1
|
de Castro DRP, Castillo CHM, Ferreira JPD, Oliveira JPA, Kirsten TF, de França PHC, Zavalhia LS, Notti RK, Kochhann R, Amantéa SL. Ethical regulation of biomedical research in Brazil: a quality improvement initiative. BMC Med Ethics 2024; 25:68. [PMID: 38858731 PMCID: PMC11163760 DOI: 10.1186/s12910-024-01065-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/28/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Q-CEP (Qualificação dos Comitês de Ética em Pesquisa que compõem o Sistema CEP/Conep) is a nationwide project resulting from a partnership between the Brazilian National Research Ethics Commission (Conep), the Ministry of Health and Hospital Moinhos de Vento (HMV). It was developed to consolidate policy for ethical review of research with human beings in all members of the CEP/Conep System, Brazil's national system of institutional review boards. The aim of this study was therefore to report on the experience and results of the Q-CEP project. METHODS An observational, retrospective study includes data from the Q-CEP, obtained from visits to all the institutional research ethics committees (RECs) in the country. The actions implemented by Q-CEP were part of a two-step process: (i) training visits to each REC; (ii) development of distance learning modules on strategic topics pertaining to research ethics evaluation. The data presented herein cover step one (training visits), defined by Q-CEP as the diagnostic stage of the project. For a country with social and economics inequalities such as Brazil, this is a particularly important stage; an accurate picture of reality is needed to inform planning of quality improvement strategies. RESULTS In 2019-2021, Q-CEP visited 832 RECs and trained 11,197 people. This sample covered almost all active RECs in the country; only 4 (0.5%) were not evaluated. Of the 94 items evaluated, 62% did not reach the target of at least 80% compliance and around 1/4 (26%) were below 50% compliance. The diagnostic stage of the process revealed inadequacies on the part of the RECs in their ethical reviews. The analysis of informed consent forms showed compliance in only 131 RECs (15.74%). The description of pending issues made by RECs in their reports was compliant in 19.33% (n = 161). Administrative and operational aspects were also considered inadequate by more than half of the RECs. CONCLUSIONS Overall, Brazilian RECs showed poor compliance in several aspects of their operation, both in ethics evaluation and in other processes, which justifies additional training. The Q-CEP project is part of a quality improvement policy promoted by the Brazilian Ministry of Health. The data obtained in the diagnostic step of the project have contributed to the qualification and consolidation of one of the world's largest research ethics evaluation systems.
Collapse
Affiliation(s)
- Daniel Ribeiro Paes de Castro
- Comissão Nacional de Ética em Pesquisa (CONEP), SRTV 701, Via W 5 Norte, lote D - Edifício PO 700, Asa Norte, Brasília, 70719040, DF, Brazil
| | - Camilo Hernan Manchola Castillo
- Comissão Nacional de Ética em Pesquisa (CONEP), SRTV 701, Via W 5 Norte, lote D - Edifício PO 700, Asa Norte, Brasília, 70719040, DF, Brazil
| | - João Paulo Dias Ferreira
- Comissão Nacional de Ética em Pesquisa (CONEP), SRTV 701, Via W 5 Norte, lote D - Edifício PO 700, Asa Norte, Brasília, 70719040, DF, Brazil
| | - João Paulo Alves Oliveira
- Comissão Nacional de Ética em Pesquisa (CONEP), SRTV 701, Via W 5 Norte, lote D - Edifício PO 700, Asa Norte, Brasília, 70719040, DF, Brazil
| | - Tassila Fernandes Kirsten
- Comissão Nacional de Ética em Pesquisa (CONEP), SRTV 701, Via W 5 Norte, lote D - Edifício PO 700, Asa Norte, Brasília, 70719040, DF, Brazil
| | - Paulo Henrique Condeixa de França
- Comissão Nacional de Ética em Pesquisa (CONEP), SRTV 701, Via W 5 Norte, lote D - Edifício PO 700, Asa Norte, Brasília, 70719040, DF, Brazil
| | | | - Regina Kuhmmer Notti
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, 90035000, RS, Brazil
| | - Renata Kochhann
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, 90035000, RS, Brazil
| | - Sérgio Luís Amantéa
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, 90035000, RS, Brazil.
- , Av Senador Tarso Dutra 161/1303, Porto Alegre, 90690-140, RS, Brazil.
| |
Collapse
|
2
|
Strohbehn GW, Stadler WM, Boonstra PS, Ratain MJ. Optimizing the doses of cancer drugs after usual dose finding. Clin Trials 2024; 21:340-349. [PMID: 38148731 DOI: 10.1177/17407745231213882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Since the middle of the 20th century, oncology's dose-finding paradigm has been oriented toward identifying a drug's maximum tolerated dose, which is then carried forward into phase 2 and 3 trials and clinical practice. For most modern precision medicines, however, maximum tolerated dose is far greater than the minimum dose needed to achieve maximal benefit, leading to unnecessary side effects. Regulatory change may decrease maximum tolerated dose's predominance by enforcing dose optimization of new drugs. Dozens of already approved cancer drugs require re-evaluation, however, introducing a new methodologic and ethical challenge in cancer clinical trials. In this article, we assess the history and current landscape of cancer drug dose finding. We provide a set of strategic priorities for postapproval dose optimization trials of the future. We discuss ethical considerations for postapproval dose optimization trial design and review three major design strategies for these unique trials that would both adhere to ethical standards and benefit patients and funders. We close with a discussion of financial and reporting considerations in the realm of dose optimization. Taken together, we provide a comprehensive, bird's eye view of the postapproval dose optimization trial landscape and offer our thoughts on the next steps required of methodologies and regulatory and funding regimes.
Collapse
Affiliation(s)
- Garth W Strohbehn
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
- Division of Medical Oncology, Lieutenant Colonel Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Walter M Stadler
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Philip S Boonstra
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL, USA
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL, USA
| |
Collapse
|
3
|
Boonstra PS, Tabarrok A, Strohbehn GW. Targeted randomization dose optimization trials enable fractional dosing of scarce drugs. PLoS One 2023; 18:e0287511. [PMID: 37903093 PMCID: PMC10615276 DOI: 10.1371/journal.pone.0287511] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 06/07/2023] [Indexed: 11/01/2023] Open
Abstract
Administering drug at a dose lower than that used in pivotal clinical trials, known as fractional dosing, can stretch scarce resources. Implementing fractional dosing with confidence requires understanding a drug's dose-response relationship. Clinical trials aimed at describing dose-response in scarce, efficacious drugs risk underdosing, leading dose-finding trials to not be pursued despite their obvious potential benefit. We developed a new set of response-adaptive randomized dose-finding trials and demonstrate, in a series of simulated trials across diverse dose-response curves, these designs' efficiency in identifying the minimum dose that achieves satisfactory efficacy. Compared to conventional designs, these trials have higher probabilities of identifying lower doses while reducing the risks of both population- and subject-level underdosing. We strongly recommend that, upon demonstration of a drug's efficacy, pandemic drug development swiftly proceeds with response-adaptive dose-finding trials. This unified strategy ensures that scarce effective drugs produce maximum social benefits.
Collapse
Affiliation(s)
- Philip S. Boonstra
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, United States of America
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Alex Tabarrok
- Department of Economics, George Mason University, Fairfax, Virginia, United States of America
| | - Garth W. Strohbehn
- Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, United States of America
- Veterans Affairs Center for Clinical Management and Research, Ann Arbor, Michigan, United States of America
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
- Division of Medical Oncology, LTC Charles S Kettles VA Medical Center, Ann Arbor, Michigan, United States of America
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| |
Collapse
|
4
|
Armitage RC. Socially optimal dosing for scarce vaccines: Ethical analysis through the principlism framework. J Eval Clin Pract 2023; 29:1090-1094. [PMID: 37128128 DOI: 10.1111/jep.13850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/13/2023] [Indexed: 05/03/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Under conditions of vaccine scarcity, the socially optimal dosing (SOD) strategy administers a lower dose of vaccine to a larger number of people than the individually optimal dosing (IOD) strategy, which administers a higher dose of vaccine to a smaller number of people. In the context of vaccines that generate diminishing returns of effectiveness with each additional dose beyond the first, SOD therefore generates a greater total amount of vaccine-induced protection than IOD and, as such, constitutes the socially optimal strategy. While the clinical and public health arguments in favour of SOD have previously been outlined, this article conducts an ethical analysis of SOD for scarce vaccines through the ethical framework of principlism. METHODS SOD is examined with regard to each principle within the principlism framework-nonmaleficence, beneficence, autonomy, and justice. RESULTS SOD is found to satisfy each of the ethical requirements under examination. Regarding nonmaleficence, SOD induces less iatrogenic harm than IOD since the dose of vaccine administered to each individual is lower in the former than the latter. Furthermore, both the good and bad effects of SOD are foreseen while only the good effects are intended, meaning this strategy simultaneously satisfies the doctrine of double effect. Regarding autonomy, SOD makes vaccine-induced protection available to a greater number of individuals who wish to receive it, thereby respecting their capacity for self-determination and to make independent decisions. Regarding beneficence, SOD renders the good-namely the protection of health-more widely available to the individuals that constitute the population in question. Finally, SOD promotes theories of justice that treat individuals equally and is unlikely to reduce the effectiveness of other distribution policies that allocate scarce vaccines in a just manner. CONCLUSION In conditions of vaccine scarcity, SOD favourably satisfies the ethical framework of principlism.
Collapse
Affiliation(s)
- Richard C Armitage
- Academic Unit of Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| |
Collapse
|
5
|
Smith J, Boro E, Kwong EJL, Schmidt-Sane M. Resisting unchecked pragmatism in global health. Lancet Glob Health 2023:S2214-109X(23)00208-5. [PMID: 37329894 DOI: 10.1016/s2214-109x(23)00208-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/21/2023] [Accepted: 04/27/2023] [Indexed: 06/19/2023]
Affiliation(s)
- James Smith
- School of Advanced Study, University of London, London, UK; Institute of Epidemiology and Health Care, University College London, London WC1E 7HB, UK.
| | - Ezekiel Boro
- Faculty of Medicine, Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Edwin Jit Leung Kwong
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | | |
Collapse
|
6
|
Abstract
OBJECTIVE A deep understanding of the relationship between a scarce drug's dose and clinical response is necessary to appropriately distribute a supply-constrained drug along these lines. SUMMARY OF KEY DATA The vast majority of drug development and repurposing during the COVID-19 pandemic - an event that has made clear the ever-present scarcity in healthcare systems -has been ignorant of scarcity and dose optimisation's ability to help address it. CONCLUSIONS Future pandemic clinical trials systems should obtain dose optimisation data, as these appear necessary to enable appropriate scarce resource allocation according to societal values.
Collapse
Affiliation(s)
- Garth Strohbehn
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care, Ann Arbor, Michigan, USA
| | - Govind Persad
- Sturm College of Law, University of Denver, Denver, Colorado, USA
| | - William F Parker
- Maclean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - Srinivas Murthy
- Paediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
7
|
Alasmar A, Kong AC, So AD, DeCamp M. Ethical challenges in mass drug administration for reducing childhood mortality: a qualitative study. Infect Dis Poverty 2022; 11:99. [PMID: 36114588 PMCID: PMC9482260 DOI: 10.1186/s40249-022-01023-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Mass drug administration (MDA) of medications to entire at-risk communities or populations has shown promise in the control and elimination of global infectious diseases. MDA of the broad-spectrum antibiotic azithromycin has demonstrated the potential to reduce childhood mortality in children at risk of premature death in some global settings. However, MDA of antibiotics raises complex ethical challenges, including weighing near-term benefits against longer-term risks—particularly the development of antimicrobial resistance that could diminish antibiotic effectiveness for current or future generations. The aim of this study was to understand how key actors involved in MDA perceive the ethical challenges of MDA. Methods We conducted 35 semi-structured interviews from December 2020–February 2022 with investigators, funders, bioethicists, research ethics committee members, industry representatives, and others from both high-income countries (HICs) and low- and middle-income countries (LMICs). Interview participants were identified via one of seven MDA studies purposively chosen to represent diversity in terms of use of the antibiotic azithromycin; use of a primary mortality endpoint; and whether the study occurred in a high child mortality country. Data were analyzed using constructivist grounded theory methodology. Results The most frequently discussed ethical challenges related to meaningful community engagement, how to weigh risks and benefits, and the need to target MDA We developed a concept map of how participants considered ethical issues in MDA for child mortality; it emphasizes MDA’s place alongside other public health interventions, empowerment, and equity. Concerns over an ethical double standard in weighing risks and benefits emerged as a unifying theme, albeit one that participants interpreted in radically different ways. Some thought MDA for reducing child mortality was ethically obligatory; others suggested it was impermissible. Conclusions Ethical challenges raised by MDA of antibiotics for childhood mortality—which span socio-cultural issues, the environment, and effects on future generations—require consideration beyond traditional clinical trial review. The appropriate role of MDA also requires attention to concerns over ethical double standards and power dynamics in global health that affect how we view antibiotic use in HICs versus LMICs. Our findings suggest the need to develop additional, comprehensive guidance on managing ethical challenges in MDA. Graphical Abstract ![]()
Collapse
|
8
|
Ashuntantang G, Miljeteig I, Luyckx VA. Bedside rationing and moral distress in nephrologists in sub- Saharan Africa. BMC Nephrol 2022; 23:196. [PMID: 35614418 PMCID: PMC9131991 DOI: 10.1186/s12882-022-02827-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/11/2022] [Indexed: 11/11/2022] Open
Abstract
Background Kidney diseases constitute an important proportion of the non-communicable disease (NCD) burden in Sub-Saharan Africa (SSA), though prevention, diagnosis and treatment of kidney diseases are less prioritized in public health budgets than other high-burden NCDs. Dialysis is not considered cost-effective, and for those patients accessing the limited service available, high out-of-pocket expenses are common and few continue care over time. This study assessed challenges faced by nephrologists in SSA who manage patients needing dialysis. The specific focus was to investigate if and how physicians respond to bedside rationing situations. Methods A survey was conducted among a randomly selected group of nephrologists from SSA. The questionnaire was based on a previously validated survey instrument. A descriptive and narrative approach was used for analysis. Results Among 40 respondents, the majority saw patients weekly with acute kidney injury (AKI) or end-stage kidney failure (ESKF) in need of dialysis whom they could not dialyze. When dialysis was provided, clinical compromises were common, and 66% of nephrologists reported lack of basic diagnostics and medication and > 80% reported high out-of-pocket expenses for patients. Several patient-, disease- and institutional factors influenced who got access to dialysis. Patients’ financial constraints and poor chances of survival limited the likelihood of receiving dialysis (reported by 79 and 78% of nephrologists respectively), while a patient’s being the family bread-winner increased the likelihood (reported by 56%). Patient and institutional constraints resulted in most nephrologists (88%) frequently having to make difficult choices, sometimes having to choose between patients. Few reported existence of priority setting guidelines. Most nephrologists (74%) always, often or sometimes felt burdened by ethical dilemmas and worried about patients out of hospital hours. As a consequence, almost 46% of nephrologists reported frequently regretting their choice of profession and 26% had considered leaving the country. Conclusion Nephrologists in SSA face harsh priority setting at the bedside without available guidance. The moral distress is high. While publicly funded dialysis treatment might not be prioritized in essential health care packages on the path to universal health coverage, the suffering of the patients, families and the providers must be acknowledged and addressed to increase fairness in these decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02827-2.
Collapse
Affiliation(s)
- Gloria Ashuntantang
- Yaoundé General Hospital Faculty of Medicine & Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.,Faculty of Health Sciences, The University of Bamenda, Bamenda, Cameroon
| | - Ingrid Miljeteig
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway. .,Department of Research and Development, Helse Bergen Health Trust, Bergen, Norway.
| | - Valerie A Luyckx
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.,Renal Division, Brigham and Women's Hospital, Harvard medical School, Boston, MA, USA.,Department of Nephrology, University Children's Hospital, Zurich, Switzerland
| |
Collapse
|
9
|
Shinn M, Richard MK. Allocating Homeless Services After the Withdrawal of the Vulnerability Index-Service Prioritization Decision Assistance Tool. Am J Public Health 2022; 112:378-382. [PMID: 35196047 PMCID: PMC8887175 DOI: 10.2105/ajph.2021.306628] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Marybeth Shinn
- Marybeth Shinn and Molly K. Richard are with Peabody College, Vanderbilt University, Nashville, TN
| | - Molly K Richard
- Marybeth Shinn and Molly K. Richard are with Peabody College, Vanderbilt University, Nashville, TN
| |
Collapse
|
10
|
Persad G. Sustainability, equal treatment, and temporal neutrality. JOURNAL OF MEDICAL ETHICS 2021; 47:106-107. [PMID: 33455944 DOI: 10.1136/medethics-2020-107186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 12/24/2020] [Indexed: 06/12/2023]
Affiliation(s)
- Govind Persad
- Sturm College of Law, University of Denver, Denver, CO 80208, USA
| |
Collapse
|
11
|
Harvey M, Neff J, Knight KR, Mukherjee JS, Shamasunder S, Le PV, Tittle R, Jain Y, Carrasco H, Bernal-Serrano D, Goronga T, Holmes SM. Structural competency and global health education. Glob Public Health 2020; 17:341-362. [PMID: 33351721 DOI: 10.1080/17441692.2020.1864751] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Structural competency is a new curricular framework for training health professionals to recognise and respond to disease and its unequal distribution as the outcome of social structures, such as economic and legal systems, healthcare and taxation policies, and international institutions. While extensive global health research has linked social structures to the disproportionate burden of disease in the Global South, formal attempts to incorporate the structural competency framework into US-based global health education have not been described in the literature. This paper fills this gap by articulating five sub-competencies for structurally competent global health instruction. Authors drew on their experiences developing global health and structural competency curricula-and consulted relevant structural competency, global health, social science, social theory, and social determinants of health literatures. The five sub-competencies include: (1) Describe the role of social structures in producing and maintaining health inequities globally, (2) Identify the ways that structural inequalities are naturalised within the field of global health, (3) Discuss the impact of structures on the practice of global health, (4) Recognise structural interventions for addressing global health inequities, and (5) Apply the concept of structural humility in the context of global health.
Collapse
Affiliation(s)
- Michael Harvey
- College of Public Health, Temple University, Philadelphia, PA, USA
| | - Joshua Neff
- Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Kelly R Knight
- School of Medicine, University of California, San Francisco, CA, USA
| | - Joia S Mukherjee
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Sriram Shamasunder
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Phuoc V Le
- School of Medicine, University of California, San Francisco, CA, USA.,School of Public Health, University of California, Berkeley, CA, USA
| | - Robin Tittle
- Division of Hospital and Specialty Medicine, Portland VA Medical Center, Oregon Health and Sciences University, Portland, OR, USA
| | | | - Héctor Carrasco
- School of Medicine and Health Sciences, Tecnológico de Monterrey, Mexico City Campus, Mexico
| | - Daniel Bernal-Serrano
- School of Medicine and Health Sciences, Tecnológico de Monterrey, Mexico City Campus, Mexico
| | | | - Seth M Holmes
- Division of Society and Environment, Department of Environmental Science, Policy, and Management, University of California, Berkeley, CA, USA
| |
Collapse
|
12
|
Kallianpur AR, Wen W, Erwin AL, Clifford DB, Hulgan T, Robbins GK. Higher iron stores and the HFE 187C>G variant delay onset of peripheral neuropathy during combination antiretroviral therapy. PLoS One 2020; 15:e0239758. [PMID: 33057367 PMCID: PMC7561201 DOI: 10.1371/journal.pone.0239758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 09/13/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE People with HIV (PWH) continue to experience sensory neuropathy and neuropathic pain in the combination antiretroviral therapy (cART) era for unclear reasons. This study evaluated the role of iron in a previously reported association of iron-loading hemochromatosis (HFE) gene variants with reduced risk of neuropathy in PWH who received more neurotoxic cART, since an iron-related mechanism also might be relevant to neuropathic symptoms in PWH living in low-resource settings today. DESIGN This time-to-event analysis addressed the impact of systemic iron levels on the rapidity of neuropathy onset in PWH who initiated cART. METHODS Soluble transferrin receptor (sTFR), the sTFR-ferritin index of iron stores, and high-sensitivity C-reactive protein (hsCRP) levels were determined in stored baseline sera from participants of known HFE genotype from AIDS Clinical Trials Group (ACTG) Study 384, a multicenter randomized clinical trial that evaluated cART strategies. Associations with incident neuropathy were evaluated in proportional-hazards, time-to-event regression models, adjusting for potential confounders. RESULTS Of 151 eligible participants with stored serum who were included in the original genetic study, 43 had cART-associated neuropathy; 108 had sufficient serum for analysis, including 30 neuropathy cases. Carriers of HFE variants had higher systemic iron (lower sTFR and sTFR-ferritin index) and lower hsCRP levels than non-carriers (all p<0.05). Higher sTFR or iron stores, the HFE 187C>G variant, and lower baseline hsCRP were associated with significantly delayed neuropathy in self-reported whites (n = 28; all p-values<0.05), independent of age, CD4+ T-cell count, plasma HIV RNA, and cART regimen. CONCLUSIONS Higher iron stores, the HFE 187C>G variant, and lower hsCRP predicted delayed onset of neuropathy among self-reported white individuals initating cART. These findings require confirmation but may have implications for cART in HIV+ populations in areas with high endemic iron deficiency, especially those PWH in whom older, more neurotoxic antiretroviral drugs are occasionally still used.
Collapse
Affiliation(s)
- Asha R. Kallianpur
- Genomic Medicine Institute, Cleveland Clinic/Lerner Research Institute, Cleveland, Ohio, United States of America
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, United States of America
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
- * E-mail:
| | - Wanqing Wen
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Angelika L. Erwin
- Genomic Medicine Institute, Cleveland Clinic/Lerner Research Institute, Cleveland, Ohio, United States of America
| | - David B. Clifford
- Division of Infectious Diseases, Departments of Medicine and Neurology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Todd Hulgan
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Gregory K. Robbins
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| |
Collapse
|
13
|
Pollack EB, Mollura DR, Chong A, Harvey SC, Scheel JR. A Global Perspective on Screening. JOURNAL OF BREAST IMAGING 2020; 2:296-303. [PMID: 38424966 DOI: 10.1093/jbi/wbaa047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Indexed: 03/02/2024]
Abstract
Breast cancer is emerging as a major global public health problem. Incidence and mortality continues to rise in low- and middle-income countries (LMICs). A significant and growing disparity exists between high-income countries and LMICs in the availability of screening services and associated preventable mortality. However, population imaging-based screening programs are not appropriate for all settings. Planners should perform a thorough assessment of the target setting prior to implementing any breast cancer detection program, as appropriate guidelines vary according to the resources available. Financial, social, and cultural barriers to breast cancer care need to be addressed to sustainably improve the morbidity and mortality of the populations and make efficient use of available services. Creative approaches, such as mobile and portable imaging and bundling of services, can facilitate the installation of early breast cancer detection programs in LMICs. While image-based screening programs are not initially resource-appropriate in many LMICs, planners can work towards this goal as part of their comprehensive breast cancer detection strategy.
Collapse
Affiliation(s)
- Erica B Pollack
- Denver Health and Hospital Authority, Department of Radiology, Denver, CO
- RAD-AID International, Chevy Chase, MD
| | | | - Alice Chong
- RAD-AID International, Chevy Chase, MD
- University of California San Diego, Department of Radiology, San Diego, CA
| | - Susan C Harvey
- RAD-AID International, Chevy Chase, MD
- Hologic Inc., Department of Breast and Skeletal Health, Danbury, CT
| | - John R Scheel
- RAD-AID International, Chevy Chase, MD
- University of Washington, Department of Radiology, Seattle, WA
- University of Washington, Department of Global Health, Seattle, WA
| |
Collapse
|
14
|
Ao RF, Liang YX, Liu XQ, Tan K, Wang X, Liu D, Zhang T, Sun G, Xie J. Stavudine exposure results in developmental abnormalities by causing DNA damage, inhibiting cell proliferation and inducing apoptosis in mouse embryos. Toxicology 2020; 439:152443. [PMID: 32278789 DOI: 10.1016/j.tox.2020.152443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/17/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022]
Abstract
Stavudine is an anti-AIDS drug widely used to prevent HIV transmission from pregnant mothers to the fetuses in underdeveloped countries for its low price. However, there is still a controversy on whether stavudine affects embryo development. In the current study, embryotoxicity of stavudine was evaluated using cultured mouse embryos with the concentrations: 5, 10, 15 μM and vehicle control. The data indicated that the effect of stavudine was dose-dependent at early neurogenesis. Stavudine exposure reduced somite numbers, yolk sac diameter, crown-rump length, and increased the rate of embryonic degeneration compared with the control. We chose the lowest but clearly toxic concentration: 5 μM to investigate the molecular mechanisms of the damage. At the molecular level, stavudine produced DNA damage, increased the levels of the phospho-CHK1 and cleaved-caspase-3, and decreased the expression level of proliferating cell nuclear antigen. These changes indicated that stavudine caused a coordinated DNA damage response, inhibited cell proliferation, and induced apoptosis in the embryos. Collectively these results suggest that stavudine exposure disturbs the embryonic development, and its use in pregnant mothers should be re-examined.
Collapse
Affiliation(s)
- Rui-Fang Ao
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China
| | - Yu-Xiang Liang
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China
| | - Xiao-Qing Liu
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China
| | - Kui Tan
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China
| | - Xiaoling Wang
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China
| | - Dan Liu
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China
| | - Ting Zhang
- Capital Institute of Pediatrics, Beijing 100020, China.
| | - Gongqin Sun
- Department of Cell & Molecular Biology, University of Rhode Island, 389 CBLS Building, 120 Flagg Road, Kingston, RI, 02881, USA
| | - Jun Xie
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Shanxi Medical University, Taiyuan 030001, Shanxi, China.
| |
Collapse
|
15
|
Flood D, Wilcox K, Ferro AA, Mendoza Montano C, Barnoya J, Garcia P, Lou-Meda R, Rohloff P, Chary A. Challenges in the provision of kidney care at the largest public nephrology center in Guatemala: a qualitative study with health professionals. BMC Nephrol 2020; 21:71. [PMID: 32111173 PMCID: PMC7049202 DOI: 10.1186/s12882-020-01732-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/19/2020] [Indexed: 01/29/2023] Open
Abstract
Background Chronic kidney disease (CKD) is increasing worldwide, and the majority of the CKD burden is in low- and middle-income countries (LMICs). However, there is wide variability in global access to kidney care therapies such as dialysis and kidney transplantation. The challenges health professionals experience while providing kidney care in LMICs have not been well described. The goal of this study is to elicit health professionals’ perceptions of providing kidney care in a resource-constrained environment, strategies for dealing with resource limitations, and suggestions for improving kidney care in Guatemala. Methods Semi-structured interviews were performed with 21 health professionals recruited through convenience sampling at the largest public nephrology center in Guatemala. Health professionals included administrators, physicians, nurses, technicians, nutritionists, psychologists, laboratory personnel, and social workers. Interviews were recorded and transcribed in Spanish. Qualitative data from interviews were analyzed in NVivo using an inductive approach, allowing dominant themes to emerge from interview transcriptions. Results Health professionals most frequently described challenges in providing high-quality care due to resource limitations. Reducing the frequency of hemodialysis, encouraging patients to opt for peritoneal dialysis rather than hemodialysis, and allocating resources based on clinical acuity were common strategies for reconciling high demand and limited resources. Providers experienced significant emotional challenges related to high patient volume and difficult decisions on resource allocation, leading to burnout and moral distress. To improve care, respondents suggested increased budgets for equipment and personnel, investments in preventative services, and decentralization of services. Conclusions Health professionals at the largest public nephrology center in Guatemala described multiple strategies to meet the rising demand for renal replacement therapy. Due to systems-level limitations, health professionals faced difficult choices on the stewardship of resources that are linked to sentiments of burnout and moral distress. This study offers important lessons in Guatemala and other countries seeking to build capacity to scale-up kidney care.
Collapse
Affiliation(s)
- David Flood
- National Clinicians Scholars Program, Division of Hospital Medicine, University of Michigan, Ann Arbor, MI, USA.,Wuqu' Kawoq
- Maya Health Alliance, Tecpán, Guatemala
| | - Katharine Wilcox
- Wuqu' Kawoq
- Maya Health Alliance, Tecpán, Guatemala.,Weill Cornell School of Medicine, New York, USA
| | | | - Carlos Mendoza Montano
- Institute of Nutrition of Central America and Panama (Instituto de Nutrición de Centroamérica y Panamá, INCAP), Guatemala City, Guatemala
| | - Joaquin Barnoya
- Unit for Cardiovascular Surgery (Unidad de Cirugía Cardiovascular de Guatemala, UNICAR), Guatemala City, Guatemala.,Institute of Research and Higher Studies in Health Sciences (El Instituto de Investigación y Estudios Superiores en Ciencias de la Salud, IECIS), Rafael Landívar University, Guatemala City, Guatemala
| | - Pablo Garcia
- Division of Nephrology, Stanford University, Palo Alto, USA
| | - Randall Lou-Meda
- Foundation for Children with Renal Disease (Fundación para el Niño Enfermo Renal, FUNDANIER), Guatemala City, Guatemala
| | - Peter Rohloff
- Wuqu' Kawoq
- Maya Health Alliance, Tecpán, Guatemala.,Department of Medicine, Department of Global Health Equity, Brigham and Women's Hospital, Boston, USA
| | - Anita Chary
- Wuqu' Kawoq
- Maya Health Alliance, Tecpán, Guatemala. .,Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA.
| |
Collapse
|
16
|
Beran D, Hirsch IB, Yudkin JS. Why Are We Failing to Address the Issue of Access to Insulin? A National and Global Perspective. Diabetes Care 2018; 41:1125-1131. [PMID: 29784696 DOI: 10.2337/dc17-2123] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 03/19/2018] [Indexed: 02/03/2023]
Abstract
Insulin was discovered in 1921 and soon became widely available in high-income countries. However, many people currently in need of this life-saving medicine are unable to access it. This is a global phenomenon, impacting not only populations of low- and middle-income countries but low-income populations in the U.S. In the U.S., the rate of diabetic ketoacidosis remains high in certain subpopulations, the cost of insulin being the main precipitating factor. On a global level the main cause of mortality for a child with type 1 diabetes is a lack of access to insulin, and in sub-Saharan Africa the life expectancy of a child with type 1 diabetes can be as low as 1 year. One lens for considering the issue of access to health and medicines is to consider society as a three-legged stool. In this paradigm, the role of the public sector is to provide "protections" to the population it serves; the private sector is made up of "responsible businesses" that supply many of the goods and services people need; and the plural sector comprises communities and not-for-profits providing the "social affiliations" that are needed. For HIV/AIDS, each of these "legs" played a role in improving access. Civil society raised awareness of the issue and advocated for access to treatment. Governments provided funding and responses both nationally and globally. Finally, the private sector played its role, under pressure from civil society and governments, in lowering the price of medicines and developing programs to expand access. Here, we use this framework to describe the shortcomings in access to insulin from a U.S. and global perspective.
Collapse
Affiliation(s)
- David Beran
- Division of Tropical and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
| | | | | |
Collapse
|
17
|
Abstract
The number of patients requiring dialysis by 2030 is projected to double worldwide, with the largest increase expected in low- and middle-income countries (LMICs). Dialysis is seldom considered a high priority by health care funders, consequently, few LMICs develop policies regarding dialysis allocation. Dialysis facilities may exist, but access remains highly inequitable in LMICs. High out-of-pocket payments make dialysis unsustainable and plunge many families into poverty. Patients, families, and clinicians suffer significant emotional and moral distress from daily life-and-death decisions imposed by dialysis. The health system's obligation to provide financial risk protection is an important component of global and national strategies to achieve universal health coverage. An ethical imperative therefore exists to develop transparent dialysis priority-setting guidelines to facilitate public understanding and acceptance of the realistic limits within the health system, and facilitate fair allocation of scarce resources. In this article, we present ethical challenges faced by patients, families, clinicians, and policy makers where dialysis is not universally accessible and discuss the potential ethical consequences of various dialysis allocation strategies. Finally, we suggest an ethical framework for use in policy development for priority setting of dialysis care. The accountability for reasonableness framework is proposed as a procedurally fair decision-making, priority-setting process.
Collapse
|
18
|
Aebischer Perone S, Martinez E, du Mortier S, Rossi R, Pahud M, Urbaniak V, Chappuis F, Hagon O, Jacquérioz Bausch F, Beran D. Non-communicable diseases in humanitarian settings: ten essential questions. Confl Health 2017; 11:17. [PMID: 28932259 PMCID: PMC5602789 DOI: 10.1186/s13031-017-0119-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 07/19/2017] [Indexed: 11/10/2022] Open
Affiliation(s)
- S. Aebischer Perone
- Health Unit, International Committee of the Red Cross (ICRC), 19, avenue de la Paix, 1202 Geneva, Switzerland
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - E. Martinez
- Health Unit, International Committee of the Red Cross (ICRC), 19, avenue de la Paix, 1202 Geneva, Switzerland
| | - S. du Mortier
- Health Unit, International Committee of the Red Cross (ICRC), 19, avenue de la Paix, 1202 Geneva, Switzerland
| | - R. Rossi
- Health Unit, International Committee of the Red Cross (ICRC), 19, avenue de la Paix, 1202 Geneva, Switzerland
| | - M. Pahud
- Health Unit, International Committee of the Red Cross (ICRC), 19, avenue de la Paix, 1202 Geneva, Switzerland
| | - V. Urbaniak
- Health Unit, International Committee of the Red Cross (ICRC), 19, avenue de la Paix, 1202 Geneva, Switzerland
| | - F. Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - O. Hagon
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - F. Jacquérioz Bausch
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - D. Beran
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Rue Gabrielle-Perret-Gentil 6, 1205 Geneva, Switzerland
| |
Collapse
|
19
|
Akachi Y, Kruk ME. Quality of care: measuring a neglected driver of improved health. Bull World Health Organ 2017; 95:465-472. [PMID: 28603313 PMCID: PMC5463815 DOI: 10.2471/blt.16.180190] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 12/20/2016] [Accepted: 12/21/2016] [Indexed: 11/27/2022] Open
Abstract
The quality of care provided by health systems contributes towards efforts to reach sustainable development goal 3 on health and well-being. There is growing evidence that the impact of health interventions is undermined by poor quality of care in lower-income countries. Quality of care will also be crucial to the success of universal health coverage initiatives; citizens unhappy with the quality and scope of covered services are unlikely to support public financing of health care. Moreover, an ethical impetus exists to ensure that all people, including the poorest, obtain a minimum quality standard of care that is effective for improving health. However, the measurement of quality today in low- and middle-income countries is inadequate to the task. Health information systems provide incomplete and often unreliable data, and facility surveys collect too many indicators of uncertain utility, focus on a limited number of services and are quickly out of date. Existing measures poorly capture the process of care and the patient experience. Patient outcomes that are sensitive to health-care practices, a mainstay of quality assessment in high-income countries, are rarely collected. We propose six policy recommendations to improve quality-of-care measurement and amplify its policy impact: (i) redouble efforts to improve and institutionalize civil registration and vital statistics systems; (ii) reform facility surveys and strengthen routine information systems; (iii) innovate new quality measures for low-resource contexts; (iv) get the patient perspective on quality; (v) invest in national quality data; and (vi) translate quality evidence for policy impact.
Collapse
Affiliation(s)
- Yoko Akachi
- United Nations University World Institute for Development, Katajanokanlaituri 6B, FI-00160, Helsinki, Finland
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, United States of America
| |
Collapse
|
20
|
Smith J, Aloudat T. Dilemmas in access to medicines: a humanitarian perspective. Lancet 2017; 389:1007-1008. [PMID: 28290989 DOI: 10.1016/s0140-6736(17)30660-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 12/13/2016] [Indexed: 11/18/2022]
Affiliation(s)
- James Smith
- Médecins sans Frontières, 78 Rue de Lausanne, Geneva 1211, Switzerland.
| | - Tammam Aloudat
- Médecins sans Frontières, 78 Rue de Lausanne, Geneva 1211, Switzerland
| |
Collapse
|
21
|
Emanuel EJ, Persad G. Dilemmas in access to medicines: a humanitarian perspective - Authors' reply. Lancet 2017; 389:1008-1009. [PMID: 28290990 DOI: 10.1016/s0140-6736(17)30659-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 12/12/2016] [Indexed: 11/22/2022]
Affiliation(s)
- Ezekiel J Emanuel
- Department of Medical Ethics and Health Policy, Department of Health Care Management, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Govind Persad
- Department of Health Policy and Management and Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|