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van Karnebeek CDM, Wortmann SB, Tarailo-Graovac M, Langeveld M, Ferreira CR, van de Kamp JM, Hollak CE, Wasserman WW, Waterham HR, Wevers RA, Haack TB, Wanders RJA, Boycott KM. The role of the clinician in the multi-omics era: are you ready? J Inherit Metab Dis 2018; 41:571-582. [PMID: 29362952 PMCID: PMC5959952 DOI: 10.1007/s10545-017-0128-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 12/10/2017] [Accepted: 12/12/2017] [Indexed: 12/11/2022]
Abstract
Since Garrod's first description of alkaptonuria in 1902, and newborn screening for phenylketonuria introduced in the 1960s, P4 medicine (preventive, predictive, personalized, and participatory) has been a reality for the clinician serving patients with inherited metabolic diseases. The era of high-throughput technologies promises to accelerate its scale dramatically. Genomics, transcriptomics, epigenomics, proteomics, glycomics, metabolomics, and lipidomics offer an amazing opportunity for holistic investigation and contextual pathophysiologic understanding of inherited metabolic diseases for precise diagnosis and tailored treatment. While each of the -omics technologies is important to systems biology, some are more mature than others. Exome sequencing is emerging as a reimbursed test in clinics around the world, and untargeted metabolomics has the potential to serve as a single biochemical testing platform. The challenge lies in the integration and cautious interpretation of these big data, with translation into clinically meaningful information and/or action for our patients. A daunting but exciting task for the clinician; we provide clinical cases to illustrate the importance of his/her role as the connector between physicians, laboratory experts and researchers in the basic, computer, and clinical sciences. Open collaborations, data sharing, functional assays, and model organisms play a key role in the validation of -omics discoveries. Having all the right expertise at the table when discussing the diagnostic approach and individualized management plan according to the information yielded by -omics investigations (e.g., actionable mutations, novel therapeutic interventions), is the stepping stone of P4 medicine. Patient participation and the adjustment of the medical team's plan to his/her and the family's wishes most certainly is the capstone. Are you ready?
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Affiliation(s)
- Clara D M van Karnebeek
- Department of Pediatrics and Clinical Genetics, Academic Medical Centre, Amsterdam, The Netherlands.
- Departments of Pediatrics, Centre for Molecular Medicine and Therapeutics, BC Children's Research Institute, University of British Columbia, Vancouver, BC, Canada.
- Deparment of Pediatrics (Room H7-224), Emma Children's Hospital, Academic Medical Centre, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Saskia B Wortmann
- Department of Pediatrics, Salzburger Landeskliniken (SALK) and Paracelsus Medical University (PMU), Salzburg, Austria
- Institute of Human Genetics, Helmholtz Zentrum München, Neuherberg, Germany
- Institute of Human Genetics, Technische Universität München, Munich, Germany
| | - Maja Tarailo-Graovac
- Departments of Pediatrics, Centre for Molecular Medicine and Therapeutics, BC Children's Research Institute, University of British Columbia, Vancouver, BC, Canada
- Departments of Medical Genetics, Centre for Molecular Medicine and Therapeutics, BC Children's Research Institute, Vancouver, BC, Canada
- Departments of Biochemistry, Molecular Biology, and Medical Genetics, Cumming School of Medicine, University of Calgary, Calgary, CA, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, CA, Canada
| | - Mirjam Langeveld
- Department of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands
| | - Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jiddeke M van de Kamp
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - Carla E Hollak
- Department of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands
| | - Wyeth W Wasserman
- Departments of Pediatrics, Centre for Molecular Medicine and Therapeutics, BC Children's Research Institute, University of British Columbia, Vancouver, BC, Canada
- Departments of Medical Genetics, Centre for Molecular Medicine and Therapeutics, BC Children's Research Institute, Vancouver, BC, Canada
| | - Hans R Waterham
- Laboratory Genetic Metabolic Diseases, Department of Clinical Chemistry, Laboratory Division & Department of Pediatrics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Ron A Wevers
- Department of Laboratory Medicine, Translational Metabolic Laboratory, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Tobias B Haack
- Institute of Medical Genetics and Applied Genomics, University of Tuebingen, Tuebingen, Germany
| | - Ronald J A Wanders
- Laboratory Genetic Metabolic Diseases, Department of Clinical Chemistry, Laboratory Division & Department of Pediatrics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Kym M Boycott
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Canada
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Affiliation(s)
- Sandra Sirrs
- Division of Endocrinology, Department of Medicine, University of British Columbia, Vancouver, Canada.
- Adult Metabolic Diseases Clinic, Vancouver General Hospital, Level 4 - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - Larry Lynd
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
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Neugebauer EAM, Rath A, Antoine SL, Eikermann M, Seidel D, Koenen C, Jacobs E, Pieper D, Laville M, Pitel S, Martinho C, Djurisic S, Demotes-Mainard J, Kubiak C, Bertele V, Jakobsen JC, Garattini S, Gluud C. Specific barriers to the conduct of randomised clinical trials on medical devices. Trials 2017; 18:427. [PMID: 28903769 PMCID: PMC5597993 DOI: 10.1186/s13063-017-2168-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 08/30/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Medical devices play an important role in the diagnosis, prevention, treatment and care of diseases. However, compared to pharmaceuticals, there is no rigorous formal regulation for demonstration of benefits and exclusion of harms to patients. The medical device industry argues that the classical evidence hierarchy cannot be applied for medical devices, as randomised clinical trials are impossible to perform. This article aims to identify the barriers for randomised clinical trials on medical devices. METHODS Systematic literature searches without meta-analysis and internal European Clinical Research Infrastructure Network (ECRIN) communications taking place during face-to-face meetings and telephone conferences from 2013 to 2017 within the context of the ECRIN Integrating Activity (ECRIN-IA) project. RESULTS In addition to the barriers that exist for all trials, we identified three major barriers for randomised clinical trials on medical devices, namely: (1) randomisation, including timing of assessment, acceptability, blinding, choice of the comparator group and considerations on the learning curve; (2) difficulties in determining appropriate outcomes; and (3) the lack of scientific advice, regulations and transparency. CONCLUSIONS The present review offers potential solutions to break down the barriers identified, and argues for applying the randomised clinical trial design when assessing the benefits and harms of medical devices.
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Affiliation(s)
- Edmund A M Neugebauer
- Brandenburg Medical School Theodor Fontane & Health Services Research Witten/Herdecke University, Campus Neuruppin, Neuruppin, Germany
| | - Ana Rath
- Orphanet, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Sunya-Lee Antoine
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Michaela Eikermann
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Doerthe Seidel
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Carsten Koenen
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Esther Jacobs
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Martine Laville
- Centre de Recherche en Nutrition Humaine Rhone-Alpes, Université de Lyon 1, Hospices Civils de Lyon, Groupement Hospitaler Sud, Pierre Benite, France
| | | | | | - Snezana Djurisic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | | | - Christine Kubiak
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
| | - Vittorio Bertele
- IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
| | - Silvio Garattini
- IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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Laville M, Segrestin B, Alligier M, Ruano-Rodríguez C, Serra-Majem L, Hiesmayr M, Schols A, La Vecchia C, Boirie Y, Rath A, Neugebauer EAM, Garattini S, Bertele V, Kubiak C, Demotes-Mainard J, Jakobsen JC, Djurisic S, Gluud C. Evidence-based practice within nutrition: what are the barriers for improving the evidence and how can they be dealt with? Trials 2017; 18:425. [PMID: 28893297 PMCID: PMC5594518 DOI: 10.1186/s13063-017-2160-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 08/24/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Evidence-based clinical research poses special barriers in the field of nutrition. The present review summarises the main barriers to research in the field of nutrition that are not common to all randomised clinical trials or trials on rare diseases and highlights opportunities for improvements. METHODS Systematic academic literature searches and internal European Clinical Research Infrastructure Network (ECRIN) communications during face-to-face meetings and telephone conferences from 2013 to 2017 within the context of the ECRIN Integrating Activity (ECRIN-IA) project. RESULTS Many nutrients occur in multiple forms that differ in biological activity, and several factors can alter their bioavailability which raises barriers to their assessment. These include specific difficulties with blinding procedures, with assessments of dietary intake, and with selecting appropriate outcomes as patient-centred outcomes may occur decennia into the future. The methodologies and regulations for drug trials are, however, applicable to nutrition trials. CONCLUSIONS Research on clinical nutrition should start by collecting clinical data systematically in databases and registries. Measurable patient-centred outcomes and appropriate study designs are needed. International cooperation and multistakeholder engagement are key for success.
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Affiliation(s)
- Martine Laville
- Centre de Recherche en Nutrition Humaine Rhone-Alpes, French Obesity Centre of Excellence (FCRIN-FORCE), Lyon 1 University, Hospices Civils de Lyon, Lyon, France
| | - Berenice Segrestin
- Centre de Recherche en Nutrition Humaine Rhone-Alpes, French Obesity Centre of Excellence (FCRIN-FORCE), Lyon 1 University, Hospices Civils de Lyon, Lyon, France
| | - Maud Alligier
- Centre de Recherche en Nutrition Humaine Rhone-Alpes, French Obesity Centre of Excellence (FCRIN-FORCE), Lyon 1 University, Hospices Civils de Lyon, Lyon, France
| | - Cristina Ruano-Rodríguez
- Nutrition Research Group, Research Institute of Biomedical and Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain.,Ciber Fisiopatología Obesidad y Nutrición (CIBEROBN, CB06/03), Instituto de Salud Carlos III (ISCII), Spanish Goverment, Madrid, Spain
| | - Lluis Serra-Majem
- Nutrition Research Group, Research Institute of Biomedical and Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain.,Ciber Fisiopatología Obesidad y Nutrición (CIBEROBN, CB06/03), Instituto de Salud Carlos III (ISCII), Spanish Goverment, Madrid, Spain
| | - Michael Hiesmayr
- Division of Cardiac, Thoracic, Vascular Anaesthesia and Intensive Care, Vienna General Hospital, Währinger Gürtel, Vienna, Austria
| | - Annemie Schols
- Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Carlo La Vecchia
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano Via Vanzetti, Milan, Italy
| | - Yves Boirie
- Service de Nutrition Clinique, CHU de Clermont-Ferrand, Unité de Nutrition Humaine, Clermont-Ferrand, France
| | - Ana Rath
- Orphanet, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Edmund A M Neugebauer
- Brandenburg Medical School, Neuruppin, and Witten/Herdecke University, Witten, Germany
| | - Silvio Garattini
- IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Vittorio Bertele
- IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Christine Kubiak
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
| | | | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK 2100, Copenhagen, Denmark.,Department of Cardiology, Holbæk Hospital, Holbaek, Denmark
| | - Snezana Djurisic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK 2100, Copenhagen, Denmark.
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK 2100, Copenhagen, Denmark.
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55
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Djurisic S, Rath A, Gaber S, Garattini S, Bertele V, Ngwabyt SN, Hivert V, Neugebauer EAM, Laville M, Hiesmayr M, Demotes-Mainard J, Kubiak C, Jakobsen JC, Gluud C. Barriers to the conduct of randomised clinical trials within all disease areas. Trials 2017; 18:360. [PMID: 28764809 PMCID: PMC5539637 DOI: 10.1186/s13063-017-2099-9] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/12/2017] [Indexed: 12/15/2022] Open
Abstract
Background Randomised clinical trials are key to advancing medical knowledge and to enhancing patient care, but major barriers to their conduct exist. The present paper presents some of these barriers. Methods We performed systematic literature searches and internal European Clinical Research Infrastructure Network (ECRIN) communications during face-to-face meetings and telephone conferences from 2013 to 2017 within the context of the ECRIN Integrating Activity (ECRIN-IA) project. Results The following barriers to randomised clinical trials were identified: inadequate knowledge of clinical research and trial methodology; lack of funding; excessive monitoring; restrictive privacy law and lack of transparency; complex regulatory requirements; and inadequate infrastructures. There is a need for more pragmatic randomised clinical trials conducted with low risks of systematic and random errors, and multinational cooperation is essential. Conclusions The present paper presents major barriers to randomised clinical trials. It also underlines the value of using a pan-European-distributed infrastructure to help investigators overcome barriers for multi-country trials in any disease area. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2099-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Snezana Djurisic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Ana Rath
- Orphanet, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Sabrina Gaber
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
| | - Silvio Garattini
- IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Vittorio Bertele
- IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Sandra-Nadia Ngwabyt
- Orphanet, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | | | - Edmund A M Neugebauer
- Brandenburg Medical School, Neuruppin, and Witten/Herdecke University, Witten, Germany
| | - Martine Laville
- Centre de Recherche en Nutrition Humaine Rhone-Alpes, Université de Lyon 1, Hospices Civils de Lyon, Groupement Hospitaler Sud, Pierre Benite, France
| | - Michael Hiesmayr
- Division of Cardiac, Thoracic, Vascular Anaesthesia and Intensive Care, Vienna General Hospital Währinger Gürtel, Vienna, Austria
| | | | - Christine Kubiak
- European Clinical Research Infrastructure Network (ECRIN), Paris, France
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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