Evaluation of the clinical application effect of eSource record tools for clinical research.

BACKGROUND: Electronic sources (eSources) can improve data quality and reduce clinical trial costs. Our team has developed an innovative eSource record (ESR) system in China. This study aims to evaluate the efficiency, quality, and system performance of the ESR system in data collection and data transcription. METHODS: The study used time efficiency and data transcription accuracy indicators to compare the eSource and non-eSource data collection workflows in a real-world study (RWS). The two processes are traditional data collection and manual transcription (the non-eSource method) and the ESR-based source data collection and electronic transmission (the eSource method). Through the system usability scale (SUS) and other characteristic evaluation scales (system security, system compatibility, record quality), the participants' experience of using ESR was evaluated. RESULTS: In terms of the source data collection (the total time required for writing electronic medical records (EMRs)), the ESR system can reduce the time required by 39% on average compared to the EMR system. In terms of data transcription (electronic case report form (eCRF) filling and verification), the ESR can reduce the time required by 80% compared to the non-eSource method (difference: 223 ± 21 s). The ESR accuracy in filling the eCRF field is 96.92%. The SUS score of ESR is 66.9 ± 16.7, which is at the D level and thus very close to the acceptable margin, indicating that optimization work is needed. CONCLUSIONS: This preliminary evaluation shows that in the clinical medical environment, the ESR-based eSource method can improve the efficiency of source data collection and reduce the workload required to complete data transcription.

Krüppel-like factor 4 is involved in cell scattering induced by hepatocyte growth factor.

Hepatocyte growth factor/scatter factor (HGF) is unique by inducing epithelial cell scattering, a cellular event pivotal to HGF-mediated invasive-growth response essential for embryonic development and metastasis. Krüppel-like factor 4 (KLF4) is a multifunctional zinc-finger transcription factor involved in cell proliferation, differentiation and self-renewal. We herein present the first evidence for the functional connection between KLF4 and HGF-induced cell scattering. In particular, we found that KLF4 was upregulated by HGF in two independent epithelial cell types, HepG2 and MDCK, whereas KLF4 knockdown inhibited HGF-induced E-cadherin suppression and cell scattering. Moreover, enforced nuclear KLF4 expression alone was sufficient to upregulate KLF4, downregulate E-cadherin and trigger scattering. Chromatin immunoprecipitation (ChIP) analysis further revealed that KLF4 induced suppression of E-cadherin transcription by directly binding to the E-cadherin promoter. Additionally, we proved that HGF-induced upregulation of KLF4 transcription and cell scattering require activation of the MEK/ERK signaling pathway and the induction of early growth response 1 (EGR-1). At the mechanistic level, ChIP analysis validated a direct binding of EGR-1 to the KLF4 promoter to induce KLF4 transcription; in turn, EGR-1-induced KLF4 binds to its own promoter, thus creating a positive feedback mechanism to sustain KLF4 expression and the resultant cell scattering. We conclude that KLF4 upregulation by HGF represents a novel mechanism mediating HGF-induced cell scattering and perhaps other associated events such as cell migration and invasion.

La-based perovskites for capacity enhancement of Li-O2 batteries.

Li-O2 batteries are a promising technology for the upcoming energy storage requirements because of their high theoretical specific energy density of 11,680 Wh kg-1. Currently, the actual capacity of Li-O2 batteries is much lower than this theoretical value. In many studies, perovskites have been applied as catalysts to improve the air electrode reactions in Li-O2 batteries. The effects of structure and doping on the catalytic activity of perovskites are still unclear. La1-xSrxCoO3-δ (x = 0.1, 0.3, and 0.5) and La0.9Sr0.1YbO3-δ mixed with carbon black (Vulcan XC500 or Super P) were used as air electrode catalysts. Electrochemical characterizations were conducted using a Swagelok-type cell. The charge-discharge capacity and cyclic voltammetry (CV) performance were investigated in this study. The La1-xSrxCoO3-δ (x = 0.1, 0.3, and 0.5) is a suitable cathode catalyst for Li-O2 batteries. In this study, the La0.5Sr0.5CoO3-δ/Super P cathode demonstrated the highest discharge capacity (6,032 mAh g-1). This excellent performance was attributed to the large reaction area and enhanced Li2CO3 generation.

Challenges and Solutions in Implementing eSource Technology for Real-World Studies in China: Qualitative Study Among Different Stakeholders.

BACKGROUND: eSources consist of data that were initially documented in an electronic structure. Typically, an eSource encompasses the direct acquisition, compilation, and retention of electronic information (such as electronic health records [EHRs] or wearable devices), which serves to streamline clinical research. eSources have the potential to enhance the accuracy of data, promote patient safety, and minimize expenses associated with clinical trials. An opinion study published in September 2020 by TransCelerate outlined a road map for the future application of eSource technology and identified 5 key areas of challenges. The background of this study concerns the use of eSource technology in clinical research. OBJECTIVE: The aim of this study was to present challenges and possible solutions for the implementation of eSource technology in real-world studies by summarizing team experiences and lessons learned from an eSource record (ESR) project. METHODS: After initially developing a simple prototype of the ESR software that can be demonstrated systematically, the researchers conducted in-depth interviews and interacted with different stakeholders to obtain guidance and suggestions. The researchers selected 5 different roles for interviewees: regulatory authorities, pharmaceutical company representatives, hospital information department employees, medical system providers, and clinicians. RESULTS: After screening all consultants, the researchers concluded that there were 25 representative consultants. The hospital information department needs to implement many demands from various stakeholders, which makes the existing EHR system unable to meet all the demands of eSources. The emergence of an ESR is intended to divert the burden of the hospital information department from the enormous functional requirements of the outdated EHR system. The entire research process emphasizes multidisciplinary and multibackground expert opinions and considers the complexity of the knowledge backgrounds of personnel involved in the chain of clinical source data collection, processing, quality control, and application in real-world scenarios. To increase the readability of the results, the researchers classified the main results in accordance with the paragraph titles in "Use of Electronic Health Record Data in Clinical Investigations," a guide released by the US Food and Drug Administration. CONCLUSIONS: This study introduces the requirement dependencies of different stakeholders and the challenges and recommendations for designing ESR software when implementing eSource technology in China. Experiences based on ESR projects will provide new insights into the disciplines that advance the eSource research field. Future studies should engage patients directly to understand their experiences, concerns, and preferences regarding the implementation of eSource technology. Moreover, involving additional stakeholders, including community health care providers and social workers, will provide valuable insights into the challenges and potential solutions across various health care settings.

Existing barriers and recommendations of real-world data standardisation for clinical research in China: a qualitative study.

OBJECTIVE: To investigate the existing barriers and recommendations of real-world data (RWD) standardisation for clinical research through a qualitative study on different stakeholders. DESIGN: This qualitative study involved five types of stakeholders based on five interview outlines. The data analysis was performed using the constructivist grounded theory analysis process. SETTING: Eight hospitals, four hospital system vendors, three big data companies, six medical products companies and four regulatory institutions were included. PARTICIPANTS: In total, 62 participants from 25 institutions were interviewed through purposive sampling. RESULTS: The findings showed that the lack of clinical applicability in existing terminology standards, lack of generalisability in existing research databases, and lack of transparency in existing data standardisation process were the barriers of data standardisation of RWD for clinical research. Enhancing terminology standards by incorporating locally used clinical terminology, reducing burden in the usage of terminology standards, improving generalisability of RWD for research by using clinical data models, and improving traceability to source data for transparency might be feasible suggestions for solving the current problems. CONCLUSIONS: Efficient and reliable data standardisation of RWD for clinical research can help generate better evidence used to support regulatory evaluation of medical products. This research suggested enhancing terminology standards by incorporating locally used clinical terminology, reducing burden in the usage of terminology standards, improving generalisability of RWD for research by using clinical data models, and improving traceability to source data for transparency to guide efforts in data standardisation in the future.

Electronic Source Data Transcription for Electronic Case Report Forms in China: Validation of the Electronic Source Record Tool in a Real-world Ophthalmology Study.

BACKGROUND: As researchers are increasingly interested in real-world studies (RWSs), improving data collection efficiency and data quality has become an important challenge. An electronic source (eSource) generally includes direct capture, collection, and storage of electronic data to simplify clinical research. It can improve data quality and patient safety and reduce clinical trial costs. Although there are already large projects on eSource technology, there is a lack of experience in using eSource technology to implement RWSs. Our team designed and developed an eSource record (ESR) system in China. In a preliminary prospective study, we selected a cosmetic medical device project to evaluate ESR software's effect on data collection and transcription. As the previous case verification was simple, we plan to choose more complicated ophthalmology projects to further evaluate the ESR. OBJECTIVE: We aimed to evaluate the data transcription efficiency and quality of ESR software in retrospective studies to verify the feasibility of using eSource as an alternative to traditional manual transcription of data in RWS projects. METHODS: The approved ophthalmic femtosecond laser project was used for ESR case validation. This study compared the efficiency and quality of data transcription between the eSource method using ESR software and the traditional clinical research model of manually transcribing the data. Usability refers to the quality of a user's experience when interacting with products or systems including websites, software, devices, or applications. To evaluate the system availability of ESR, we used the System Usability Scale (SUS). The questionnaire consisted of the following 2 parts: participant information and SUS evaluation of the electronic medical record (EMR), electronic data capture (EDC), and ESR systems. By accessing log data from the EDC system previously used by the research project, all the time spent from the beginning to the end of the study could be counted. RESULTS: In terms of transcription time cost per field, the eSource method can reduce the time cost by 81.8% (11.2/13.7). Compared with traditional manual data transcription, the eSource method has higher data transcription quality (correct entry rate of 2356/2400, 98.17% vs 47,991/51,424, 93.32%). A total of 15 questionnaires were received with a response rate of 100%. In terms of usability, the average overall SUS scores of the EMR, EDC, and ESR systems were 50.3 (SD 21.9), 51.5 (SD 14.2), and 63.0 (SD 11.3; contract research organization experts: 69.5, SD 11.5; clinicians: 59.8, SD 10.2), respectively. The Cronbach α for the SUS items of the EMR, EDC, and ESR systems were 0.591 (95% CI -0.012 to 0.903), 0.588 (95% CI -0.288 to 0.951), and 0.785 (95% CI 0.576-0.916), respectively. CONCLUSIONS: In real-world ophthalmology studies, the eSource approach based on the ESR system can replace the traditional clinical research model that relies on the manual transcription of data.

Clinical Source Data Production and Quality Control in Real-world Studies: Proposal for Development of the eSource Record System.

BACKGROUND: An eSource generally includes the direct capture, collection, and storage of electronic data to simplify clinical research. It can improve data quality and patient safety and reduce clinical trial costs. There has been some eSource-related research progress in relatively large projects. However, most of these studies focused on technical explorations to improve interoperability among systems to reuse retrospective data for research. Few studies have explored source data collection and quality control during prospective data collection from a methodological perspective. OBJECTIVE: This study aimed to design a clinical source data collection method that is suitable for real-world studies and meets the data quality standards for clinical research and to improve efficiency when writing electronic medical records (EMRs). METHODS: On the basis of our group's previous research experience, TransCelerate BioPharm Inc eSource logical architecture, and relevant regulations and guidelines, we designed a source data collection method and invited relevant stakeholders to optimize it. On the basis of this method, we proposed the eSource record (ESR) system as a solution and invited experts with different roles in the contract research organization company to discuss and design a flowchart for data connection between the ESR and electronic data capture (EDC). RESULTS: The ESR method included 5 steps: research project preparation, initial survey collection, in-hospital medical record writing, out-of-hospital follow-up, and electronic case report form (eCRF) traceability. The data connection between the ESR and EDC covered the clinical research process from creating the eCRF to collecting data for the analysis. The intelligent data acquisition function of the ESR will automatically complete the empty eCRF to create an eCRF with values. When the clinical research associate and data manager conduct data verification, they can query the certified copy database through interface traceability and send data queries. The data queries are transmitted to the ESR through the EDC interface. The EDC and EMR systems interoperate through the ESR. The EMR and EDC systems transmit data to the ESR system through the data standards of the Health Level Seven Clinical Document Architecture and the Clinical Data Interchange Standards Consortium operational data model, respectively. When the implemented data standards for a given system are not consistent, the ESR will approach the problem by first automating mappings between standards and then handling extensions or corrections to a given data format through human evaluation. CONCLUSIONS: The source data collection method proposed in this study will help to realize eSource's new strategy. The ESR solution is standardized and sustainable. It aims to ensure that research data meet the attributable, legible, contemporaneous, original, accurate, complete, consistent, enduring, and available standards for clinical research data quality and to provide a new model for prospective data collection in real-world studies.

Implications of the lack of a unified research project framework: an investigation into the registration of clinical trials of COVID-19.

Objective: The aim of this study was to provide recommendations for improving the design of subsequent studies through analysis of the registered coronavirus disease 2019 (COVID-19) clinical trials.Methods: A retrospective analysis of 189 trial retrievals achieved on 20 February 2020.Results: A total of 189 trials are included in the study. There were 69.3% interventional studies, 21.7% observational studies, 5.3% diagnostic tests and 3.7% other studies. The following statistics are provided only for the interventional studies. Severity of disease: 5.3% light and common type, 17.6% severe and critically ill and 59.6% with no restricted classification. Medication use: 51.1% Western medicine, 32.1% Chinese medicine, 10.7% blood related product and 6.1% non-drug therapy. The median and inner quantile range of the sample sizes included in these studies: 104 (IQR: 60, 200). Primary outcome type most used: 45.8% with clinical characteristics and 21.4% with virological. Study design characteristics: 71% of all studies were randomized, 5% of all studies were blinded, 18% of all studies were multicenter and 76% of all studies were single center.Conclusion: Although many COVID-19 studies include randomization in their design, the lack of additional double-blind and placebo-controlled elements in their designs result in a less robust evaluation of intervention safety and efficacy. Furthermore, similar or repeated research and small sample studies that have less promise in gains of new information have possibly led to a shortage of recruitable patients and become a barrier to the completion of large multicenter clinical trial studies.

COVID-19 Clinical Trials Registered Worldwide for Drug Intervention: An Overview and Characteristic Analysis.

OBJECTIVE: This study aims to comprehensively evaluate the characteristics of clinical drug trials to facilitate the collection of evidence for COVID-19 drug treatments. METHODS: A retrospective analysis of 910 trials retrieved on August 7, 2020. RESULTS: A total of 910 registered clinical trials with at least one drug intervention were evaluated. The number of registrations (32.4%, 295) from the United States accounted for nearly one-third of the total and far exceeded that of other countries individually. Furthermore, the peak number of trials were registered in April (34.3%, 312). Over half of the trials (51.2%, 466) are in the recruitment phase, and only 4.2% (38) of the trials have been completed. The median (interquartile range) estimated enrollment is 127 (59, 365). In 39% (355) of trials, the estimated enrollment is less than 100 participants. A total of 94.5% (790) of the trials use randomization in the allocation, 82.7% (753) use a parallel intervention mode, and 52.2% (475) use masking. A total of 287 drug names have been standardized and mapped. "Hydroxychloroquine" is the leading drug among the registered trials (7.47%, 68). Among the main countries contributing to investigations on "hydroxychloroquine", the United States ranks first with 36.76% (25) of the trials. CONCLUSION: The designs of COVID-19 clinical drug trials have greatly improved in terms of the implementation of randomization and, particularly, blinding methods. In terms of drug reuse, the number of drug types has greatly increased, and hundreds of drugs have been used for efficacy screening. The emergence of large-sample registration trials is expected to address the uncertainty regarding the current clinical efficacy of some drugs.

Gap between real-world data and clinical research within hospitals in China: a qualitative study.

OBJECTIVE: To investigate the gap between real-world data and clinical research initiated by doctors in China, explore the potential reasons for this gap and collect different stakeholders' suggestions. DESIGN: This qualitative study involved three types of hospital personnel based on three interview outlines. The data analysis was performed using the constructivist grounded theory analysis process. SETTING: Six tertiary hospitals (three general hospitals and three specialised hospitals) in Beijing, China, were included. PARTICIPANTS: In total, 42 doctors from 12 departments, 5 information technology managers and 4 clinical managers were interviewed through stratified purposive sampling. RESULTS: Electronic medical record data cannot be directly downloaded into clinical research files, which is a major problem in China. The lack of data interoperability, unstructured electronic medical record data and concerns regarding data security create a gap between real-world data and research data. Updating hospital information systems, promoting data standards and establishing an independent clinical research platform may be feasible suggestions for solving the current problems. CONCLUSIONS: Determining the causes of gaps and targeted solutions could contribute to the development of clinical research in China. This research suggests that updating the hospital information system, promoting data standards and establishing a clinical research platform could promote the use of real-world data in the future.

EpCAM Signaling Promotes Tumor Progression and Protein Stability of PD-L1 through the EGFR Pathway.

Although epithelial cell adhesion molecule (EpCAM) has previously been shown to promote tumor progression, the underlying mechanisms remain largely unknown. Here, we report that the EGF-like domain I within the extracellular domain of EpCAM (EpEX) binds EGFR, activating both AKT and MAPK signaling to inhibit forkhead transcription factor O3a (FOXO3a) function and stabilize PD-L1 protein, respectively. Treatment with the EpCAM neutralizing antibody, EpAb2-6, inhibited AKT and FOXO3a phosphorylation, increased FOXO3a nuclear translocation, and upregulated high temperature requirement A2 (HtrA2) expression to promote apoptosis while decreasing PD-L1 protein levels to enhance the cytotoxic activity of CD8+ T cells. In vivo, EpAb2-6 markedly extended survival in mouse metastasis and orthotopic models of human colorectal cancer. The combination of EpAb2-6 with atezolizumab, an anti-PD-L1 antibody, almost completely eliminated tumors. Moreover, the number of CD8+ T cells in combination-treated tumors was increased compared with atezolizumab alone. Our findings suggest a new combination strategy for cancer immunotherapy in patients with EpCAM-expressing tumors. SIGNIFICANCE: This study shows that treatment with an EpCAM neutralizing antibody promotes apoptosis while decreasing PD-L1 protein to enhance cytotoxic activity of CD8+ T cells.

Electrospun Polylactic Acid (PLLA) Microtube Array Membrane (MTAM)-An Advanced Substrate for Anticancer Drug Screening.

The advent of personalized cancer treatment resulted in the shift from the administration of cytotoxic drugs with broad activity spectrum to a targeted tumor-specific therapy. Aligned to this development, the focus of this study revolved around the application of our novel and patented microtube array membrane (MTAM) in the US National Cancer Institute (NCI) developed an HFA (hollow fiber assay) assay; hereinafter known as MTAM/HFA. Electrospun poly-L-lactic acid (PLLA) MTAM was sterilized and loaded with cell lines/patient derived tumor cells (PDTC) and subcutaneously implanted into the backs of BALB/C mice. Anticancer drugs were administered at the respective time points and the respective MTAMs were retrieved and the viability tumor cells within were quantified with the MTT assay. Results revealed that the MTAMs were excellent culture substrate for various cancer cell lines and PDTCs (patient derived tumor cells). Compared to traditional HFA systems that utilize traditional hollow fibers, MTAM/HFA revealed superior drug sensitivity for a wide range of anticancer drug classes. Additionally, the duration for each test was <14 days; all this while capable of producing similar trend outcome to the current gold-standard xenograft models. These benefits were observed in both the in vitro and in vivo stages, making it a highly practical phenotypic-based solution that could potentially be applied in personalized medicine.

Extracellular domain of EpCAM enhances tumor progression through EGFR signaling in colon cancer cells.

Epithelial cell adhesion molecule (EpCAM) is highly expressed in colon cancers, but its role in cancer progression remains to be elucidated. In this work, we found that the extracellular domain of EpCAM (EpEX) activated EGFR and downstream ERK1/2 signaling to promote colon cancer cell migration and proliferation, as well as tumor growth. Mechanistically, we discovered that EpEX-EGFR-ERK1/2 signaling positively regulated intramembrane proteolysis (RIP) of EpCAM and shedding of the intracellular domain (EpICD). Treatment with an EGFR inhibitor ablated the EpEX-induced phosphorylation of ERK1/2 and AKT. Additionally, treatment with inhibitors of either EGFR or MEK decreased EpEX-induced EpICD shedding and further revealed that EpICD is necessary for nuclear accumulation of ß-catenin and the induction of HIF1α target gene expression in vitro and in vivo. Moreover, an anti-EpCAM neutralizing monoclonal antibody, EpAb2-6, inhibited the nuclear translocation of EpICD and ß-catenin and induced apoptosis in colon cancer cells. Importantly, analysis of colorectal cancer tissues showed that nuclear accumulation of EpICD was highly correlated with metastasis and poor prognosis, suggesting that it may play an important functional role in cancer progression. Thus, we provide novel insights into the mechanisms and functions of EpEX-mediated signaling, which may be considered as a promising target for the treatment of colon cancer.

An anti-EpCAM antibody EpAb2-6 for the treatment of colon cancer.

Epithelial cell adhesion molecule (EpCAM) is known to be overexpressed in epithelial cancers associated with enhanced malignant potential, particularly colorectal carcinoma (CRC) and head and neck squamous cell carcinoma (HNSCC). However, it is unknown whether progression of malignance can be directly inhibited by targeting EpCAM. Here, we have generated five novel monoclonal antibodies (mAbs) against EpCAM. One of these anti-EpCAM mAbs, EpAb2-6, was found to induce cancer cell apoptosis in vitro, inhibit tumor growth, and prolong the overall survival of both a pancreatic cancer metastatic mouse model and mice with human colon carcinoma xenografts. EpAb2-6 also increases the therapeutic efficacy of irinotecan, fluorouracil, and leucovorin (IFL) therapy in a colon cancer animal model and gemcitabine therapy in a pancreatic cancer animal model. Furthermore, EpAb2-6, which binds to positions Y95 and D96 of the EGF-II/TY domain of EpCAM, inhibits production of EpICD, thereby decreasing its translocation and subsequent signal activation. Collectively, our results indicate that the novel anti-EpCAM mAb can potentially be used for cancer-targeted therapy.

Undecylprodigiosin selectively induces apoptosis in human breast carcinoma cells independent of p53.

Undecylprodigiosin (UP) is a bacterial bioactive metabolite produced by Streptomyces and Serratia. In this study, we explored the anticancer effect of UP. Human breast carcinoma cell lines BT-20, MCF-7, MDA-MB-231 and T47D and one nonmalignant human breast epithelial cell line, MCF-10A, were tested in this study. We found that UP exerted a potent cytotoxicity against all breast carcinoma cell lines in a dose- and time-dependent manner. In contrast, UP showed limited toxicity to MCF-10A cells, indicating UP's cytotoxic effect is selective for malignant cells. UP's cytotoxic effect was due to apoptosis, as confirmed by positive TUNEL signals, annexin V-binding, caspase 9 activation and PARP cleavage. Notably, UP-induced apoptosis was blocked by the pan-caspase inhibitor z-VAD.fmk, further indicating the involvement of caspase activity. Moreover, UP caused a marked decrease of the levels of antiapoptotic BCL-X(L), Survivin and XIAP while enhancing the levels of proapoptotic BIK, BIM, MCL-1S and NOXA, consequently favoring induction of apoptosis. Additionally, we found that cells with functional p53 (MCF-7, T47D) or mutant p53 (BT-20, MDA-MB-231) were both susceptible to UP's cytotoxicity. Importantly, UP was able to induce apoptosis in MCF-7 cells with p53 knockdown by RNA interference, confirming the dispensability of p53 in UP-induced apoptosis. Overall, our results establish that UP induces p53-independent apoptosis in breast carcinoma cells with no marked toxicity to nonmalignant cells, raising the possibility of its use as a new chemotherapeutic drug for breast cancer irrespective of p53 status.