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Harsányi L, Weltner J, Zaránd A. [Why is the scientometric gap widening? Deterioration of the scientific parameters of surgical specialties]. Magy Seb 2013; 66:3-13. [PMID: 23428722 DOI: 10.1556/maseb.66.2013.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- László Harsányi
- Semmelweis Egyetem Általános Orvostudományi Kar I. sz. Sebészeti Klinika 1082 Budapest.
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102
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Abstract
Publicly sponsored trials, conducted primarily by cooperative groups sponsored by the National Cancer Institute, and commercially sponsored trials are necessary to create new knowledge, improve the care of oncology patients, and develop new drugs and devices. Commercial sponsors launch clinical trials that will result in drug approval, label extension, expansion of market share, and an increase in shareholder value. Conversely, publicly sponsored trials seek to optimize therapy for a particular disease, create new knowledge, and improve public health; these trials can also result in label extension of a drug and even in initial drug approval. Publicly sponsored trials may combine and/or compare drugs developed by different commercial sponsors, develop multimodality therapies (e.g., the combination of chemotherapy and radiation), or develop novel treatment schedules or routes of drug administration (e.g., intraperitoneal chemotherapy). Publicly sponsored trials are more likely to focus on therapies for rare diseases and to study survivorship and quality of life; these areas may not be a priority for commercial entities. Screening and prevention strategies have been developed almost exclusively by the public sector given the large sample size and long follow-up period needed to complete the trial and, therefore, the lack of short-term commercial gain. Finally, given the public nature of the funding, clinical investigators are expected to publish their results even if the outcomes are unfavorable for the investigational therapy. With the ongoing reorganization of the cooperative groups to form a national clinical trials network, opportunities exist to create a robust platform for biomarker discovery and validation through the expanded collection of well-annotated biospecimens obtained from clinical trial participants. Thus, publicly funded trials are vital to developing and refining new cancer treatments and disseminating results to the medical community and the general public.
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Affiliation(s)
- Richard L Schilsky
- Section of Hematology-Oncology, The University of Chicago, Chicago, Illinois, USA.
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103
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Lawrence YR, Vikram B, Dignam JJ, Chakravarti A, Machtay M, Freidlin B, Takebe N, Curran WJ, Bentzen SM, Okunieff P, Coleman CN, Dicker AP. NCI-RTOG translational program strategic guidelines for the early-stage development of radiosensitizers. J Natl Cancer Inst 2013; 105:11-24. [PMID: 23231975 PMCID: PMC3536642 DOI: 10.1093/jnci/djs472] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 09/15/2012] [Accepted: 10/02/2012] [Indexed: 12/21/2022] Open
Abstract
The addition of chemotherapeutic agents to ionizing radiation has improved survival in many malignancies. Cure rates may be further improved by adding novel targeted agents to current radiotherapy or radiochemotherapy regimens. Despite promising laboratory data, progress in the clinical development of new drugs with radiation has been limited. To define and address the problems involved, a collaborative effort between individuals within the translational research program of the Radiation Oncology Therapy Group and the National Cancer Institute was established. We discerned challenges to drug development with radiation including: 1) the limited relevance of preclinical work, 2) the pharmaceutical industry's diminished interest, and 3) the important individual skills and institutional commitments required to ensure a successful program. The differences between early-phase trial designs with and without radiation are noted as substantial. The traditional endpoints for early-phase clinical trials-acute toxicity and maximum-tolerated dose-are of limited value when combining targeted agents with radiation. Furthermore, response rate is not a useful surrogate marker of activity in radiation combination trials.Consequently, a risk-stratified model for drug-dose escalation with radiation is proposed, based upon the known and estimated adverse effects. The guidelines discuss new clinical trial designs, such as the time-to-event continual reassessment method design for phase I trials, randomized phase II "screening" trials, and the use of surrogate endpoints, such as pathological response. It is hoped that by providing a clear pathway, this article will accelerate the rate of drug development with radiation.
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104
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Abstract
Clinical use of allografts of fetal ventral mesencephalic tissue as a treatment to replace dopaminergic neurons in patients with Parkinson's disease was first done more than 20 years ago. Since then, many patients have received transplants, with variable results. During this time, our knowledge of Parkinson's disease has changed and the nature and extent of problems associated with the disorder have been better defined. Our understanding on how best to implement this cell-replacement strategy for patients has grown, but gaining this insight has entailed critical reappraisal of data from transplant trials that have already been undertaken.
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105
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Baron R, Förster M, Binder A. Subgrouping of patients with neuropathic pain according to pain-related sensory abnormalities: a first step to a stratified treatment approach. Lancet Neurol 2012; 11:999-1005. [PMID: 23079556 DOI: 10.1016/s1474-4422(12)70189-8] [Citation(s) in RCA: 205] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Patients with neuropathic pain present with various pain-related sensory abnormalities. These sensory features form different patterns or mosaics-the sensory profile-in individual patients. One hypothesis for the development of sensory profiles is that distinct pathophysiological mechanisms of pain generation produce specific sensory abnormalities. Several controlled trials of promising new drugs have produced negative results, but these findings could have been a result of heterogeneity in the patient population. Subgrouping patients on the basis of individual sensory profiles could reduce this heterogeneity and improve trial design. RECENT DEVELOPMENTS A statistical categorisation of patients with neuropathic pain showed that subgroups of patients with distinct sensory profiles who perceive their pain differently do exist across a range of neuropathic disorders, although some distinct disorder-specific profiles were also detected. Results of the first clinical trials to use the subgroup approach at baseline could show a superior effect of the study drugs in specific subgroups, rather than in the entire cohort of patients. WHERE NEXT?: A new classification of neuropathic pain should take into account subgroups of patients with different sensory profiles. Sensory phenotyping has the potential to improve clinical trial design by enriching the study population with potential treatment responders, and might lead to a stratified treatment approach and ultimately to personalised treatment.
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Affiliation(s)
- Ralf Baron
- Sektion Neurologische Schmerzforschung und Therapie, Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.
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106
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107
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Ploug T, Holm S. Pharmaceutical information systems and possible implementations of informed consent -- developing an heuristic. BMC Med Ethics 2012; 13:30. [PMID: 23157854 PMCID: PMC3507876 DOI: 10.1186/1472-6939-13-30] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 10/17/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Denmark has implemented a comprehensive, nationwide pharmaceutical information system, and this system has been evaluated by the Danish Council of Ethics. The system can be seen as an exemplar of a comprehensive health information system for clinical use. ANALYSIS The paper analyses 1) how informed consent can be implemented in the system and how different implementations create different impacts on autonomy and control of information, and 2) arguments directed towards justifying not seeking informed consent in this context. RESULTS AND CONCLUSION Based on the analysis a heuristic is provided which enables a ranking and estimation of the impact on autonomy and control of information of different options for consent to entry of data into the system and use of data from the system.The danger of routinisation of consent is identified.The Danish pharmaceutical information system raises issues in relation to autonomy and control of information, issues that will also occur in relation to other similar comprehensive health information systems. Some of these issues are well understood and their impact can be judged using the heuristic which is provided. More research is, however needed in relation to routinisation of consent.
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Affiliation(s)
- Thomas Ploug
- Centre for Applied Ethics and Philosophy of Science, Department of Communication, Aalborg University Copenhagen, A. C. Meyers Vænge, 2450, København SV, Denmark
| | - Søren Holm
- University of Manchester, Centre for Social Ethics and Policy, School of Law, Manchester M13 9PL, United Kingdom
- Center for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway
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108
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Sledge G. Q&A: George Sledge on trends in clinical trials. Interview by Eric Bender. Cancer Discov 2012; 2:967. [PMID: 23148359 DOI: 10.1158/2159-8290.cd-nd2012-038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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109
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Abdool Karim Q, Kharsany ABM, Frohlich JA, Werner L, Mlotshwa M, Madlala BT, Abdool Karim SS. HIV incidence in young girls in KwaZulu-Natal, South Africa--public health imperative for their inclusion in HIV biomedical intervention trials. AIDS Behav 2012; 16:1870-6. [PMID: 22618892 DOI: 10.1007/s10461-012-0209-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Young women are particularly vulnerable for acquiring HIV yet they are often excluded from clinical trials testing new biomedical intervention. We assessed the HIV incidence and feasibility of enrolling a cohort of young women for potential participation in future clinical trials. Between March 2004 and May 2007, 594 HIV uninfected 14-30 year old women were enrolled into a longitudinal HIV risk reduction study in KwaZulu-Natal, South Africa. The overall HIV prevalence at screening in young girls below the age of 18 years was 27.6 % compared to 52.0 % in the women above 18 years, p < 0.001. HIV incidence was 4.7 [95 % Confidence interval (CI) 1.5-10.9) and 6.9 (95 % CI 4.8-9.6)/100 women years (wy), p = 0.42 and pregnancy rates were 23.7 (95 % CI 14.9-35.9) and 16.4 (95 % CI 12.9-20.6)/100 wy, p = 0.29, in the women below and above 18 years respectively. Retention was similar in both groups (71.0 vs. 71.5 %, p = 0.90). This study demonstrates that the inclusion of young girls between the ages of 14 and 17 years in longitudinal studies is feasible and their inclusion in clinical trials would maintain scientific integrity and power of the study.
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Affiliation(s)
- Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Congella, Durban 4013, South Africa
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110
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Abstract
It is widely agreed that medical researchers who conduct studies in low- and middle-income countries (LMICs) are morally required to ensure that their research benefits the broader host community, not only the subjects. The justification for this moral requirement has not been adequately examined. Most attempts to justify this requirement focus on researchers' interaction with the community as a whole, not on their relationship with their subjects. This paper argues that in some cases, research must benefit the broader host community for researchers to treat subjects and prospective subjects ethically. If research presents substantial net risks to subjects, researchers can ethically ask LMIC citizens to participate only if people in LMICs, normally including people in the host community, stand to benefit.
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Affiliation(s)
- Robert C Hughes
- Department of Bioethics, National Institutes of Health, Clinical Center, 10 Center Drive, Bldg. 10 room 1C118, Bethesda, MD 20892-1156, USA.
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111
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Rowe SM, Borowitz DS, Burns JL, Clancy JP, Donaldson SH, Retsch-Bogart G, Sagel SD, Ramsey BW. Progress in cystic fibrosis and the CF Therapeutics Development Network. Thorax 2012; 67:882-90. [PMID: 22960984 PMCID: PMC3787701 DOI: 10.1136/thoraxjnl-2012-202550] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cystic fibrosis (CF), the most common life-shortening genetic disorder in Caucasians, affects approximately 70 000 individuals worldwide. In 1998, the Cystic Fibrosis Foundation (CFF) launched the CF Therapeutics Development Network (CF-TDN) as a central element of its Therapeutics Development Programme. Designed to accelerate the clinical evaluation of new therapies needed to fulfil the CFF mission to control and cure CF, the CF-TDN has conducted 75 clinical trials since its inception, and has contributed to studies as varied as initial safety and proof of concept trials to pivotal programmes required for regulatory approval. This review highlights recent and significant research efforts of the CF-TDN, including a summary of contributions to studies involving CF transmembrane conductance regulator (CFTR) modulators, airway surface liquid hydrators and mucus modifiers, anti-infectives, anti-inflammatories, and nutritional therapies. Efforts to advance CF biomarkers, necessary to accelerate the therapeutic goals of the network, are also summarised.
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Affiliation(s)
- Steven M Rowe
- Department of Medicine, University of Alabama at Birmingham, 1819 University Boulevard (MCLM 768), Birmingham, AL 35294, USA.
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112
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Koen J, Essack Z, Slack C, Lindegger G, Newman PA. 'It looks like you just want them when things get rough': civil society perspectives on negative trial results and stakeholder engagement in HIV prevention trials. Dev World Bioeth 2012; 13:138-48. [PMID: 22998395 DOI: 10.1111/j.1471-8847.2012.00338.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Civil society organizations (CSOs) have significantly impacted on the politics of health research and the field of bioethics. In the global HIV epidemic, CSOs have served a pivotal stakeholder role. The dire need for development of new prevention technologies has raised critical challenges for the ethical engagement of community stakeholders in HIV research. This study explored the perspectives of CSO representatives involved in HIV prevention trials (HPTs) on the impact of premature trial closures on stakeholder engagement. Fourteen respondents from South African and international CSOs representing activist and advocacy groups, community mobilisation initiatives, and human and legal rights groups were purposively sampled based on involvement in HPTs. Interviews were conducted from February-May 2010. Descriptive analysis was undertaken across interviews and key themes were developed inductively. CSO representatives largely described positive outcomes of recent microbicide and HIV vaccine trial terminations, particularly in South Africa, which they attributed to improvements in stakeholder engagement. Ongoing challenges to community engagement included the need for principled justifications for selective stakeholder engagement at strategic time-points, as well as the need for legitimate alternatives to CABs as mechanisms for engagement. Key issues for CSOs in relation to research were also raised.
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113
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Stiller CA, Kroll ME, Pritchard-Jones K. Population survival from childhood cancer in Britain during 1978-2005 by eras of entry to clinical trials. Ann Oncol 2012; 23:2464-2469. [PMID: 22811513 DOI: 10.1093/annonc/mds183] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Inclusion in clinical trials is generally viewed as best practice for most newly diagnosed childhood cancers, but the impact on population-based survival has rarely been examined. PATIENTS AND METHODS The population-based data were analysed for 25 853 children (66% of all registered childhood cancers) diagnosed in Britain during 1978-2005 with acute lymphoblastic leukaemia (ALL), acute myeloid leukaemia (AML), Hodgkin lymphoma, non-Hodgkin lymphoma, medulloblastoma, neuroblastoma, Wilms tumour, hepatoblastoma, osteosarcoma, Ewing sarcoma, rhabdomyosarcoma and germ-cell tumours. The Kaplan-Meier survival curves were compared by log-rank tests. Time trends were analysed by Cox regression. Separate analyses were done for children with ALL, medulloblastoma and neuroblastoma according to clinically relevant age thresholds. RESULTS Survival increased significantly during 1978-2005 for every diagnostic category; the annual reduction in risk of death ranged from 2.7% (rhabdomyosarcoma) to 12.0% (gonadal germ-cell tumours). Survival increased steadily between trial eras for ALL (age 1-14 years) and neuroblastoma (age 1-14 years), but changed little since the mid-1980s for medulloblastoma (age 0-2 years), osteosarcoma or Ewing sarcoma. CONCLUSIONS Changes in survival between trial eras parallel those reported by the relevant clinical trials. The increasing level of participation in trials, facilitated by the organisation of specialist care, has underpinned the substantial improvements in survival seen at the population level.
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Affiliation(s)
- C A Stiller
- Childhood Cancer Research Group, Department of Paediatrics.
| | - M E Kroll
- Childhood Cancer Research Group, Department of Paediatrics; Cancer Epidemiology Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford
| | - K Pritchard-Jones
- Department of Paediatric Oncology, Institute of Child Health, University College London, Great Ormond Street Hospital for Children NHS Trust, London, UK
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114
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Jarman AF, Wray NP, Wenner DM, Ashton CM. Trials and tribulations: the professional development of surgical trialists. Am J Surg 2012; 204:339-346.e5. [PMID: 22920404 PMCID: PMC3567847 DOI: 10.1016/j.amjsurg.2011.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 11/18/2011] [Accepted: 11/18/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND Regulatory and professional bodies issue an ever-increasing number of guidance documents on the ethics and methods of clinical trials, but the quality of clinical trials of invasive therapeutic procedures continues to be a concern. We interviewed aspiring and accomplished surgical trialists to understand how they use guidance documents and other resources in their work. METHODS We performed a qualitative research study involving semistructured interviews of a diverse sample of 15 surgical trialists. RESULTS Professional development as a surgical trialist was haphazard, inefficient, and marked by avoidable mistakes. Four types of resources played constructive roles: formal education; written materials on clinical trials; experience with actual trials; and interpersonal interactions with peers, experts, collaborators, and mentors. Recommendations for improvement centered on education, mentoring, networking, participating in trials, and facilitation by department chairs. CONCLUSIONS The haphazard and unstructured nature of the current system is adding unnecessarily to the numerous challenges faced by surgical trialists.
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Affiliation(s)
- Anna F. Jarman
- Department of Surgery, The Methodist Hospital, Houston, TX, USA
- The Methodist Hospital Research Institute, 6550 Fannin St, Houston, TX 77030, USA
| | - Nelda P. Wray
- Department of Surgery, The Methodist Hospital, Houston, TX, USA
- The Methodist Hospital Research Institute, 6550 Fannin St, Houston, TX 77030, USA
- Weill Cornell Medical College, New York, NY, USA
| | | | - Carol M. Ashton
- Department of Surgery, The Methodist Hospital, Houston, TX, USA
- The Methodist Hospital Research Institute, 6550 Fannin St, Houston, TX 77030, USA
- Weill Cornell Medical College, New York, NY, USA
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115
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Pui CH, Mullighan CG, Evans WE, Relling MV. Pediatric acute lymphoblastic leukemia: where are we going and how do we get there? Blood 2012; 120:1165-74. [PMID: 22730540 PMCID: PMC3418713 DOI: 10.1182/blood-2012-05-378943] [Citation(s) in RCA: 373] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 06/19/2012] [Indexed: 01/19/2023] Open
Abstract
Improved supportive care, more precise risk stratification, and personalized chemotherapy based on the characteristics of leukemic cells and hosts (eg, pharmacokinetics and pharmacogenetics) have pushed the cure rate of childhood acute lymphoblastic leukemia to near 90%. Further increase in cure rate can be expected from the discovery of additional recurrent molecular lesions, coupled with the development of novel targeted treatment through high-throughput genomics and innovative drug-screening systems. We discuss specific areas of research that promise to further refine current treatment and to improve the cure rate and quality of life of the patients.
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Affiliation(s)
- Ching-Hon Pui
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
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116
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Houthuizen P, Van Garsse LAFM, Poels TT, de Jaegere P, van der Boon RMA, Swinkels BM, Ten Berg JM, van der Kley F, Schalij MJ, Baan J, Cocchieri R, Brueren GRG, van Straten AHM, den Heijer P, Bentala M, van Ommen V, Kluin J, Stella PR, Prins MH, Maessen JG, Prinzen FW. Left Bundle-Branch Block Induced by Transcatheter Aortic Valve Implantation Increases Risk of Death. Circulation 2012; 126:720-8. [PMID: 22791865 DOI: 10.1161/circulationaha.112.101055] [Citation(s) in RCA: 227] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Transcatheter aortic valve implantation (TAVI) is a novel therapy for treatment of severe aortic stenosis. Although 30% to 50% of patients develop new left bundle-branch block (LBBB), its effect on clinical outcome is unclear.
Methods and Results—
Data were collected in a multicenter registry encompassing TAVI patients from 2005 until 2010. The all-cause mortality rate at follow-up was compared between patients who did and did not develop new LBBB. Of 679 patients analyzed, 387 (57.0%) underwent TAVI with the Medtronic CoreValve System and 292 (43.0%) with the Edwards SAPIEN valve. A total of 233 patients (34.3%) developed new LBBB. Median follow-up was 449.5 (interquartile range, 174–834) days in patients with and 450 (interquartile range, 253–725) days in patients without LBBB (
P
=0.90). All-cause mortality was 37.8% (n=88) in patients with LBBB and 24.0% (n=107) in patients without LBBB (
P
=0.002). By multivariate regression analysis, independent predictors of all-cause mortality were TAVI-induced LBBB (hazard ratio [HR], 1.54; confidence interval [CI], 1.12–2.10), chronic obstructive lung disease (HR, 1.56; CI, 1.15–2.10), female sex (HR, 1.39; CI, 1.04–1.85), left ventricular ejection fraction ≤50% (HR, 1.38; CI, 1.02–1.86), and baseline creatinine (HR, 1.32; CI, 1.19–1.43). LBBB was more frequent after implantation of the Medtronic CoreValve System than after Edwards SAPIEN implantation (51.1% and 12.0%, respectively;
P
<0.001), but device type did not influence the mortality risk of TAVI-induced LBBB.
Conclusions—
All-cause mortality after TAVI is higher in patients who develop LBBB than in patients who do not. TAVI-induced LBBB is an independent predictor of mortality.
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118
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119
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Wujcik DM. Much has changed in cancer clinical trials in the past 10 years. ONS Connect 2012; 27:7. [PMID: 22855982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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120
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Abstract
INTRODUCTION In times of short health care budgets, reimbursement for self-monitoring of blood glucose (SMBG) in diabetes patients without insulin treatment is subject to debate. The Structured Testing Program (STeP) trial found a positive correlation of test frequency and improved hemoglobin A1c (HbA1c) levels in poorly controlled type 2 diabetes patients not treated with insulin. METHODS A structured literature search for other clinical studies reporting on SMBG frequency was performed. RESULTS There is scarce evidence: three trials, including STeP, noted a significant and relevant correlation between testing frequency and improved HbA1c levels (FA effect), whereas two studies did not. The comparability between the identified studies is problematic. CONCLUSION Future research should consider correlations between testing frequency and level of glycemic control. More emphasis should be placed on a structured approach to use SMBG and to address adherence to testing and therapy.
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Affiliation(s)
- Wendelin Schramm
- GECKO Institute for Medicine, Informatics, and Economics, Heilbronn University, Heilbronn, Germany.
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121
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122
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Julian-Reynier C. [Human, economics and social sciences: rebounds of ideas on genomics and clinical trials]. Med Sci (Paris) 2012; 28 Spec No 1:3-4. [PMID: 22494647 DOI: 10.1051/medsci/2012281s101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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125
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Abstract
There have been significant advancements in understanding the immunopathogenesis of systemic lupus erythematosus. However, the developments in therapeutics have been rather slow. Belimumab, a B lymphocyte stimulator (BLyS) inhibitor has been approved for the treatment of this disease after more than 50 years. Numerous biological agents are being developed which target the B cells, T cells, and various cytokines. Among anti-B cell therapy, drugs target CD20+ cells (ocrelizumab, SBI-087), CD22+ cells (epratuzumab) \or the receptors of tumor necrosis factor (TNF) superfamily (atacicept, LY2127399, A-623). Monoclonal antibodies targeting interferon alpha (IFN-α) and gamma (IFN-γ) and interleukins (IL-6, 10) are being investigated for SLE. Novel targets include toll like receptors, phosphodiesterases, CD40 ligand and retinoid receptors. This review discusses various drugs which are in different phases of clinical trials and hold promise for patients suffering from this chronic debilitating disease.
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Affiliation(s)
- Preeta Kaur Chugh
- Department of Pharmacology, Maulana Azad Medical College and Associated Hospitals, Bahadur Shah Zafar Marg, New Delhi 110002, India.
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126
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Abstract
This paper responds to the fact that over 200 Alzheimer's disease (AD) drug candidates have failed to date and draws on searches of the literature for studies of error effects in drug developments and the authors' published works. In the same period, basic knowledge of AD pathology has greatly expanded providing both potential therapeutic targets and rationales for modifications in strategies for testing AD drug candidates. Current opinion generally holds that AD drug candidates have failed because they address pathology that is already too advanced. Less attention is paid to numerous reported methodological weaknesses capable of biasing AD clinical trials and drug developments and thus invalidating conclusions to be reached about the drugs being tested. The costs of quality controls possibly needed to better insure validity in AD drug developments raises concerns that progress toward success in AD drug development may be hindered by the costs of intervening against current methodological barriers to the successful completions of AD drug developments.
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127
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Pergolizzi J, Alegre C, Blake D, Alén JC, Caporali R, Casser HR, Correa-Illanes G, Fernandes P, Galilea E, Jany R, Jones A, Mejjad O, Morovic-Vergles J, Oteo-Álvaro Á, Radrigán Araya FJ, Simões MEC, Uomo G. Current considerations for the treatment of severe chronic pain: the potential for tapentadol. Pain Pract 2012; 12:290-306. [PMID: 21797962 DOI: 10.1111/j.1533-2500.2011.00487.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Studies suggest that around 20% of adults in Europe experience chronic pain, which not only has a considerable impact on their quality of life but also imposes a substantial economic burden on society. More than one-third of these people feel that their pain is inadequately managed. A range of analgesic drugs is currently available, but recent guidelines recommend that NSAIDs and COX-2 inhibitors should be prescribed cautiously. Although the short-term efficacy of opioids is good, adverse events are common and doses are frequently limited by tolerability problems. There is a perceived need for improved pharmacological treatment options. Currently, many treatment decisions are based solely on pain intensity. However, chronic pain is multifactorial and this apaproach ignores the fact that different causative mechanisms may be involved. The presence of more than one causative mechanism means that chronic pain can seldom be controlled by a single agent. Therefore, combining drugs with different analgesic actions increases the probability of interrupting the pain signal, but is often associated with an increased risk of drug/drug interactions, low compliance and increased side effects. Tapentadol combines μ-opioid receptor agonism and noradrenaline reuptake inhibition in a single molecule, with both mechanisms contributing to its analgesic effects. Preclinical testing has shown that μ-opioid agonism is primarily responsible for analgesia in acute pain, whereas noradrenaline reuptake inhibition is more important in chronic pain. In clinical trials in patients with chronic pain, the efficacy of tapentadol was similar to that of oxycodone, but it produced significantly fewer gastrointestinal side-effects and treatment discontinuations. Pain relief remained stable throughout a 1-year safety study. Thus, tapentadol could possibly overcome some of the limitations of currently available analgesics for the treatment of chronic pain.
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Affiliation(s)
- Joseph Pergolizzi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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128
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Hayashi K, Masuda S, Kimura H. Analyzing global trends of biomarker use in drug interventional clinical studies. Drug Discov Ther 2012; 6:102-107. [PMID: 22622020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The trend of biomarker use in drug interventional clinical studies was analyzed using ClinicalTrials.gov to provide an overview of how biomarkers are used to streamline clinical studies and to examine regional differences. A total of 3,383 clinical study data was analyzed according to phase, region, sponsor, and therapeutic class. The number of clinical studies using biomarkers has been increasing constantly and is dependent on the number of Phase I and II studies. The majority of studies (58.5%) were sponsored by the United States, with the studies being conducted mainly in the sponsor's home region (80.3%). The use of biomarkers was prominent in the oncology area (37.1%). Although current data indicates some bias in the clinical use of biomarkers, it is expected that their use will increase in later phase studies or other therapeutic areas as biomarker development proceeds. In addition, limited regional use of biomarkers may lead to differences in biomarker use in drug development and in combination with political support may result in differences in competitiveness of drug development. Biomarkers would be a powerful tool against deteriorating research and development productivity when used more in appropriate clinical study conditions.
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Affiliation(s)
- K Hayashi
- Graduate School of Pharmaceutical Science, The University of Tokyo, Tokyo, Japan.
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129
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130
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131
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Clinical Trials as Topic/economics
- Clinical Trials as Topic/ethics
- Clinical Trials as Topic/methods
- Clinical Trials as Topic/trends
- Drugs, Investigational/therapeutic use
- Ethics Committees, Research
- Europe
- Expert Testimony
- Humans
- Informed Consent/standards
- Medical Oncology
- National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division
- National Cancer Institute (U.S.)
- Patient Selection
- Precision Medicine/standards
- Precision Medicine/trends
- Research Design/trends
- Research Support as Topic
- Societies, Medical
- Translational Research, Biomedical/methods
- Translational Research, Biomedical/standards
- Translational Research, Biomedical/trends
- United States
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132
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King ER, Wong KK. Insulin-like growth factor: current concepts and new developments in cancer therapy. Recent Pat Anticancer Drug Discov 2012; 7:14-30. [PMID: 21875414 PMCID: PMC3724215 DOI: 10.2174/157489212798357930] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 01/20/2011] [Accepted: 01/05/2011] [Indexed: 01/23/2023]
Abstract
The insulin-like growth factor (IGF) family and the IGF-1 receptor (IGF-1R) play an important role in cancer. This intricate and complex signaling pathway provides many opportunities for therapeutic intervention, and several novel therapeutics aimed at the IGF-1R, particularly monoclonal antibodies and small molecule tyrosine kinase inhibitors, are under clinical investigation. This article provides a patent overview of the IGF signaling pathway and its complexity, addresses the justification for the use of IGF-1R-targeted therapy, and reviews the results of in vivo and in vitro novel therapeutics. Over the past year, the completion of several phase I, II, and III trials have provided interesting new information about the clinical activity of these novel compounds, particularly CP-751,871, IMC-A12, R1507, AMG-479, AVE-1642, MK-0646, XL-228, OSI-906, and BMS-754807. We review the important preliminary results from clinical trials with these compounds and conclude with a discussion about future therapeutic efforts.
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Affiliation(s)
- Erin R King
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Unit 1362, 1515 Holcombe Boulevard, Houston, Texas 77030, USA.
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133
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Wendler DS. Time to stop worrying about the therapeutic misconception. J Clin Ethics 2012; 23:272-287. [PMID: 23256408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Work on the therapeutic misconception suggests that investigators should ensure that potential research subjects understand the fundamental differences between clinical research and clinical care. Yet, what potential research subjects should understand depends on their circumstances and the study in question. This analysis implies that researchers and review committees should stop attempting to define, measure, and dispel the therapeutic misconception, and instead should focus on what potential subjects should understand to participate in individual studies.
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Affiliation(s)
- David S Wendler
- Department of Bioethics, National Institutes of Health Clinical Center, Bethesda, Maryland, USA.
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134
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Dainesi SM, Goldbaum M. [Clinical research as a strategy for health development]. Rev Assoc Med Bras (1992) 2012; 58:2-6. [PMID: 22392304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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135
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136
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Kurokawa T. [Recent efforts for the attainment of a single standard of clinical studies (intervention)]. Nihon Yakurigaku Zasshi 2011; 138:244-247. [PMID: 22156261 DOI: 10.1254/fpj.138.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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137
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Ichiki T. [The Asian Study Clinical Trial: a step towards introducing global standards for clinical research in Japan]. Nihon Yakurigaku Zasshi 2011; 138:248-251. [PMID: 22156262 DOI: 10.1254/fpj.138.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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138
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Abstract
OBJECTIVES The prognosis after Lyme neuroborreliosis (LNB) is debated. The aim of this study was to assess health-related Quality of Life (QoL) and neurological symptoms 30 months after treatment in European patients with LNB. MATERIALS AND METHODS In a prospective case-control designed study, we investigated 50 well-characterized patients with LNB who had participated in a treatment trial for LNB 30 months earlier and 50 matched control persons with the health QoL questionnaire Short-Form 36 (SF-36), the Fatigue Severity Scale (FSS), the Montgomery and Åsberg Depression Rating Scale (MADRS), the Starkstein Apathy Scale (SAS), and the Mini Mental State (MMS). Clinical and demographic data were collected by semi-structured interviews and clinical neurological examination. RESULTS Lyme neuroborreliosis-treated patients scored lower than control persons in the SF-36 domains physical component summary (PCS) (44 vs 51 P < 0.001) and mental component summary (MCS) (49 vs 54 P = 0.010). They also scored lower than control persons in all the SF-36 subscales, except for bodily pain, and on FSS (3.5 vs 2.1 P < 0.001), but not on MMS (28 vs 29 P = 0.106). There was a difference in MADRS (3.1 vs 0. 8 P = 0.003) and SAS (13 vs 11 P = 0.016), but the scores were low in both groups. Fatigue was the most frequently reported symptom among LNB-treated patients (50%). Patients who reported complete recovery (56%) after LNB had similar QoL scores as the controls. CONCLUSION European persons treated for LNB have poorer health-related QoL and have more fatigue than persons without LNB.
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Affiliation(s)
- R Eikeland
- Department of Neurology, Sørlandet Hospital, Arendal, Norway.
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139
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Ichimaru K. [Current situation and future perspective for clinical trials in Japan]. Rinsho Shinkeigaku 2011; 51:1085. [PMID: 22277488 DOI: 10.5692/clinicalneurol.51.1085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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140
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McMurdo MET, Roberts H, Parker S, Wyatt N, May H, Goodman C, Jackson S, Gladman J, O'Mahony S, Ali K, Dickinson E, Edison P, Dyer C. Improving recruitment of older people to research through good practice. Age Ageing 2011; 40:659-65. [PMID: 21911335 DOI: 10.1093/ageing/afr115] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is widespread evidence both of the exclusion of older people from clinical research, and of under-recruitment to clinical trials. This review and opinion piece provides practical advice to assist researchers both to adopt realistic, achievable recruitment rates and to increase the number of older people taking part in research. It analyses 14 consecutive recently published trials, providing the number needed to be screened to recruit one older participant (around 3:1), numbers excluded (up to 49%), drop out rates (5-37%) and whether the planned power was achieved. The value of planning and logistics are outlined, and approaches to optimising recruitment in hospital, primary care and care home settings are discussed, together with the challenges of involving older adults with mental incapacity and those from minority groups in research. The increasingly important task of engaging older members of the public and older patients in research is also discussed. Increasing the participation of older people in research will improve the generalisability of research findings and inform best practice in the clinical management of the growing older population.
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Affiliation(s)
- Marion E T McMurdo
- Ageing and Health, Ninewells Hospital and Medical School, University of Dundee, UK.
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141
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Abstract
Adipose tissue is an endocrine organ secreting biologically active factors called adipokines that act on both local and distant tissues. Adipokines have an important role in the development of obesity-related comorbidities not only in adults but also in children and adolescents. Retinol binding protein 4 (RBP4) is a recently identified adipokine suggested to link obesity with its comorbidities, especially insulin resistance, type 2 diabetes (T2D), and certain components of the metabolic syndrome. However, data, especially resulting from the clinical studies, are conflicting. In this review, we summarize up-to-date knowledge on RBP4's role in obesity, development of insulin resistance, and T2D. Special attention is given to studies on children and adolescents. We also discuss the role of possible confounding factors that should be taken into account when critically evaluating published studies or planning new studies on this exciting adipokine.
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Affiliation(s)
- Primoz Kotnik
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics and Adolescent Medicine, University of Ulm, Ulm, Germany
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142
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Lee J. Relocating abroad. FDA sends staff overseas to help monitor imports. Mod Healthc 2011; 41:32. [PMID: 22111150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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143
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144
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Abstract
More than 1 million people in the United States live with a spinal cord injury (SCI). Despite medical advances, many patients with SCIs still experience substantial neurological disability, with loss of motor, sensory, and autonomic function. Cell therapy is ideally suited to address the multifactorial nature of the secondary events following SCI. Remarkable advances in our understanding of the pathophysiology of SCI, structural and functional magnetic resonance imaging, image-guided micro-neurosurgical techniques, and transplantable cell biology have enabled the use of cell-based regenerative techniques in the clinic. It is important to note that there are more than a dozen recently completed, ongoing, or recruiting cell therapy clinical trials for SCI that reflect the views of many key stakeholders. The field of regenerative neuroscience has reached a stage in which the clinical trials are scientifically and ethically justified. Although experimental models and analysis methods and techniques continue to evolve, no model will completely replicate the human condition. It is recognized that more work with cervical models of contusive/compressive SCI are required in parallel with clinical trials. It is also important that the clinical translation of advances made through well-established and validated experimental approaches in animal models move forward to meet the compelling needs of individuals with SCI and to advance the field of regenerative neuroscience. However, it is imperative that such efforts at translation be done in the most rigorous and informed fashion to determine safety and possible efficacy, and to provide key information to clinicians and basic scientists, which will allow improvements in regenerative techniques and the validation and refinement of existing preclinical animal models and research approaches. The field of regenerative neuroscience should not be stalled at the animal model stage, but instead the clinical trials need to be focused, safe, and ethical, backed up by a robust, translationally relevant preclinical research strategy.
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Affiliation(s)
- Michael G. Fehlings
- University Health Network, Toronto Western Hospital, Toronto, ON M5T 2S8 Canada
| | - Reaz Vawda
- University Health Network, Toronto Western Hospital, Toronto, ON M5T 2S8 Canada
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145
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Abstract
The doctrine of informed consent in bioethics has relied on the view that consent is valid when it represents a patient or research subject's autonomous authorization. In this article we challenge this reigning conception of the validity of informed consent in clinical research, focusing in particular on the problem of the therapeutic misconception. We argue that the autonomous authorization model of informed consent suffers from four defects: (1) it fails to do justice to the relevance of risk-benefit considerations in shaping the criteria for the validity of consent, (2) it compromises the interests of subjects by preventing them from consenting to research participation with less than substantial understanding when doing so would likely be consistent with their preferences and beneficial to them or at least be unlikely to cause them harm, (3) it jeopardizes the interests of investigators by denying them fair notice regarding when the consent of research subjects can be considered valid and thus make it permissible for them to be enrolled in research, and (4) it threatens the reasonable limits on the responsibility of investigators to assure the adequacy of subjects' understanding of what research participation involves. In place of the autonomous authorization model, we present and defend a fair transaction model of informed consent, which better reflects the values served by consent.
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Affiliation(s)
- Franklin G Miller
- Department of Clinical Bioethics at the National Institutes of Health, USA
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146
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Goodman M, Bostick RM, Kucuk O, Jones DP. Clinical trials of antioxidants as cancer prevention agents: past, present, and future. Free Radic Biol Med 2011; 51:1068-84. [PMID: 21683786 DOI: 10.1016/j.freeradbiomed.2011.05.018] [Citation(s) in RCA: 153] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Revised: 05/09/2011] [Accepted: 05/17/2011] [Indexed: 02/07/2023]
Abstract
The purpose of this review is to summarize the most important human clinical trials of antioxidants as cancer prevention agents conducted to date, provide an overview of currently ongoing studies, and discuss future steps needed to advance research in this field. To date there have been several large (at least 7000 participants) trials testing the efficacy of antioxidant supplements in preventing cancer. The specific agents (diet-derived direct antioxidants and essential components of antioxidant enzymes) tested in those trials included β-carotene, vitamin E, vitamin C, selenium, retinol, zinc, riboflavin, and molybdenum. None of the completed trials produced convincing evidence to justify the use of traditional antioxidant-related vitamins or minerals for cancer prevention. Our search of ongoing trials identified six projects at various stages of completion. Five of those six trials use selenium as the intervention of interest delivered either alone or in combination with other agents. The lack of success to date can be explained by a variety of factors that need to be considered in the next generation research. These factors include lack of good biological rationale for selecting specific agents of interest; limited number of agents tested to date; use of pharmacological, rather than dietary, doses; and insufficient duration of intervention and follow-up. The latter consideration underscores the need for alternative endpoints that are associated with increased risk of neoplasia (i.e., biomarkers of risk), but are detectable prior to tumor occurrence. Although dietary antioxidants are a large and diverse group of compounds, only a small proportion of candidate agents have been tested. In summary, the strategy of focusing on large high-budget studies using cancer incidence as the endpoint and testing a relatively limited number of antioxidant agents has been largely unsuccessful. This lack of success in previous trials should not preclude us from seeking novel ways of preventing cancer by modulating oxidative balance. On the contrary, the well demonstrated mechanistic link between excessive oxidative stress and carcinogenesis underscores the need for new studies. It appears that future large-scale projects should be preceded by smaller, shorter, less expensive biomarker-based studies that can serve as a link from mechanistic and observational research to human cancer prevention trials. These relatively inexpensive studies would provide human experimental evidence for the likely efficacy, optimum dose, and long-term safety of the intervention of interest that would then guide the design of safe, more definitive large-scale trials.
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Affiliation(s)
- Michael Goodman
- Emory University Rollins School of Public Health, Atlanta, GA 30322, USA.
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147
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Arano I, Imaeda T. [Current and future views from pharmaceutical industry perspectives on development of antidepressants]. Nihon Shinkei Seishin Yakurigaku Zasshi 2011; 31:181-186. [PMID: 21941853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
It has recently become possible to conduct placebo-controlled clinical studies in Japan. However, worldwide, there has been much discussion of the problems in placebo-controlled studies, such as the fact that the increase in the placebo response in clinical studies in depression increases the risk of failed studies and the number of patients that need to be enrolled. Japan has been participating in more multinational studies aimed at obtaining simultaneous worldwide approval. This paper discusses an overview of the development of antidepressants and examples of research that has been conducted on the placebo response, and describes the controversy regarding the designs of future studies as well as the issues involved in Japanese participation in multinational studies.
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Affiliation(s)
- Ichiro Arano
- Pfizer Japan Inc., 3-22-7 Yoyogi, Shibuya-ku, Tokyo 151-8589, Japan.
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148
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Li J, Ng J, Allendorf J, Saif MW. Locally advanced pancreatic adenocarcinoma: are we making progress? Highlights from the "2011 ASCO Annual Meeting". Chicago, IL, USA; June 3-7, 2011. JOP 2011; 12:347-350. [PMID: 21737893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Pancreatic cancer, as the 4th leading cause of cancer death in the U.S., remains a challenging disease for all oncologists. Less than 20% of all cases could be potentially cured by surgical resection, while the majority of cases are deemed either unresectable or metastatic upon diagnosis. In this year's American Society of Clinical Oncology (ASCO) Annual Meeting, several studies were presented with novel approaches towards treating locally advanced pancreatic cancer. The LAP-07 study, a large phase III study with two separate randomizations, updated their accrual status, but with no interim data yet reported (Abstract #e14619). A single institutional review study reported its promising results on the incorporation of interferon to chemoradiation, but the toxicities could be concerning (Abstract #e14648). Abstract #e14607 demonstrated promising survival data from a tri-modality approach incorporating local and systemic chemotherapy concurrent with external beam radiation as well as radiofrequency ablation. The tolerability of sorafenib in locally advanced pancreatic cancer was shown in a small phase I study (Abstract #e14525). CyberKnife® stereotactic body radiation therapy was investigated as a modality for local palliation (Abstract #e14506). More effective therapeutic agents and approaches are still needed in this difficult disease. This highlight article will focus on the management of locally advanced pancreatic cancer.
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Affiliation(s)
- Jia Li
- VA Connecticut Healthcare System, Yale School of Medicine, Yale Cancer Center, West Haven, CT, USA
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149
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Bulters D, Kirkpatrick P. Intracranial cerebral revascularization. J Neurosurg Sci 2011; 55:97-105. [PMID: 21623322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Stroke is a heterogeneous disorder. A small number are due to hemodynamic insufficiency. In these cases, blood supply is sufficient at rest but unable to meet increased demand. This is demonstrated by loss of cerebrovascular reactivity (CVR) or increased oxygen extraction fraction (OEF). This may be improved by a superficial temporal artery to middle cerebral artery bypass. Whilst too small to completely replace cerebral blood supply, this is sufficient to augment existing blood flow to meet any increases in demand. Practically it has been difficult to demonstrate any reduction in stroke rate with intracranial revascularization. Only one of three randomized studies has shown a benefit. Two problems have been how hemodynamic insufficiency and symptomatic patients have been defined. Hemodynamic insufficiency can only be reliably demonstrated by changes in OEF and CVR. Symptomatic has traditionally described a patient who was had one or more strokes. However, in most cases these occur at the time of occlusion following which the patient remains stable. These patients are not necessarily at a high risk of future stroke as collaterals develop over time to compensate. We prefer to reserve the term symptomatic for those who have ongoing fluctuating symptoms after demonstration of carotid occlusion. This much smaller subset may still benefit from surgery in our view. Therefore although bypass surgery has relatively low morbidity, and high graft patency, extremely careful patient selection is essential for it to benefit patients, and unless there are both severe hemodynamic insufficiency and ongoing symptoms medical management is preferable.
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Affiliation(s)
- D Bulters
- Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK.
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150
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Wong GKC, Kwan MCL, Ng RYT, Yu SCH, Poon WS. Flow diverters for treatment of intracranial aneurysms: Current status and ongoing clinical trials. J Clin Neurosci 2011; 18:737-40. [PMID: 21514166 DOI: 10.1016/j.jocn.2010.10.011] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 10/22/2010] [Accepted: 10/22/2010] [Indexed: 12/01/2022]
Affiliation(s)
- George K C Wong
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
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