Recruitment and retention of participants in UK surgical trials: survey of key issues reported by trial staff

BACKGROUND

Recruitment and retention of participants in surgical trials is challenging. Knowledge of the most common and problematic issues will aid future trial design. This study aimed to identify trial staff perspectives on the main issues affecting participant recruitment and retention in UK surgical trials.

METHODS

An online survey of UK surgical trial staff was performed. Respondents were asked whether or not they had experienced a range of recruitment and retention issues, and, if yes, how relatively problematic these were (no, mild, moderate or serious problem).

RESULTS

The survey was completed by 155 respondents including 60 trial managers, 53 research nurses, 20 trial methodologists and 19 chief investigators. The three most common recruitment issues were: patients preferring one treatment over another (81·5 per cent of respondents); clinicians' time constraints (78·1 per cent); and clinicians preferring one treatment over another (76·8 per cent). Seven recruitment issues were rated moderate or serious problems by a majority of respondents, the most problematic being a lack of eligible patients (60·3 per cent). The three most common retention issues were: participants forgetting to return questionnaires (81·4 per cent); participants found to be ineligible for the trial (74·3 per cent); and long follow-up period (70·7 per cent). The most problematic retention issues, rated moderate or serious by the majority of respondents, were participants forgetting to return questionnaires (56·4 per cent) and insufficient research nurse time/funding (53·6 per cent).

CONCLUSION

The survey identified a variety of common recruitment and retention issues, several of which were rated moderate or serious problems by the majority of participating UK surgical trial staff. Mitigation of these problems may help boost recruitment and retention in surgical trials.

Sulphoacetaldehyde as a product of taurine chloramine peroxidation at site of inflammation

It has been reported, that sulphoacetalhehyde is formed in the fagocytozing PMNs and its production is taurine monochloramine mediated. Since H(2)O(2) and secreted MPO are present in the medium the non- and enzymatic peroxidation of taurine of its mono- and dichloramines were examined within the pH range 5.3-7.4. The formation of sulphoacetaldehyde was observed in nonenzymatic hydrolysis of taurine N,N-dichloramine (pH 5.3) as well as for monochloramine at pH 7.4. It was found also that its formation was accelerated in the presence of H(2)O(2), in the MPO/H(2)O(2) and in the full system containing Cl(-). Additionally it was shown that also horseradish peroxidase (HRP) could catalyze sulphoacetaldehyde production. The sulphoacetaldehyde formation in the examined systems was confirmed with the use of (1)HNMR spectra of separated 2,4-dinitrophenylhydrazone derivative. Our results suggest that both non- and ezymatic processes could contribute to the sulphoacetaldehyde formation at site of inflammation.

Chemiluminescence of ABEI-labelled IgG triggered by the N-chloramine-H(2)O(2)-p-iodophenol system

Light is emitted in systems containing N-chloramines or hypochlorite, H(2)O(2) and N-(4-aminobutyl)-N-ethylisoluminol (ABEI). The emission is enhanced by 4-iodophenol (PIP) in alkaline solution (1 mol/L NaOH), while at lower pH range (9-11) PIP is not only inactive but also its presence reduces chemiluminescence (CL) of the monochloramine-H(2)O(2)-ABEI system to the background. Two procedures for ABEI-labelled IgG assays were developed, with PIP in 1 mol/L NaOH and without PIP at pH 11, and the standard curves of free ABEI in these conditions were examined. We suggest also that the oxidative deamination of taurine chloramine leads to the formation of the various carbonyl derivatives and their formation is accelerated in the presence of H(2)O(2), especially in less alkaline solutions (pH 11). Moreover, the formation of enol forms of aldehydes in assay buffers was observed. The yield of the phenoxy radical mediators of ABEI oxidation and the pH-dependent H(2)O(2):HO(2) ratio seems to be decisive for the overall CL in the system examined. The main advantage of this method is that CL does not need precise timing of measurements and assays can be performed over a long period of time (hours) using a plate luminometer.

Oxidative modification of ovalbumin

Stimulated neutrophils (PMNL) are a source of the active oxygen species: O2, H2O2 and HOCl/OCl- which in turn can act on proteins yielding a variety of mixed oxidation products. A system is proposed in which a model protein-ovalbumin (OVA) first undergoes chlorination by HOCl/OCl- and next is oxidised by H2O2. The modification of functional groups (-NH2, -SH, -S-S-, > C = O, Tyr and Trp) in OVA was monitored as well as their accessibility to promote aggregation. Chlorination resulted in additional inter- or intra -S-S- bond formation followed by a decrease in the total sulfhydryl group content. Amino groups were oxidised to carbonyl moieties with a concomitant acidic shift of pI. Formation of chlorotyrosine at the chlorination step was confirmed and its further H2O2-mediated transformation to bityrosine was demonstrated. It has also been confirmed that tryptophan, and not tyrosine, is the first target for chlorination. SDS/PAGE and HPLC profiles revealed that HOCl/OCl- chlorination promotes formation of aggregates stabilised by non covalent bonds. In conclusion, we suggest that a dramatic change in the OVA molecule structure begins when the molar excess of HOCl/OCl- is about 2 per one reactive group in OVA.

Oxidative modification of ovalbumin

Stimulated neutrophils (PMNL) are a source of the active oxygen species: O2, H2O2 and HOCl/OCl- which in turn can act on proteins yielding a variety of mixed oxidation products. A system is proposed in which a model protein-ovalbumin (OVA) first undergoes chlorination by HOCl/OCl- and next is oxidised by H2O2. The modification of functional groups (-NH2, -SH, -S-S-, > C = O, Tyr and Trp) in OVA was monitored as well as their accessibility to promote aggregation. Chlorination resulted in additional inter- or intra -S-S- bond formation followed by a decrease in the total sulfhydryl group content. Amino groups were oxidised to carbonyl moieties with a concomitant acidic shift of pI. Formation of chlorotyrosine at the chlorination step was confirmed and its further H2O2-mediated transformation to bityrosine was demonstrated. It has also been confirmed that tryptophan, and not tyrosine, is the first target for chlorination. SDS/PAGE and HPLC profiles revealed that HOCl/OCl- chlorination promotes formation of aggregates stabilised by non covalent bonds. In conclusion, we suggest that a dramatic change in the OVA molecule structure begins when the molar excess of HOCl/OCl- is about 2 per one reactive group in OVA.

Effects of gamma-interferon on human neutrophils: protection from deterioration on storage

Human polymorphonuclear leukocytes (PMN) preincubated overnight with 100 U/mL gamma-interferon (IFN-gamma) had an increased metabolic response, as measured by iodination and/or superoxide production, to stimulation by tumor necrosis factor (TNF), granulocyte-macrophage colony-stimulating factor (GM-CSF), formylmethionyl-leucyl-phenylalanine (FMLP), opsonized zymosan, and lipopolysaccharide (LPS), as compared with cells comparably preincubated in the absence of IFN-gamma. The decline in the staphylocidal activity of the stored PMN was also prevented in part by IFN-gamma, as was the depressed adherence of PMN stimulated with phorbol myristate acetate (PMA), FMLP, TNF, GM-CSF, and LPS. This protective effect of IFN-gamma on PMN function was associated with the prolonged surface expression of the complement receptor three (CR3) alpha-chain (CD11b), CR3 beta-chain (CD18), FcRII (CD32), and FcRIII (CD16), and the appearance of surface FcRI (CD64). The polymerase chain reaction (PCR) was used to amplify neutrophil RNA-derived cDNA recognized by synthetic oliogonucleotides designed from published nucleotide sequences for specific proteins. Using this procedure, mRNA for gp91-phox, p67-phox, p47-phox, CD64, two forms of CD32, CD16, CD11b, CD18, and actin were found to be depressed after overnight storage of neutrophils, and this decrease in steady-state mRNA levels was in part or totally prevented by IFN-gamma. CD64 and gp91-phox mRNA were generally increased by IFN-gamma to a level greater than that of freshly isolated neutrophils. Northern analysis of CD64 and p47 phox mRNAs confirmed the findings with the PCR method. These findings suggest that storage of PMN in a functionally active state is favored by the presence of IFN-gamma.

Enhancement of trinitrophenyl-specific humoral response to TNP proteins as the result of carrier chlorination

Trinitrophenyl (TNP)-specific humoral response was tested after immunization with TNP-protein conjugates composed of either native proteins or proteins modified by chlorination. Significant enhancement of the hapten-specific response was observed as a result of carrier chlorination. This effect was dose dependent and affected mainly T-helper-cell activation. Since stimulated neutrophils chlorinate in vivo proteins, we propose that they take part in the induction phase of immune response by facilitation of antigen processing and/or presentation.

Enhancement of immunogenic properties of ovalbumin as a result of its chlorination

1. Chlorination of ovalbumin results in its enhanced immunogenic properties. 2. This has been evaluated by the interleukin-2 production after incubation of the modified protein with antigen presenting cells and T helper cells.

Enhancement of proteinase-mediated degradation of proteins modified by chlorination

1. Pretreatment of some proteins (albumin, immunoglobulin G, elastin and fibrinogen) with hypochlorite or with the MPO-H2O2-Cl- system increased their susceptibility to proteolysis by trypsin, chymotrypsin or elastase. 2. The optimal activities of these three proteinases were attained at a different extent of albumin chlorination. 3. Elastase was found to develop a specially efficient activity towards chlorinated albumin or chlorinated elastin being by itself resistant to chlorinating species.

A possible origin of chemiluminsecence in phagocytosing neutrophils. Myeloperoxidase-mediated chlorination of proteins and tryptophan

Chlorination of proteins by the myeloperoxidase-H2O2-Cl- system results in light emission. Out of all amino acids present in proteins only tryptophan delivers light during chlorination. Chlorination of tryptophan by the myeloperoxidase-H2O2-Cl- system, as well as by HOCl or taurine chloramine is associated with chemiluminescence. pH dependence and time pattern of light emission is similar for chlorination of tryptophan by the myeloperoxidase system and taurine, but appears to be different for chlorination by HOCl. Aerobic conditions are necessary for chemiluminescence of chlorinated tryptophan.

A possible origin of chemiluminescence in phagocytosing neutrophils. Reaction between chloramines and H2O2

A mixture of chloramines and hydrogen peroxide emits light. It was found that the reaction between taurine monochloramine and hydrogen peroxide is very slow. The stoichiometry of the reaction is 1:1 and taurine is detected as one of the products. The chlorinated proteins and bacteria, containing N-Cl groups, when reacting with hydrogen peroxide, are more effective in emitting light than low-molecular chloramines. Luminol enhances considerably light yield of the chloramine-hydrogen peroxide reaction. The chloramine-H2O2 reaction may account for light emitted by neutrophils during phagocytosis.