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Songstad NT, Roberts CT, Manley BJ, Owen LS, Davis PG. Retrospective Consent in a Neonatal Randomized Controlled Trial. Pediatrics 2018; 141:peds.2017-2092. [PMID: 29288162 DOI: 10.1542/peds.2017-2092] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The requirement for prospective consent in clinical trials in acute settings may result in samples unrepresentative of the study population, potentially altering study findings. However, using retrospective consent may raise ethical issues. We assessed whether using retrospective consent affected recruitment, participant characteristics, and outcomes within a randomized controlled trial. METHODS We conducted a secondary analysis of a randomized trial, which compared nasal high flow (nHF) with nasal continuous positive airway pressure (CPAP) for primary respiratory support in preterm infants. In Era 1, all infants were consented prospectively; in Era 2, retrospective consent was available. We assessed inclusion rates of eligible infants, demographic data, and primary trial outcome (treatment failure within 72 hours). RESULTS In Era 1, recruitment of eligible infants was lower than in Era 2: 111 of 220 (50%) versus 171 of 209 (82%), P < .001; intrapartum antibiotic administration was lower: 23 of 111 (21%) versus 84 of 165 (51%), P < .001; full courses of antenatal steroids were higher: 86 of 111 (78%) versus 103 of 170 (61%), P = .004; and more infants received pre-randomization CPAP: 77 of 111 (69%) versus 48 of 171 (28%), P < .001. In Era 1, nHF failure (15 of 56, 27%) and CPAP failure (14 of 55, 26%) rates were similar, P = .9. In Era 2, failure rates differed: 24 of 85 (28%) nHF infants versus 13 of 86 (15%) CPAP infants, P = .04. The χ2 interaction test was nonsignificant (P = .20). CONCLUSIONS The use of retrospective consent resulted in greater recruitment and differences in risk factors between eras. Using retrospective consent altered the study sample, which may be more representative of the whole population. This may improve scientific validity but requires further ethical evaluation.
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Affiliation(s)
- Nils T Songstad
- Newborn Research Centre and .,Department of Pediatrics and Adolescent Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Calum T Roberts
- Newborn Research Centre and.,Neonatal Services, The Royal Women's Hospital, Melbourne, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; and
| | - Brett J Manley
- Newborn Research Centre and.,Neonatal Services, The Royal Women's Hospital, Melbourne, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; and
| | - Louise S Owen
- Newborn Research Centre and.,Neonatal Services, The Royal Women's Hospital, Melbourne, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; and.,Murdoch Children's Research Institute, Melbourne, Australia
| | - Peter G Davis
- Newborn Research Centre and.,Neonatal Services, The Royal Women's Hospital, Melbourne, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; and.,Murdoch Children's Research Institute, Melbourne, Australia
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Palmer S, Pudwell J, Smith GN, Reid RL. Optimizing Participation of Pregnant Women in Clinical Trials: Factors Influencing Decisions About Participation in Medication and Vaccine Trials. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:945-954. [PMID: 27720094 DOI: 10.1016/j.jogc.2016.04.100] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/13/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To obtain information on women's attitudes and opinions about participation in vaccine and medication trials during pregnancy. METHODS A quantitative, cross-sectional survey was administered to 110 consenting women over a four-week period in the waiting room of an ambulatory obstetrics and gynaecology clinic in Ontario. RESULTS The final response rate was 74.8%, with the majority of participants agreeing with statements about the importance of obtaining safety data about products in pregnancy and the importance of a woman having the ability to choose whether to participate in such research. Of all participants, 16.3% indicated they would consider participating in vaccine research during pregnancy and 20.0% would consider participating in medication research during pregnancy. Factors relating to maternal or fetal/child health were the most frequently cited factors influencing willingness to participate, with lack of trust in researchers and pharmaceutical companies as factors that would discourage participation. CONCLUSION A minority of pregnant women were willing to consider participating in medication or vaccine research during pregnancy. Optimizing participation requires providing women (and if appropriate, their partners) with detailed, multidisciplinary education about the maternal and fetal benefits and risks of such trials. Education about the principles of research ethics, including the limits of involvement of pharmaceutical companies, would be beneficial.
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Affiliation(s)
- Sophie Palmer
- Queen's School of Medicine, Faculty of Health Sciences, Queen's University, Kingston ON
| | - Jessica Pudwell
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Queen's University, Kingston ON
| | - Graeme N Smith
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Heath Sciences, Queen's University, Kingston ON
| | - Robert L Reid
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Queen's University, Kingston ON
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Feasibility of evaluating treatment of early hypotension in extremely low birth weight infants. J Pediatr 2012; 161:4-7. [PMID: 22484355 DOI: 10.1016/j.jpeds.2012.02.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Accepted: 02/20/2012] [Indexed: 11/23/2022]
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Stark AR, Tyson JE, Hibberd PL. Variation among institutional review boards in evaluating the design of a multicenter randomized trial. J Perinatol 2010; 30:163-9. [PMID: 19798046 PMCID: PMC2924664 DOI: 10.1038/jp.2009.157] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The objective of the study was to examine the variation among institutional review boards (IRBs) in evaluation of the study design of a multicenter trial. STUDY DESIGN We assessed the first written response of local IRBs to each site investigator for a multicenter trial of vitamin A supplementation in extremely low birth weight (ELBW) infants performed by the National Institute of Child Health and Human Development Neonatal Research Network. Each author of this paper independently reviewed and categorized IRB concerns as major, minor or none, according to the predefined criteria. RESULT Initially, 9 of 18 IRBs withheld approval because of at least one major concern. These concerns reflected difficulties in evaluating specific scientific issues for the design of the trial, including its justification, enrollment criteria, control and experimental therapies, co-interventions, toxicity assessment, outcome monitoring and informed consent. CONCLUSION The difficulty in assessing appropriate trial design for the specific hypothesis under investigation resulted in considerable variability in the evaluation by local IRBs.
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Affiliation(s)
- AR Stark
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Houston, TX, USA
| | - JE Tyson
- Center for Clinical Research and Evidence Based Medicine, University of Texas Health Science Center at Houston Medical School, Houston, TX, USA
| | - PL Hibberd
- Center for Global Health Research, Tufts University School of Medicine, Boston, MA, USA
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Slomka J. Manufacturing mistrust: issues in the controversy regarding foster children in the pediatric HIV/AIDS clinical trials. SCIENCE AND ENGINEERING ETHICS 2009; 15:503-516. [PMID: 19859829 DOI: 10.1007/s11948-009-9179-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Accepted: 09/21/2009] [Indexed: 05/28/2023]
Abstract
The use of foster children as subjects in the pediatric HIV/AIDS clinical trials has been the subject of media controversy, raising a range of ethical and social dimensions. Several unsettled issues and debates in research ethics underlie the controversy and the lack of consensus among professional researchers on these issues was neither adequately appreciated nor presented in media reports. These issues include (1) the tension between protecting subjects from research risk while allowing them access to the possible benefits of research; (2) the blurring of the potentially conflicting roles of investigator and physician and the boundaries between research and therapy; (3) the adequacy of Institutional Review Board oversight; and (4) trust and the relationships among physicians, investigators and industry. The media controversy about the pediatric HIV/AIDS clinical trials can be seen as a means of "manufacturing mistrust" in health care, research and social services that have not always met the needs and expectations of the public. In an era of emerging infections, it is critical to the public's health that people understand the role of rigorous and ethical research in the development of safe and effective care. Investigators, journalists and the public need to become knowledgeable about major ethical issues in the conduct of research in order to engage in dialogue about balancing research risks and benefits and to be able to distinguish fact from distortion in an era of multiple and rapid transmission of information.
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Affiliation(s)
- Jacquelyn Slomka
- Division of Health Promotion and Behavioral Sciences, School of Public Health,UCT 2530, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA.
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Ambalavanan N, Kennedy K, Tyson J, Carlo WA. Survey of vitamin A supplementation for extremely-low-birth-weight infants: is clinical practice consistent with the evidence? J Pediatr 2004; 145:304-7. [PMID: 15343179 DOI: 10.1016/j.jpeds.2004.04.046] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To survey the attitudes and practices among level III neonatal intensive care units in the United States regarding vitamin A supplementation for extremely-low-birth-weight (ELBW; birth weight < or =1000 g) infants. Study design A pretested questionnaire regarding vitamin A supplementation was distributed to all (n=102) neonatal-perinatal training program directors (TPD) and 105 randomly selected directors of level III neonatal intensive care units (nontraining program directors, NTPD). RESULTS Ninety-nine percent of TPD and 94% of NTPD responded. In a minority of programs (20% TPD, 13% NTPD), >90% of eligible extremely-low-birth-weight neonates are supplemented with vitamin A, whereas in most programs (69% TPD, 82% NTPD), routine supplementation is not practiced. Most centers (91% TPD, 81% NTPD) supplementing vitamin A use a dose of 5000 IU IM 3 times per week for 4 weeks. The most common reason that TPD give for not supplementing vitamin A is the perceived small benefit, whereas the most common reason for NTPD is that they consider the intervention unproven. CONCLUSIONS These findings indicate inconsistency in practicing evidence-based medicine in neonatal practice, where therapies are often administered on the basis of weaker evidence of safety and benefit than supports vitamin A supplementation. Educational interventions may be required to endorse the benefits and safety of vitamin A supplementation.
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Affiliation(s)
- Namasivayam Ambalavanan
- Department of Pediatrics, University of Alabama at Birmingham, 619 South 20th Street, Birmingham, AL 35249, USA.
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Sokol GM, Ehrenkranz RA. Inhaled nitric oxide therapy in neonatal hypoxic respiratory failure: insights beyond primary outcomes. Semin Perinatol 2003; 27:311-9. [PMID: 14510322 DOI: 10.1016/s0146-0005(03)00043-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Neonatal Research Network developed and initiated 3 multicenter randomized controlled clinical trials evaluating inhaled nitric oxide therapy. Additional projects evolved from these efforts including basic science research and observational investigations. This article provides a historical prospective of the Network's investigations related to the diagnosis and management of neonatal hypoxic respiratory failure, especially those related to inhaled nitric oxide therapy. It will review the Network's contributions toward advancing the clinical care of the newborn with severe hypoxic respiratory failure.
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Affiliation(s)
- Gregory M Sokol
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202-5271, USA.
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Abstract
The care of extremely premature infants involves a number of complex clinical and ethical issues. The ethical and scientific quality of decisions made in the care of these infants has profound long-term consequences for these infants and their families. In circumstances when it is unclear whether intensive care should be initiated or continued, evidence-based ethics provides an approach to facilitate treatment decisions that over time will be progressively better informed, better justified, and more broadly acceptable to parents, caregivers, and the general public.
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Affiliation(s)
- Jon E Tyson
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas-Houston Medical School, 6431 Fannin Street, MSB 2.106, Houston, TX 77030, USA
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Van Reempts PJ, Van Acker KJ. Ethical aspects of cardiopulmonary resuscitation in premature neonates: where do we stand? Resuscitation 2001; 51:225-32. [PMID: 11738771 DOI: 10.1016/s0300-9572(01)00427-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Advances in diagnosis, techniques, therapeutic interventions, organisation of perinatal care, and socio-economic factors have all contributed to the survival after resuscitation and intensive care of neonates with extremely low birth weight and gestational age. While morbidity during the first years of life in those infants does not increase, at school age multiple dysfunctions may become apparent. What are the limits of intensive care for the newborn? Is it right to use extreme technical and economic measures for neonates with a borderline chance of survival? What is justifiable for the neonate, the family, the society and how does legislation interfere in a decision process which involves starting, stopping or continuing intensive care? A short historical overview for the care of the newborn is given, followed by the outcome after resuscitation and treatment of the very low birth weight infant. Published management strategies and recommendations are discussed.
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Affiliation(s)
- P J Van Reempts
- Department of Pediatrics, Division of Neonatology, University Hospital Antwerp, Wilrijkstraat 10, B-2650, Edegem, Antwerp, Belgium
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Affiliation(s)
- J E Tyson
- Center for Population Health and Evidence-Based Medicine, and Institutional Review Board, University of Texas-Houston Medical School, 77030, USA
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Wiswell TE, Gannon CM, Jacob J, Goldsmith L, Szyld E, Weiss K, Schutzman D, Cleary GM, Filipov P, Kurlat I, Caballero CL, Abassi S, Sprague D, Oltorf C, Padula M. Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial. Pediatrics 2000; 105:1-7. [PMID: 10617696 DOI: 10.1542/peds.105.1.1] [Citation(s) in RCA: 338] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Disagreement exists concerning the appropriate delivery room management of the airway of vigorous meconium-stained infants. Some suggest a universal approach to intubation and suctioning of the airway in all such neonates, whereas others advocate a selective approach. We performed this investigation: 1) to assess whether intubation and suctioning of apparently vigorous, meconium-stained neonates would reduce the incidence of meconium aspiration syndrome (MAS); and 2) to determine the frequency of complications from delivery room intubation and suctioning of such infants. METHODS Inclusion criteria included: 1) gestational age >/=37 weeks; 2) birth through meconium-stained amniotic fluid of any consistency; and 3) apparent vigor immediately after birth. Subjects were randomized to be intubated and suctioned (INT) or to expectant management (EXP). Primary outcome measures included: 1) the incidence of respiratory distress, including MAS, and 2) the incidence of complications from intubation. RESULTS A total of 2094 neonates were enrolled from 12 participating centers (1051 INT and 1043 EXP). Meconium-stained amniotic fluid consistency was similar in both groups. Of the 149 (7.1%) infants that subsequently demonstrated respiratory distress, 62 (3.0%) had MAS and 87 (4.2%) had findings attributed to other disorders. There were no significant differences between groups in the occurrence of MAS (INT = 3.2%; EXP = 2.7%) or in the development of other respiratory disorders (INT = 3.8%; EXP = 4.5%). Of 1098 successfully intubated infants, 42 (3.8%) had a total of 51 complications of the procedure. In all cases, the complications were mild and transient in nature. CONCLUSIONS Compared with expectant management, intubation and suctioning of the apparently vigorous meconium-stained infant does not result in a decreased incidence of MAS or other respiratory disorders. Complications of intubation are infrequent and short-lived.
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Affiliation(s)
- T E Wiswell
- Neonatology services at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Affiliation(s)
- R Soll
- Department of Paediatrics, University of Vermont College of Medicine, Burlington 05405, USA
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Kennedy KA, Tyson JE. Narcotic analgesia for ventilated newborns: are placebo-controlled trials ethical and necessary? J Pediatr 1999; 134:127-9. [PMID: 9931512 DOI: 10.1016/s0022-3476(99)70399-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Grimmett MR, Sulmasy DP. The Call of the Sirens: Ethically Navigating the Sea of Nonvalidated Therapies. J Refract Surg 1998; 14:559-66. [PMID: 9791823 DOI: 10.3928/1081-597x-19980901-15] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Medical research and innovation are vital to the advancement of medicine and, ultimately, benefit society and individual patients. However, the ethical principles of beneficence, respect for persons, and justice must guide the development and implementation of new practices. Ethical codes governing clinical practice and research already warn practitioners to avoid the use of nonvalidated practices outside of controlled clinical trials. Nonetheless, lack of compliance with these codes places many patients at risk for harm. Ophthalmologists, as well as all physicians, must recommit themselves to these ethical principles and codes and establish more vigorous peer-review methods to protect patients from nonvalidated practices that are implemented without a scientific basis.
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Affiliation(s)
- M R Grimmett
- Bascom Palmer Eye Institute, University of Miami, School of Medicine, FL, USA
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Affiliation(s)
- D Wolke
- University of Hertfordshire, Department of Psychology, Hatfield, UK
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Rogers CG, Tyson JE, Kennedy KA, Broyles RS, Hickman JF. Conventional consent with opting in versus simplified consent with opting out: an exploratory trial for studies that do not increase patient risk. J Pediatr 1998; 132:606-11. [PMID: 9580757 DOI: 10.1016/s0022-3476(98)70347-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The objective of this study was to assess a modified consent procedure allowed under federal regulations and developed for studies, particularly clinical trials, that are judged by the Institutional Review Board to reduce or have no effect on patient risk. STUDY DESIGN This was a randomized trial of a conventional consent procedure that required parental signature to give consent (opting in) after a comprehensive disclosure of the rights of participants in research versus a modified consent procedure that required parental signature to refuse consent (opting out) after specific disclosures appropriate when risk is not increased. Consent was sought for a trial of primary follow-up care for disadvantaged infants at high risk, a trial judged by our Institutional Review Board to increase access to care for both groups. A blinded assessor interviewed mothers within 24 hours of the consent decision. RESULTS Among the 44 mothers interviewed, the modified consent group scored higher than the conventional consent group in recall and understanding of study purpose and methods (47% vs 30%; p < 0.02). Other comparisons provided no evidence that the modified consent procedure was less desirable. Virtually all mothers reported satisfaction. CONCLUSIONS The modified approach may improve communication and facilitate studies judged by the Institutional Review Board to be risk-neutral or risk-reducing. Further evaluation of a modified consent procedure for such studies is warranted.
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Affiliation(s)
- C G Rogers
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, USA
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Kennedy KA, Ipson MA, Birch DG, Tyson JE, Anderson JL, Nusinowitz S, West L, Spencer R, Birch EE. Light reduction and the electroretinogram of preterm infants. Arch Dis Child Fetal Neonatal Ed 1997; 76:F168-73. [PMID: 9175946 PMCID: PMC1720640 DOI: 10.1136/fn.76.3.f168] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIMS To examine the effects of light on retinal development and function in preterm infants as measured by the electroretinogram (ERG). Secondary outcomes included visual acuity testing, the incidence of retinopathy of prematurity, and general wellbeing, reflected in feeding tolerance, rate of weight gain, and length of hospital stay. METHODS Eligibility criteria for enrollment were birthweight < or = 1250 g and gestational age < or = 31 weeks. Sixty one infants were randomly allocated by 6 hours after birth to a control or treatment group which wore 97% light filtering goggles for a minimum of four weeks or until the infant reached 31 weeks postmenstrual age. RESULTS There were no significant differences between the two groups in the numbers of electroretinograms performed at 36 weeks of postmenstrual age. Although the sample size was not large enough to exclude clinically important differences in secondary outcomes, no significant differences were observed between the groups in visual acuity testing at 4-6 months corrected age, incidence of retinopathy of prematurity, weight gain, or length of stay. CONCLUSION These data support the safety and feasibility of this intervention. A much larger study will be needed to determine whether light reduction to the eyes of very low birthweight infants will reduce the incidence of retinopathy of prematurity or enhance general well-being.
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Affiliation(s)
- K A Kennedy
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas 75235, USA
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