE

Biobanking helps source tissue and blood for studying cancer genomics. Access to biorepository resources in low- and middle-income countries is lacking. Memorial Sloan Kettering Cancer Center (MSK) and the American University of Beirut (AUB) established a joint tissue biorepository at AUB in Beirut, Lebanon. The undertaking encountered key challenges that were unanticipated.

MATERIALS AND METHODS

Patients age 18 years or older were eligible for enrollment at AUB. After consent, biospecimens were obtained at the time of routine diagnostic and/or therapeutic interventions. Both normal and abnormal tissue and solid and/or liquid specimens were collected from varied body sites. Early on, declining consent was frequently observed, and this was highlighted for investigation to understand potential participants reasoning.

RESULTS

Of 850 patients approached, 704 (70.8%) elected to consent and 293 (29.5%) declined participation. The number of declined consents led to an amendment permitting the documentation of reasons for same. Of 100 potential participants who declined to consent and to whom outreach was undertaken, 63% indicated lack of research awareness and 27% deferral to their primary physician or family member. A financial gain for AUB was cited as concern by 5%, cultural boundaries in 4%, and 1% expressed concern about confidentiality. Of the patients who elected to consent, 682 biospecimens were procured.

CONCLUSION

The AUB-MSK biospecimen repository has provided a unique resource for interrogation. Patient participation rate was high, and analyses of those who elected not to consent (29%) provide important insights into educational need and the local and cultural awareness and norms.

Digitalizing the Clinical Research Informed Consent Process: Assessing the Participant Experience in Comparison With Traditional Paper-Based Methods

PURPOSE

Consent processes are critical for clinical care and research and may benefit from incorporating digital strategies. We compared an electronic informed consent (eIC) option to paper consent across four outcomes: (1) technology burden, (2) protocol comprehension, (3) participant agency (ability to self-advocate), and (4) completion of required document fields.

METHODS

We assessed participant experience with eIC processes compared with traditional paper-based consenting using surveys and compared completeness of required fields, over 3 years (2019-2021). Participants who consented to a clinical trial at a large academic cancer center via paper or eIC were invited to either pre-COVID-19 pandemic survey 1 (technology burden) or intrapandemic survey 2 (comprehension and agency). Consent document completeness was assessed via electronic health records.

RESULTS

On survey 1, 83% of participants (n = 777) indicated eIC was easy or very easy to use; discomfort with technology overall was not correlated with discomfort using eIC. For survey 2, eIC (n = 262) and paper consenters (n = 193) had similar comprehension scores. All participants responded favorably to at least five of six agency statements; however, eIC generated a higher proportion of positive free-text comments (P < .05), with themes such as thoroughness of the discussion and consenter professionalism. eIC use yielded no completeness errors across 235 consents versus 6.4% for paper (P < .001).

CONCLUSION

Our findings suggest that eIC when compared with paper (1) did not increase technology burden, (2) supported comparable comprehension, (3) upheld key elements of participant agency, and (4) increased completion of mandatory consent fields. The results support a broader call for organizations to offer eIC for clinical research discussions to enhance the overall participant experience and increase the completeness of the consent process.

Electronic research consents for complex early-phase I-II clinical trials integrated with telemedicine visits compared with in-person encounters

1514

Background: Based on our previous research with patient satisfaction for electronic consenting (95% of 940 respondents would recommend it another patient), we hypothesized that telemedicine (telemed) would be received as well as or better than in-person clinical research (CR) consent encounters for complex early-phase clinical trial (Phase I-II) and clinical genetic consent discussions by patients. Oncologist experiences to date have shown that telemed works well for uncomplicated clinical scenarios, but its performance alongside increased care complexity is less clear from the patient perspective. Methods: We conducted a one-time survey of adult patients having a telemed consent visit between 8/31/21 and 2/13/22 and an in-person clinic visit. Nine CR specific questions covered visit preference and empowerment across 6 high value consent agency domains. Results: 513 patients completed the survey and consented across 96 Clinical trials (CT), including genetic, therapeutic, diagnostic, and quality of life. Consent discussions were performed by 75 clinicians and 41 non-clinicians, with the majority (64%) for clinical genetic and Phase I-II CTs. Most patients (52%) preferred telemed over in-person clinic visits (19%) when all visit related factors (time, cost, convenience, quality of care, healthcare team interaction) were considered ( P<.05) (Table). Comparing their last in-person visit with telemed, patients reported feeling either less stressed/overwhelmed (16%) for their consent discussion or about the same (39%) using telemed, and 6% were more stressed ( P<.05). Patients expressed equal comfort taking agency-supported action across 6 domains regardless of consent setting. Conclusions: Electronic consenting via telemed is the preferred method for consent in complex early-phase clinical trials when all visit factors are considered and performs as well across 6 key agency domains when compared with in-person visits. Telemed does not contribute additional stress to consent appointments for most patients and performs well across complex clinical genetic and Phase I-II clinical trial discussions. Our findings suggest telemed and electronic consent should be offered as an option for patients throughout their treatment continuum. Beyond MSK, our data support a broader call for organizations to offer telemed platforms for CT discussions to increase overall patient satisfaction and potentially increase participation. [Table: see text]

One committee to review them all: A single, multi-disciplinary COVID-19 research committee

On 1/20/2020 when the first case of a novel coronavirus (COVID-19) was confirmed in Washington state, its major impact was unknown. Memorial Sloan Kettering Cancer Center's (MSK) Hospital Incident Command System (HICS) was activated on 2/5, with our first COVID-19 case identified in early March. By 3/17, our Protocol Activation and Human Research Protection Program was fully remote and on 3/23, MSK leadership requested the creation of the COVID-19 Research Committee. Given the race to identify safe and effective treatments for COVID-19, modifications to workflows and review processes were needed. The goal was to provide quick access to COVID-19 treatments to our patients by creating a COVID-19 Committee as a “one-stop” committee, providing comprehensive review of clinical research related to COVID-19 including scientific review mandated by the Cancer Center Support Grant (CCSG) guidelines, prior to IRB review and protocol activation. Protocols that were reviewed by the COVID-19 Committee opened to accrual in an unprecedented 44 days from submission to the committee to open to accrual. Patients were accrued on most of the therapeutic protocols within 1 day of opening. These statistics have prompted our institution to explore how more protocols can benefit from this “one-stop” committee structure.

Reducing complexity and unidentifiability when modelling human atrial cells

Mathematical models of a cellular action potential (AP) in cardiac modelling have become increasingly complex, particularly in gating kinetics, which control the opening and closing of individual ion channel currents. As cardiac models advance towards use in personalized medicine to inform clinical decision-making, it is critical to understand the uncertainty hidden in parameter estimates from their calibration to experimental data. This study applies approximate Bayesian computation to re-calibrate the gating kinetics of four ion channels in two existing human atrial cell models to their original datasets, providing a measure of uncertainty and indication of potential issues with selecting a single unique value given the available experimental data. Two approaches are investigated to reduce the uncertainty present: re-calibrating the models to a more complete dataset and using a less complex formulation with fewer parameters to constrain. The re-calibrated models are inserted back into the full cell model to study the overall effect on the AP. The use of more complete datasets does not eliminate uncertainty present in parameter estimates. The less complex model, particularly for the fast sodium current, gave a better fit to experimental data alongside lower parameter uncertainty and improved computational speed. This article is part of the theme issue 'Uncertainty quantification in cardiac and cardiovascular modelling and simulation'.

Reducing complexity and unidentifiability when modelling human atrial cells

Mathematical models of a cellular action potential (AP) in cardiac modelling have become increasingly complex, particularly in gating kinetics, which control the opening and closing of individual ion channel currents. As cardiac models advance towards use in personalized medicine to inform clinical decision-making, it is critical to understand the uncertainty hidden in parameter estimates from their calibration to experimental data. This study applies approximate Bayesian computation to re-calibrate the gating kinetics of four ion channels in two existing human atrial cell models to their original datasets, providing a measure of uncertainty and indication of potential issues with selecting a single unique value given the available experimental data. Two approaches are investigated to reduce the uncertainty present: re-calibrating the models to a more complete dataset and using a less complex formulation with fewer parameters to constrain. The re-calibrated models are inserted back into the full cell model to study the overall effect on the AP. The use of more complete datasets does not eliminate uncertainty present in parameter estimates. The less complex model, particularly for the fast sodium current, gave a better fit to experimental data alongside lower parameter uncertainty and improved computational speed. This article is part of the theme issue 'Uncertainty quantification in cardiac and cardiovascular modelling and simulation'.

MSK eConsent: Digitalizing the informed consent process to improve participant engagement and understanding

2066

Background: eConsent was developed to digitize the research participant consenting experience with an educational engagement model. The eConsent platform tiers consent document content in an easy-to-navigate format, using videos, images, and access to supplementary information. We hypothesize that enhancing the consenting experience improves participant engagement and comprehension. Methods: Here we present two projects: 1) qualitative assessment of patient engagement in the eConsent process using a standardized 5-question survey sent to all patients who used it during 9 months in 2019, and 2) a report of our preliminary findings from exempt protocol, Assessing Participant Engagement and Protocol Education in the Consent Process (X19-055) that quantitatively compares paper and electronic consenting and a) assesses patient agency and b) tests comprehension of key consent elements in 2 protocols: Storage and Research Use of Human Biospecimens (06-107) and Genomic Profiling in Cancer Patients (12-245). Results: 1) 940 patients completed the qualitative experience survey (27% response). Most respondents (777; 83%) indicated that electronic consenting was very easy (371) or easy (406) to use. Only 25 (3%) said electronic consenting was somewhat difficult to use, 3 indicated it was difficult (0.3%), and 64 were neutral. Most (896; 95%) recommended electronic consenting to other MSK patients. Those who reported a 1 unit increase in technology discomfort, only reported a .48 unit increase in eConsent discomfort ( P< .001). 2)Quantitative 10-question electronic tests were sent to each patient’s portal account within 72h after consenting via paper or eConsent to protocols 06-107 and 12-245. To date, for 06-107: 18 paper consenters completed the test with a score of 76% vs 23 eConsent users who scored 80%. For 12-245: 43 paper consenters scored 69% vs 13 eConsent users scoring 80%. Scores are a surrogate marker for patient comprehension and show that 12-245 protocol participants’ average testing scores are higher when participants are consented with eConsent vs paper (P < .01). 06-107 protocol participants’ average test scores are trending toward eConsent improving patient understanding ( P= .11). We will follow this trend as our sample size increases to a total of 500 participants. Patient agency questions received favorable responses from most patients (100%-84%). Conclusions: eConsent enhances participant engagement and understanding and does not impose a digital burden on participants.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

An outbreak of food-borne botulism in Scotland, United Kingdom, November 2011

An investigation is currently underway to explain an outbreak of food-borne botulism in Scotland. Three children in the same family were confirmed as having botulism following consumption of a meal made with a jar of korma sauce. Residual sauce from the jar, the jar lid and a remnant of the meal, all tested positive for Clostridium botulinum type A toxin. The children are recovering, although two remain ventilated and in intensive care unit.

Variation in management of community-acquired pneumonia requiring admission to Alberta, Canada hospitals

Previous studies have shown small area variation in the rate of admission to hospital for patients with community-acquired pneumonia. We determined the rates of admission and length of stay for patients with community-acquired pneumonia in Alberta and the factors influencing admission rates and length of stay. Using hospital abstracts, hospital admissions for community-acquired pneumonia from 1 April 1994 to 31 March 1999 were compared. We classified Alberta hospitals according to geographical regions, by the number of beds, and by number of community-acquired pneumonia cases. There were 12,000 annual hospital discharges for community-acquired pneumonia costing over $40 million per year. The overall in-hospital mortality rate was 12% and the 1 year mortality rate was 26%. Compared with rural hospitals, regional and metropolitan hospitals admitted patients with greater severity of illness as demonstrated by greater in-hospital mortality, cost per case and comorbidity. Age-sex adjusted hospital discharge rates were significantly below the provincial average in both urban regions. Hospital discharge rates for residents in all rural regions and 4 of 5 regions with a regional hospital were significantly higher than the provincial average. After adjusting for comorbidity, the relative risk for a longer length of stay was 22% greater in regional hospitals and about 30% greater in urban hospitals compared to rural hospitals. Seasonal variation in the admission rate was evident, with higher rates in the winter of each year. We conclude that rural hospitals would be likely to benefit from a protocol to help with the admission decision and urban hospitals from a programme to reduce length of stay.

The relationship between parental modeling, eating patterns, and dietary intake among African-American parents

OBJECTIVE

This article examines the relationship between the frequency with which African-American parents report modeling healthful dietary behaviors for their children and parental dietary intake.

DESIGN

Cross-sectional, baseline data from a community-based dietary change study to reduce fat intake and increase fruit and vegetable consumption among African-American parents was analyzed to identify role-modeling behaviors.

SUBJECTS/SETTING

Subjects were 456 African-American parents who participated in a dietary change study as part of a national parent education group. Participants completed the Parental Dietary Modeling Scale, an eating patterns questionnaire and a food frequency questionnaire.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics and stepwise multiple linear regression analyses were conducted.

RESULTS

Parental modeling of healthful dietary behavior was associated with the performance low-fat eating patterns (r = 0.48; P < .001), lower dietary fat intake (r = -0.30; P < .001), and higher consumption of fruits and vegetables (r = 0.18; P < .001).

APPLICATIONS

The frequency with which parents model healthful dietary behaviors may be associated with parental dietary intake and may have long-term implications for the development of childhood eating patterns. Dietetics professionals need to carefully assess parents' current dietary modeling behaviors and inform parents about how performance of these general behaviors may affect their child's ultimate nutrition health.

A community research partnership to improve the diet of African Americans

OBJECTIVE

To describe a community research partnership in which a national parent education organization collaborated with academic institutions to develop a dietary change program for underserved African American parents.

METHODS

Qualitative methods were used to characterize issues that impacted partnership operations.

RESULTS

Data are reported on partnership activities including program development and implementation with African American parents. Lessons learned and strategies for improving the partnership are presented.

CONCLUSIONS

Ongoing assessment and evaluation of how a partnership operates, especially in the context of multiple sites, are important to sustaining successful functioning.

The feasibility of recruiting hospitalized patients with diabetes for a smoking cessation program

The aims of this study were to identify hospitalized smokers with diabetes, assess the severity of their physical condition, and determine their willingness to participate in a postdischarge smoking cessation program. Hospitalized smokers with diabetes were identified through referrals from the Dietetics Department. Smoking status was determined via medical charts, healthcare staff, and patient self-report. Among all patients with diabetes who were identified (n = 314), smoking status was routinely recorded only for those with a primary cardiac diagnosis (41%). Smokers (n = 59) were significantly younger and reported multiple but fewer concomitant diagnoses than nonsmokers. Ninety-one percent of the smokers who were contacted refused to participate in a postdischarge smoking cessation program. We conclude that accurate methods are needed for identifying all smokers to facilitate cessation efforts. The severity and chronicity of the physical condition of hospitalized smokers with diabetes may limit willingness to participate in a postdischarge smoking cessation intervention.

Consumption of fruits and vegetables in Missouri

High consumption of fruits and vegetables has been linked with a reduced risk of several important chronic diseases. The authors utilized telephone survey techniques to assess the level of fruit and vegetable consumption among adult Missouri residents. Only 28% of respondents reported consumption of five servings of fruits and vegetables per day. Older females had the highest rate of consuming five servings per day, while young males had the lowest rate. These findings, in conjunction with national data, show the need for increasing emphasis on the "5 A Day" campaign.

Acute mountain sickness in a general tourist population at moderate altitudes

OBJECTIVE

To determine the incidence of acute mountain sickness in a general population of visitors to moderate elevations, the characteristics associated with it, and its effect on physical activity.

DESIGN

A cross-sectional study.

SETTING

Resort communities located at 6300 to 9700 feet elevation in the Rocky Mountains of Colorado.

PARTICIPANTS

Convenience sample of 3158 adult travelers, 16 to 87 years old (mean age [+/- SD], 43.8 +/- 11.8 years).

RESULTS

Twenty-five percent of the travelers to moderate elevations developed acute mountain sickness, which occurred in 65% of travelers within the first 12 hours of arrival. Fifty-six percent of those with symptoms reduced their physical activity. The odds favoring acute mountain sickness were 3.5 times as large for visitors whose permanent residence was below 3000 feet elevation as for those whose residence was above 3000 feet; 2.8 times as large for visitors with previous symptoms of acute mountain sickness; and twice as large in travelers younger than 60 years. Women, obese persons, those in poor or average physical condition, and those with underlying lung disease also had a higher occurrence of acute mountain sickness (P < 0.05).

CONCLUSIONS

Acute mountain sickness occurs in 25% of visitors to moderate altitudes and affects activity in most symptomatic visitors. Persons who are younger, less physically fit, live at sea level, have a history of acute mountain sickness, or have underlying lung problems more often develop these symptoms.

A phase II trial of carboplatin and vinblastine in the treatment of advanced squamous cell carcinoma of the esophagus

Cisplatin-containing regimens are active in the treatment of esophageal cancer, with response rates of 25% to 35% in advanced disease. Carboplatin is less toxic than cisplatin; as a single agent, several responses were seen against esophageal tumors. To better define the role of carboplatin in esophageal cancer, the authors treated 19 chemotherapy-naive patients with advanced squamous cell carcinoma of the esophagus with carboplatin and vinblastine. Carboplatin (450 mg/m2 intravenously [IV] on days 1, 29, 57, and every 6 weeks thereafter) was given with vinblastine (5 mg/m2 IV on day 1 and then every 2 weeks). No major responses were seen. No significant renal toxicity and only mild gastrointestinal toxicity (emesis, diarrhea) were observed. Hematologic toxicity was more severe in patients with prior radiation therapy (RT), with three of six patients with prior RT exhibiting Grade 4 hematologic toxicity. Although generally less toxic than cisplatin-containing regimens, carboplatin and vinblastine is also less active in the treatment of squamous cell carcinoma of the esophagus. Hematologic toxicity with this regimen was severe in patients who had received prior RT.

Interferon alpha-2a and 5-fluorouracil for advanced colorectal carcinoma. Assessment of activity and toxicity

Preclinical data showed that the cytotoxic effects of 5-fluorouracil (5-FU) are augmented by interferon (IFN). In a small study, 13 of 17 patients with advanced colorectal cancer responded to a regimen of 5-FU with IFN. Using the same dose and schedule as in this pilot study, 38 previously untreated patients with metastatic colorectal carcinoma were treated with continuous intravenous (IV) infusion of 5-FU 750 mg/m2 daily for 5 days, followed by weekly bolus 5-FU at 750 mg/m2 and subcutaneous IFN at 9 million units three times per week. Of 35 evaluable patients, nine (26%) had a partial response (95% confidence limit, 11% to 41%), with a median response duration of 7.5 months (range, 4.4 to greater than 11.7 months). Seven patients (20%) had a minor response, and ten (28%) had stable disease. The most common toxicities observed were stomatitis (52%) and diarrhea (43%). Neurotoxicity was seen in 34% of patients and consisted of gait disturbance, dizziness, confusion, memory loss, and dementia. Because of toxicity, 84% of patients required a reduction of the IFN dose by at least 50%, and 63% required reduction of the 5-FU dose by at least 25%. Although the combination of 5-FU and IFN in patients with advanced colorectal carcinoma has some activity, the regimen was toxic, and the observed response rate (26%) was not substantially superior to alternative 5-FU programs.

The sleep electrocardiogram at extreme altitudes (Operation Everest II)

To evaluate the effect of sleep at extreme altitudes upon heart rate and rhythm, continuous sleep monitoring was performed in 8 normal young men during a 40-day simulated ascent of Mt. Everest in a hypobaric chamber. Recordings were made for 1 hour before sleep, during sleep and for 1 hour after awakening in all subjects at 760 torr (sea level), in 7 subjects at 390 torr (5,490 m), in 6 at 347 torr (6,100 m) and in 4 at 282 torr (7,620 m). The following results were obtained: periods of sinus bradycardia occurred during sleep in all subjects at 3 altitudes with a mean heart rate of 41 +/- 0.5 beats/min compared to a rate of 44 +/- 2 beats/min at sea level; cycling of the heart rate, presumably due to periodic breathing, occurred in 14 of 17 studies at altitude but not at sea level (cycles consisted of bradycardia [40 beats/min] for 13 seconds and tachycardia [120 beats/min for 5 seconds]; and arrhythmias were observed in all subjects during sleep and consisted of transient bradycardia (heart rates as low as 20 beats/min), sinus pauses frequently associated with escape rhythms and occasional blocked P waves. No arrhythmias were observed at sea level. Simultaneous records of respiration and the electrocardiogram at 12,500 feet (3,810 m) in 5 other normal subjects revealed tachycardia occurring during hyperpnea and bradycardia occurring during apnea. Data indicate that during sleep in normal young subjects at high altitude, cycling of the heart rate with periodic breathing is common, as are bradyarrhythmias. The mechanism of these arrhythmias has yet to be defined.

Automatic implantable defibrillator for the patient with recurrent refractory malignant ventricular arrhythmias: case report

Clinically, the first line of treatment for patients experiencing potentially lethal arrhythmias includes antiarrhythmic medications and/or treatment of underlying causes such as ischemia or congestive heart failure. However, if the treatment is not successful in controlling the arrhythmia, the automatic implantable defibrillator is a viable alternative for the prevention of sudden death in these patients. The case report presents one example of how the automatic implantable defibrillator can supplement conventional medical therapy when success in suppressing recurrent arrhythmias cannot be obtained. This concept has been demonstrated in this 59-year-old woman who underwent several medication trials in an attempt to control her life-threatening arrhythmias.

Fibromuscular dysplasia of the external iliac arteries: surgical treatment by graduated internal dilatation technique

A case of fibromuscular dysplasia of the external iliac arteries treated by graduated internal dilatation is presented. At follow-up extending to 7 years, the external iliac arteries are patent with no evidence of recurrent disease by arteriography, and the patient remains asymptomatic. The recently reported successes with percutaneous balloon catheter angioplasty offers a nonsurgical alternative in the treatment of external iliac fibromuscular disease. A consideration of balloon catheter angioplasty in future similar cases is suggested. If balloon catheter angioplasty is unsuccessful, the option of operation remains available.