Clinical trial regulation in Argentina: overview and analysis of regulatory framework, use of existing tools, and researchers' perspectives to identify potential barriers

OBJECTIVE

To review and analyze the regulatory framework of clinical trial registration, use of existing tools (publicly accessible national/international registration databases), and users' perspectives to identify possible barriers to registration compliance by sponsors and researchers in Argentina.

METHODS

Internationally registered trials recruiting patients in Argentina were found through clincialtrials.gov and the International Clinical Trial Registration Platform (ICTRP) and compared with publically available clinical trials registered through the National Administration of Drugs, Foods, and Medical Devices (ANMAT). A questionnaire addressing hypothesized attitudinal, knowledge-related, idiomatic, technical, economic, and regulatory barriers that could discourage or impede registration of clinical trials was developed, and semi-structured, in-depth interviews were conducted with a purposively selected sample of researchers (investigators, sponsors, and monitors) in Argentina.

RESULTS

A response rate of 74.3% (n = 29) was achieved, and 27 interviews were ultimately used for analysis. Results suggested that the high proportion of foreign-sponsored or multinational trials (64.8% of all protocols approved by ANMAT from 1994-2006) may contribute to a communication gap between locally based investigators and foreign-based administrative officials. A lack of knowledge about available international registration tools and limited awareness of the importance of registration were also identified as limiting factors for local investigators and sponsors.

CONCLUSIONS

To increase compliance and promote clinical trial registration in Argentina, national health authorities, sponsors, and local investigators could take the following steps: implement a grassroots educational campaign to improve clinical trial regulation, support local investigator-sponsor-initiated clinical trials, and/or encourage local and regional scientific journal compliance with standards from the International Committee of Medical Journal Editors (ICMJE) and/or the World Association of Medical Editors (WAME).

Interactions between hypoxia and sewage-derived contaminants on gene expression in fish embryos

Fish embryos were used to evaluate the interaction among common environmental and chemical stressors found in urban coastal environments, namely hypoxia, aryl hydrocarbon receptor (AhR) agonists, and estrogenic compounds. At the molecular level, the systems responding to these stressors share common response factors, and evidence exists for cross-talk between them. Biomarkers of exposure to these stressors, cytochrome P4501a (Cyp1a), estrogen receptor alpha (ERα), brain cytochrome P450 aromatase (Cyp19a2 or AromB), and hypoxia inducible factor 1 alpha (Hif-1α) mRNA expression were examined using qRT-PCR simultaneously in embryos of two well studied species, the Atlantic killifish, Fundulus heteroclitus, and the zebrafish Danio rerio. Embryos of both species were exposed to the model Cyp1a inducer β-naphthoflavone (BNF) or 17-β estradiol (E2) under either normoxic or hypoxic (5% oxygen atmosphere) conditions and harvested prior to hatch at 9 days post fertilization (dpf) for the killifish, and 48h post fertilization (hpf) for the zebrafish. BNF significantly induced Cyp1a expression in embryos of both species with killifish embryos being more responsive (700-fold>control) than zebrafish embryos (7-100-fold>control). AromB was also significantly influenced by treatment, but to a lesser extent, with mean expression levels increased by less than two-fold over control values in response to E2, and in one case upregulated by BNF. ERα and Hif-1α were constitutively expressed in embryos of both species, but expression was unaffected by exposure to either BNF or E2. Hypoxic conditions downregulated AromB expression strongly in killifish but not in zebrafish embryos. The impact of hypoxia on expression of other genes in either species was inconsistent, although an interactive effect between hypoxia and BNF on several of the genes evaluated was observed. These data are the first to examine expression patterns of these important environmental response genes together in embryos of two important model fish species. The results support the use of Cyp1a expression as a biomarker of AhR agonists in fish embryos, and indicate that AromB may be more responsive than ERα to estrogenic chemicals at this stage in development. Hif-1α expression was not found to be a good biomarker of hypoxic exposure in either killifish or zebrafish embryos. The interaction observed between BNF and co-exposure to hypoxia warrants further investigation. Finally killifish embryos are generally more sensitive than zebrafish embryos at this stage of development supporting their use in environmental assessments.

Patient self-assessment of hospital pain, mood and health-related quality of life in adults with sickle cell disease

INTRODUCTION

Acute pain is a hallmark of sickle cell disease (SCD) for which frequent hospital admissions may be required, affecting the quality of life of patients.

OBJECTIVES

To characterise the relationship between adult patient self-reported sickle cell pain, mood and quality of life during and after hospital admissions.

DESIGN

Longitudinal study across three time-points.

SETTING

Secondary care, single specialist sickle cell centre.

PARTICIPANTS

510 adult patients with SCD admitted to hospital daycare or inpatient units.

OUTCOME MEASURES

Self-assessments of pain, mood and health-related quality of life with health utility (measured on the EQ-5D) on admission, before discharge and at 1-week postdischarge.

RESULTS

Mood, general health and quality of life showed significant steady improvements with reduction of pain in patients with SCD on admission to hospital, before discharge and at 1-week follow-up (p<0.01). Health utility scores derived from the EQ-5D showed a negative association with pain in regression analysis over the three time-points.

CONCLUSION

Examining health-related quality of life and health utility in relation to pain during hospital admissions is valuable in terms of targeting appropriate psychological interventions within the context of a multidisciplinary approach to managing sickle cell pain. This has implications for healthcare costs.

Mismatch Negativity and P300 to Behaviorally Perceptible and Imperceptible Frequency and Intensity Contrasts

Mismatch negativity and the P300 have been investigated as electrophysiological indices of behavioral auditory discrimination of duration. Using an oddball paradigm, responses were evoked to stimuli that had been behaviorally demonstrated to be either perceptible or imperceptible. The results indicated P300 events were present with the perceptible contrast but absent for the imperceptible contrast with all participants, while mismatch negativities were present in approximately 80 and 20% of participants to the perceptible and imperceptible contrasts, respectively. The present study extended the findings by applying the same paradigm to the discrimination of spectral and amplitude contrasts. 10 young adults with normal hearing were participants. Assuming that auditory assessment should involve representation and processing in all acoustic domains (i.e., temporal/duration, spectral/frequency and amplitude/intensity), the effects seen with temporal contrasts were predicted to be similar for spectral and amplitude contrasts. The findings generally illustrated that the P300 was more accurate than the mismatch negativity in reflecting behavioral discrimination. Together, these studies challenge the use of mismatch negativity as an electrophysiological correlate for behavioral discrimination of auditory perceptible contrasts.

Diabetes Medication Assistance Service Stage 1: impact and sustainability of glycaemic and lipids control in patients with Type 2 diabetes

AIMS

To investigate (i) optimal intensity (four visits vs. six visits) and duration (6 vs. 12 months) of the Diabetes Medication Assistance Service in community pharmacy and (ii) sustainability of improvements in patients' diabetes control associated with differing intensities of intervention.

METHODS

A national quota sample of 90 community pharmacies in Australia were randomly assigned into group 1 (6-month Diabetes Medication Assistance Service) or group 2 (12-month Diabetes Medication Assistance Service) and subsequently recruited a total of 524 patients. A wide range of clinical (HbA(1c) , blood pressure, lipids) and quality-of-life outcome measures were assessed.

RESULTS

The 6- and 12-month Diabetes Medication Assistance Service resulted in significant and similar reductions in HbA(1c) (-0.9 mmol/mol; 95% CI -0.7 to -1.1) -, total cholesterol (-0.3 mmol/l; 95% CI -0.1 to -0.4) and triglycerides (-0.3 mmol/l; 95% CI -0.1 to -0.5). There was also a significant reduction in the number of patients who were at risk of having a cardiovascular event in the next 10 years. For the subset of patients for whom data were available at baseline, completion and 18 months, improvements in HbA(1c) and total cholesterol were sustained at 18 months and triglycerides showed a further improvement at 18 months.

CONCLUSIONS

The Diabetes Medication Assistance Service resulted in significant improvements in diabetes control that were independent of intensity and duration of the service and showed evidence of being sustained at 18 months. The extent and sustainability of clinical improvements achieved by the Diabetes Medication Assistance Service, together with the resulting reduction in cardiovascular risk, should translate into future cost savings to healthcare systems by delaying and reducing diabetes-related complications.

Association of von Willebrand Factor Activity with ACE I/D and MTHFR C677T Polymorphisms in Migrainecha

Angiotensin-converting enzyme (ACE) insertion (I)/deletion (D) and methylene-tetrahydrofolate reductase (MTHFR) C677T polymorphisms are linked to endothelial dysfunction and to cerebral white matter lesions. Objectives of this study were to determine if ACE and MTHFR gene polymorphisms are associated with von Willebrand factor (vWF) activity, an endothelial dysfunction marker, and with a distinct headache phenotype. We enrolled 64 women (18–50 years old) with International Classification of Headache Disorders, 2nd edn migraine without aura (MoA) and 61 with aura (MA). Genotypic frequencies: ACE DD 35%, ID 42%, II 23%, and MTHFR TT 17%, CT 40%, CC 43%. Those with ACE DD genotype had higher levels of vWF activity (152%) compared with ID and II genotypes. Levels were highest (179%) with combined ACE DD and MTHFR TT genotypes. ACE DD was associated with higher headache frequency, and MTHFR TT was associated with MA. In migraine, vWF activity may be a marker of endothelial-mediated genetic risk for ischaemic conditions.

FDG-PET and MIBI-Tc SPECT as follow-up tools in a patient with cardiac sarcoidosis requiring a pacemaker

A 63-year-old man presented with recent-onset symptoms secondary to third-degree atrio-ventricular block, for which a dual-chamber pacemaker was inserted. Additional investigations resulted in the diagnosis of cardiac sarcoidosis. FDG-PET and MIBI-technetium SPECT were used as follow-up tools for monitoring active granulomatous myocardial infiltration.

A randomised controlled trial of cognitive behaviour therapy in adolescents with major depression treated by selective serotonin reuptake inhibitors. The ADAPT trial

OBJECTIVES

To determine if, in the short term, depressed adolescents attending routine NHS Child and Adolescent Mental Health Services (CAMHS), and receiving ongoing active clinical care, treatment with selective serotonin reuptake inhibitors (SSRIs) plus cognitive behaviour therapy (CBT) compared with SSRI alone, results in better healthcare outcomes.

DESIGN

A pragmatic randomised controlled trial (RCT) was conducted on depressed adolescents attending CAMHS who had not responded to a psychosocial brief initial intervention (BII) prior to randomisation.

SETTING

Six English CAMHS participated in the study.

PARTICIPANTS

A total of 208 patients aged between 11 and 17 years were recruited and randomised.

INTERVENTIONS

All participants received active routine clinical care in a CAMHS outpatient setting and an SSRI and half were offered CBT.

MAIN OUTCOME MEASURES

The duration of the trial was a 12-week treatment phase, followed by a 16-week maintenance phase. Follow-up assessments were at 6, 12 and 28 weeks. The primary outcome measure was the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). Secondary outcome measures were self-report depressive symptoms, interviewer-rated depressive signs and symptoms, interviewer-rated psychosocial impairment and clinical global impression of response to treatment. Information on resource use was collected in interview at baseline and at the 12- and 28-week follow-up assessments using the Child and Adolescent Service Use Schedule (CA-SUS).

RESULTS

Of the 208 patients randomised, 200 (96%) completed the trial to the primary end-point at 12 weeks. By the 28-week follow-up, 174 (84%) participants were re-evaluated. Overall, 193 (93%) participants had been assessed at one or more time points. Clinical characteristics indicated that the trial was conducted on a severely depressed group. There was significant recovery at all time points in both arms. The findings demonstrated no difference in treatment effectiveness for SSRI + CBT over SSRI only for the primary or secondary outcome measures at any time point. This lack of difference held when baseline and treatment characteristics where taken into account (age, sex, severity, co-morbid characteristics, quality and quantity of CBT treatment, number of clinic attendances). The SSRI + CBT group was somewhat more expensive over the 28 weeks than the SSRI-only group (p=0.057) and no more cost-effective. Over the trial period there was on average a decrease in suicidal thoughts and self-harm compared with levels recorded at baseline. There was no significant increase in disinhibition, irritability and violence compared with levels at baseline. Around 20% (n=40) of patients in the trial were non-responders. Of these, 17 (43%) showed no improvement by 28 weeks and 23 (57%) were considered minimally (n=10) or moderately to severely worse (n=13).

CONCLUSIONS

For moderately to severely depressed adolescents who are non-responsive to a BII, the addition of CBT to fluoxetine plus routine clinical care does not improve outcome or confer protective effects against adverse events and is not cost-effective. SSRIs (mostly fluoxetine) are not likely to result in harmful adverse effects. The findings are broadly consistent with existing guidelines on the treatment of moderate to severe depression. Modification is advised for those presenting with moderate (6-8 symptoms) to severe depressions (>8 symptoms) and in those with either overt suicidal risk and/or high levels of personal impairment. In such cases, the time allowed for response to psychosocial interventions should be no more than 2-4 weeks, after which fluoxetine should be prescribed. Further research should focus on evaluating the efficacy of specific psychological treatments against brief psychological intervention, determining the characteristics of patients with severe depression who are non-responsive to fluoxetine, relapse prevention in severe depression and improving tools for determining treatment responders and non-responders.

When would you like to be treated?--A short survey of radiotherapy outpatients

AIMS

To determine whether patients undergoing radiotherapy would choose to attend appointments for a course of treatment scheduled outside the normal working day and working week.

MATERIALS AND METHODS

A survey of radiotherapy outpatients was conducted on two single days in late 2005 and early 2006. There were four departments in the first cohort and five in the second cohort. Departments were selected from across the UK and were chosen to reflect both city centre and out of town locations. Six of the nine departments were working extended hours at the time of the survey. The second cohort received a modified questionnaire that included two additional questions relating to appointments at weekends.

RESULTS

In total, 471 and 332 questionnaires were returned by the first and second cohorts, respectively. For all age groups, 9.00 am to 12.00 pm was the most preferred time for treatment. Outside the normal working day, the 8.00-9.00 am interval was the most selected, being chosen by 23.4% of respondents. Overall, 32.8% (n=260) of respondents would attend a reasonable appointment time outside the normal working day and 10.7% (n=85) were unsure. On Saturdays, 39.3% (n=130) would attend and 11.5% (n=38) were unsure. For Sundays, 31.1% (n=103) would attend and 10.9% (n=36) were unsure.

CONCLUSIONS

There is sufficient support from patients for attendance outside the normal working day to ensure appointment slots would not go unfilled during a moderate extension to the working day. However, the percentage of patients that would attend varied between departments. This demonstrates the need for local evaluation of patient preference before the introduction of extended working hours.