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Alvarez M, Hotton EJ, Harding S, Ives J, Crofts JF, Wade J. Women's and midwives' views on the optimum process for informed consent for research in a feasibility study involving an intrapartum intervention: a qualitative study. Pilot Feasibility Stud 2023; 9:98. [PMID: 37322539 DOI: 10.1186/s40814-023-01330-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/26/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Recruitment to intrapartum research is complex. Women are expected to understand unfamiliar terminology and assess potential harm versus benefit to their baby and themselves, often when an urgent intervention is required. Time pressures of intrapartum interventions are a major challenge for recruitment discussions taking place during labour, with research midwives expected to present, discuss and answer questions whilst maintaining equipoise. However, little is known about these interactions. An integrated qualitative study (IQS) was used to investigate information provision for women invited to participate in the Assist II feasibility study investigating the OdonAssist™-a novel device for use in assisted vaginal birth with an aim to generate a framework of good practice for information provision. METHODS Transcripts of in-depth interviews with women participants (n = 25), with recruiting midwives (n = 6) and recruitment discussions between midwives and women (n = 21), accepting or declining participation, were coded and interpreted using thematic analysis and content analysis to investigate what was helpful to women and what could be improved. RESULTS Recruiting women to intrapartum research is complicated by factors that impact on women's understanding and decision-making. Three key themes were derived from the data: (i) a woman-centred recruitment process, (ii) optimising the recruitment discussion and (iii) making a decision for two. CONCLUSION Despite evidence from the literature that women would like information provision and the research discussion to take place in the antenatal period, intrapartum studies still vary in the recruitment processes they offer women. Particularly concerning is that some women are given information for the first time whilst in labour, when they are known to feel particularly vulnerable, and contextual factors may influence decision-making; therefore, we propose a framework for good practice for information provision for research involving interventions initiated in the intrapartum period as a woman centred, and acceptable model of recruitment, which addresses the concerns of women and midwives and facilitates fair inclusion into intrapartum trials. TRIAL REGISTRATION ISRCTN. This qualitative research was undertaken as part of the ASSIST II Trial (trial registration number: ISRCTN38829082. Prospectively registered on 26/06/2019).
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Affiliation(s)
- Mary Alvarez
- Department of Women's and Children's Health, Southmead Hospital, North Bristol NHS Trust, BS10 5NB, Bristol, UK.
- Bristol Medical School, Bristol University, BS8 2PS, Bristol, UK.
| | - Emily J Hotton
- Department of Women's and Children's Health, Southmead Hospital, North Bristol NHS Trust, BS10 5NB, Bristol, UK
- Translational Health Sciences, Bristol University, Bristol, UK
| | - Sam Harding
- Department of Women's and Children's Health, Southmead Hospital, North Bristol NHS Trust, BS10 5NB, Bristol, UK
- Research and Innovation, Learning and Research Building, Southmead Hospital, North Bristol NHS Trust, BS10 5NB, Bristol, UK
| | - Jonathan Ives
- Bristol Medical School, Bristol University, BS8 2PS, Bristol, UK
- Centre for Ethics in Medicine, Bristol University, Bristol, UK
| | - Joanna F Crofts
- Department of Women's and Children's Health, Southmead Hospital, North Bristol NHS Trust, BS10 5NB, Bristol, UK
| | - Julia Wade
- Bristol Medical School, Bristol University, BS8 2PS, Bristol, UK
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2
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Viscarret JJ, Ballestero A, Úriz MJ, Idareta F. What Ethical Dilemmas Do Social Workers Face in the Healthcare Area in Spain? SOCIAL WORK IN PUBLIC HEALTH 2023; 38:135-146. [PMID: 35872638 DOI: 10.1080/19371918.2022.2104414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The purpose of the article is to identify the types of ethical dilemmas that Spanish social workers face in the healthcare arena (health centers, hospitals and mental health). A quantitative methodology was chosen using the questionnaire prepared by Eileen J. Ain. The questionnaire has been translated and adapted for Social Work in Spain. The statistical analysis shows the correlation between the different areas of intervention in Social Work and the most significant ethical dilemmas that such professionals have to solve (autonomy, confidentiality and informed consent). This article is an essential study on Social Work at the national level that emphasizes the importance of the ethics of Social Work in the Healthcare area.
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Affiliation(s)
| | - Alberto Ballestero
- Department of Social Work, Public University of Navarre, Pamplona, Spain
| | - María-Jesús Úriz
- Department of Social Work, Public University of Navarre, Pamplona, Spain
| | - Francisco Idareta
- Department of Social Work, Public University of Navarre, Pamplona, Spain
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Sweeney L, Lanz D, Daru J, Rasijeff AMP, Khanom F, Thomas A, Harden A, Green L. Deferred consent in emergency obstetric research: findings from qualitative interviews with women and recruiters in the ACROBAT pilot trial for severe postpartum haemorrhage. BMJ Open 2022; 12:e054787. [PMID: 35508349 PMCID: PMC9073399 DOI: 10.1136/bmjopen-2021-054787] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 03/11/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The ACROBAT pilot trial of early cryoprecipitate for severe postpartum haemorrhage used deferred consent procedures. Pretrial discussions with a patient and public involvement group found mixed views towards deferred consent. This study aimed to build an understanding of how the deferred consent procedures worked in practice, to inform plans for a full-scale trial. SETTING Qualitative interview study within a cluster-randomised pilot trial, involving four London maternity services. PARTICIPANTS Individual interviews were conducted postnatally with 10 women who had received blood transfusion for severe postpartum haemorrhage and had consented to the trial. We also interviewed four 'recruiters'-two research midwives and two clinical trials practitioners who conducted trial recruitment. RESULTS Consent procedures in the ACROBAT pilot trial were generally acceptable and the intervention was viewed as low risk, but most women did not remember much about the consent conversation. As per trial protocol, recruiters sought to consent women before hospital discharge, but this time pressure had to be balanced against the need to ensure women were not approached when distressed or very unwell. Extra efforts had to be made to communicate trial information to women due to the exhaustion of their recovery and competing demands for their attention. Participant information was further complicated by explanations about the cluster design and change in transfusion process, even though the consent sought was for access to medical data. CONCLUSION Our findings indicate that deferred consent procedures raise similar concerns as taking consent when emergency obstetric research is occurring-that is, the risk that participants may conflate research with clinical care, and that their ability to process trial information may be impacted by the stressful nature of recovery and newborn care. A future trial may support more meaningful informed consent by extending the window of consent discussion and ensuring trial information is minimal and easy to understand. TRIAL REGISTRATION NUMBER ISRCTN12146519.
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Affiliation(s)
| | - Doris Lanz
- Barts Research Centre for Women's Health, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Jahnavi Daru
- Barts Research Centre for Women's Health, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Annika M P Rasijeff
- Blizard Institute, Queen Mary University of London, London, UK
- Katie's Team Patient and Public Advisory Group, Barts Research Centre for Women's Health, Queen Mary University of London, London, UK
| | - Farzana Khanom
- Katie's Team Patient and Public Advisory Group, Barts Research Centre for Women's Health, Queen Mary University of London, London, UK
| | | | - Angela Harden
- School of Health Sciences, City University of London, London, UK
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
- NHS Blood and Transplant, London, UK
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Facilitators and barriers for parental consent to pediatric emergency research. Pediatr Res 2022; 91:1156-1162. [PMID: 34088985 DOI: 10.1038/s41390-021-01600-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 03/15/2021] [Accepted: 05/20/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Obtaining informed consent for clinical research in the pediatric emergency department (ED) is challenging. Our objective was to understand the factors that influence parental consent for ED studies. METHODS This was a cross-sectional survey assessing parents' willingness to enroll their children into an ED research study. Parents reporting a willingness to enroll in ED studies were presented with two hypothetical scenarios, a low-risk and a high-risk study, and then asked about decision influencers affecting consent. Parents expressing a lack of willingness to enroll were asked which decision influencers impacted their consent decision. RESULTS Among 118 parents, 90 (76%) stated they would be willing to enroll their child into an ED study; of these, 86 (96%) would consent for a low-risk study and 54 (60%) would consent for a high-risk study. Caucasian parents, and those with previous research exposure, were more likely to report willingness to participate. Those who would consent to the high-risk study cited "benefits that research would provide to future children" most strongly influenced their decision to agree. CONCLUSIONS ED investigators should highlight the benefits for future children and inquire about parents' previous exposure to research to enhance ED research enrollment. Barriers to consent in non-Caucasian families should be further investigated. IMPACT Obtaining consent for pediatric emergency research is challenging and this study identified factors influencing parental consent for research in EDs. Benefits for future children and parents' previous research experience were two of the most influential factors in parents' willingness to consent to ED research studies. These findings will help to improve enrollment in ED research studies and better our understanding of how to promote the health and well-being of pediatric patients.
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Abstract
Children are considered a vulnerable population and have traditionally been excluded from research studies. This exclusion of children in general, and neonates in particular, from clinical research hampers the development of safe and effective therapies in this population. However, research involving children (including infants) is essential to guide therapy and optimize care. Neonatal research is complex, time intensive, difficult and expensive to conduct, and raises some unique ethical considerations. The complexity of research in this population is highlighted by the fear of causing harm to fragile sick infants which has led to the creation of special regulations on the degree of risk exposure permissible in research involving infants. This is further compounded by the inability of infants to provide informed consent or assent and the reliance on obtaining surrogate consent from parents who may themselves be vulnerable and overwhelmed by their infant's illness and the amount of information provided to them. In this review, we discuss the evolution of ethical regulations related to research, the justification for research in infants, and some of the ethical nuances of research in this population.
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Affiliation(s)
- Sunil Krishna
- Department of Pediatrics, University of Illinois College of Medicine, Rockford, IL
| | - Mamta Fuloria
- Division of Neonatology, Department of Pediatrics, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
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Nanyunja C, Sadoo S, Mambule I, Mathieson SR, Nyirenda M, Webb EL, Mugalu J, Robertson NJ, Nabawanuka A, Gilbert G, Bwambale J, Martinello K, Bainbridge A, Lubowa S, Srinivasan L, Ssebombo H, Morgan C, Hagmann C, Cowan FM, Le Doare K, Wintermark P, Kawooya M, Boylan GB, Nakimuli A, Tann CJ. Protocol for the Birth Asphyxia in African Newborns (Baby BRAiN) Study: a Neonatal Encephalopathy Feasibility Cohort Study. Gates Open Res 2022; 6:10. [PMID: 35614965 PMCID: PMC9110736 DOI: 10.12688/gatesopenres.13557.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND: Neonatal encephalopathy (NE) is a leading cause of child mortality worldwide and contributes substantially to stillbirths and long-term disability. Ninety-nine percent of deaths from NE occur in low-and-middle-income countries (LMICs). Whilst therapeutic hypothermia significantly improves outcomes in high-income countries, its safety and effectiveness in diverse LMIC contexts remains debated. Important differences in the aetiology, nature and timing of neonatal brain injury likely influence the effectiveness of postnatal interventions, including therapeutic hypothermia. METHODS: This is a prospective pilot feasibility cohort study of neonates with NE conducted at Kawempe National Referral Hospital, Kampala, Uganda. Neurological investigations include continuous video electroencephalography (EEG) (days 1-4), serial cranial ultrasound imaging, and neonatal brain Magnetic Resonance Imaging and Spectroscopy (MRI/ MRS) (day 10-14). Neurodevelopmental follow-up will be continued to 18-24 months of age including Prechtl's Assessment of General Movements, Bayley Scales of Infant Development, and a formal scored neurological examination. The primary outcome will be death and moderate-severe neurodevelopmental impairment at 18-24 months. Findings will be used to inform explorative science and larger trials, aiming to develop urgently needed neuroprotective and neurorestorative interventions for NE applicable for use in diverse settings. DISCUSSION: The primary aims of the study are to assess the feasibility of establishing a facility-based cohort of children with NE in Uganda, to enhance our understanding of NE in a low-resource sub-Saharan African setting and provide infrastructure to conduct high-quality research on neuroprotective/ neurorestorative strategies to reduce death and disability from NE. Specific objectives are to establish a NE cohort, in order to 1) investigate the clinical course, aetiology, nature and timing of perinatal brain injury; 2) describe electrographic activity and quantify seizure burden and the relationship with adverse outcomes, and; 3) develop capacity for neonatal brain MRI/S and examine associations with early neurodevelopmental outcomes.
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Affiliation(s)
| | - Samantha Sadoo
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Ivan Mambule
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | | | - Emily L Webb
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - J Mugalu
- Kawempe National Referral Hospital, Kampala, UK
| | - Nicola J Robertson
- University College London, London, UK
- University of Edinburgh, Edinburgh, UK
| | | | | | | | | | | | | | | | | | - Cathy Morgan
- Cerebral Palsy Alliance Research Institute, University of Sydney, Sydney, Australia
| | | | | | - Kirsty Le Doare
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- St George's, University of London, London, UK
| | | | - Michael Kawooya
- Ernest Cook Ultrasound Research and Education Institute (ECUREI), Kampala, Uganda
| | | | - Annettee Nakimuli
- Kawempe National Referral Hospital, Kampala, UK
- Makarere University, Kampala, Uganda
| | - Cally J Tann
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
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Dahan S, Jung C, Dassieu G, Durrmeyer X, Caeymaex L. Trust and consent: a prospective study on parents' perspective during a neonatal trial. JOURNAL OF MEDICAL ETHICS 2021; 47:678-683. [PMID: 32079742 DOI: 10.1136/medethics-2019-105597] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 01/21/2020] [Accepted: 02/03/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE This study aimed to describe how parents and physicians experienced the informed consent interview and to investigate the aspects of the relationship that influenced parents' decision during the consent process for a randomised clinical trial in a tertiary neonatal intensive care unit (NICU). The secondary objective was to describe the perspectives of parents and physicians in the specific situation of prenatal informed consent. SETTING Single centre study in NICU of the Centre Hospitalier Intercommunal de Créteil, France, using a convenience period from February to May 2016. DESIGN Ancillary study to a randomised clinical trial: Prettineo. Records of interviews for consent. POPULATION parents and physicians. Mixed study including qualitative and quantitative interview data about participants' recall and feelings about the consent process. Interviews were reviewed using thematic discourse analysis. RESULTS Parents' recall and understanding of the study's main goal and design was good. Parents and physicians had a positive experience, and trust was one of the main reasons for parents to consent. Misunderstanding (bad comprehension) was the main reason for refusal.Before birth, three situations can compromise parents' consent: the mother already consented to participate in other studies, the absence of the father during the interview and the feeling that the baby's birth is not an imminent possibility. CONCLUSIONS Confronting parents and physicians' perspectives in research can help us reach answers to sensitive issues such as content and timing of information. Each different types of study raises different ethical dilemmas for consent that might be discussed in a more individual way.
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Affiliation(s)
- Sonia Dahan
- Neonatal intensive care unit, Centre hospitalier intercommunal de Créteil, Créteil, Ile-de-France, France
- Faculté de Médecine, Université Paris Est Créteil Val de Marne, Faculté de Médecine, Créteil, Ile-de-France, France
| | - Camille Jung
- Faculté de Médecine, Université Paris Est Créteil Val de Marne, Faculté de Médecine, Créteil, Ile-de-France, France
- Pediatrics, Centre hospitalier Intercommunal de Créteil Val-de-Marne, Creteil, Île-de-France, France
| | - Gilles Dassieu
- Neonatal intensive care unit, Centre hospitalier intercommunal de Créteil, Créteil, Ile-de-France, France
- Faculté de Médecine, Université Paris Est Créteil Val de Marne, Faculté de Médecine, Créteil, Ile-de-France, France
| | - Xavier Durrmeyer
- Neonatal intensive care unit, Centre hospitalier intercommunal de Créteil, Créteil, Ile-de-France, France
- Faculté de Médecine, Université Paris Est Créteil Val de Marne, Faculté de Médecine, Créteil, Ile-de-France, France
| | - Laurence Caeymaex
- Neonatal intensive care unit, Centre hospitalier intercommunal de Créteil, Créteil, Ile-de-France, France
- Faculté de Médecine, Université Paris Est Créteil Val de Marne, Faculté de Médecine, Créteil, Ile-de-France, France
- CEDITEC, Universite Paris-Est Creteil Val de Marne, Creteil, France
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Jackson SM, Daverio M, Perez SL, Gesualdo F, Tozzi AE. Improving Informed Consent for Novel Vaccine Research in a Pediatric Hospital Setting Using a Blended Research-Design Approach. Front Pediatr 2021; 8:520803. [PMID: 33511090 PMCID: PMC7835206 DOI: 10.3389/fped.2020.520803] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 09/22/2020] [Indexed: 02/02/2023] Open
Abstract
It is necessary to conduct Clinical Trials in children, including for novel vaccines. Children cannot legally provide valid consent, but can assent to research participation. Informed consent and assent communications are frequently criticized for their lack of comprehensibility and often, researchers do not involve patients in informed consent design. We tested a blended research-design approach to co-design multimedia informed consent prototypes for experimental vaccine studies targeted at the pediatric population. We report details on the methodology utilized, and the insights, ideas, and prototype solutions we generated using social media data analysis, a survey, and workshops. A survey of clinical trial researchers indicated that while the most did not use technology for informed consent, they considered its utilization favorable. Social media analysis enabled researchers to quickly understand where community perspectives were concordant and discordant and build their understanding of the types of topics that they may want to focus on during the design workshops. Participatory design workshops for children and their families reaped insights, ideas, and prototypes for a range of tools including apps and websites. Participants felt that the prototypes were better able to communicate necessary content than the original text document format. We propose using a participatory, mixed-methods approach to design informed consent so that it is better adapted to patients' needs. Such an approach would be helpful in better addressing the needs of different segments of the populations involved in clinical trials. Further evidence should be gained about the impact of this strategy in improving recruitment, decreasing withdrawals and litigations, and improving patient satisfaction during clinical trials.
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Affiliation(s)
- Sally M. Jackson
- Multifactorial and Complex Diseases Research Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | | | - Francesco Gesualdo
- Multifactorial and Complex Diseases Research Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Alberto E. Tozzi
- Multifactorial and Complex Diseases Research Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
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9
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De Sutter E, Coopmans B, Vanendert F, Dooms M, Allegaert K, Borry P, Huys I. Clinical Research in Neonates: Redesigning the Informed Consent Process in the Digital Era. Front Pediatr 2021; 9:724431. [PMID: 34540773 PMCID: PMC8441012 DOI: 10.3389/fped.2021.724431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 07/30/2021] [Indexed: 01/10/2023] Open
Abstract
Background: Currently, many initiatives are devoted to optimizing informed consent for participation in clinical research. Due to the digital transformation in health care, a shift toward electronic informed consent (eIC) has been fostered. However, empirical evidence on how to implement eIC in clinical research involving neonates is lacking. Methods: Semi-structured interviews were conducted with 31 health care professionals active in Belgium or the Netherlands. All health care professionals had experience in conducting clinical research involving neonates. Interviews were audio-recorded, transcribed and analyzed using the framework method. Results: Interviewees generally supported the use of eIC in clinical research involving neonates. For example, eIC could enable parents to receive study feedback via the eIC system. Requirements were expressed for parental involvement to decide on which feedback would be appropriate to return. Moreover, experts specialized in presenting information and designing electronic systems should be involved. Broad consensus among health care professionals indicates that the face-to-face-interaction between parents and the research team is vital to establish a relationship of trust. Therefore, it is necessary that the use of eIC runs alongside personal interactions with the parents. Concerns were raised about the accessibility of eIC to parents. For this reason, it was suggested that parents should always be given the possibility to read and sign a paper-based informed consent form or to use eIC. Conclusions: Health care professionals' views indicate that the use of eIC in clinical research with neonates may offer various opportunities. Further development and implementation will require a multi-stakeholder approach.
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Affiliation(s)
- Evelien De Sutter
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Birte Coopmans
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Femke Vanendert
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Marc Dooms
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Karel Allegaert
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Clinical Pharmacy, Erasmus MC, Rotterdam, Netherlands
| | - Pascal Borry
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Isabelle Huys
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Lonhart JA, Edwards AR, Agarwal S, Lucas BP, Schroeder AR. Consent Rates Reported in Published Pediatric Randomized Controlled Trials. J Pediatr 2020; 227:281-287. [PMID: 32599033 DOI: 10.1016/j.jpeds.2020.06.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/19/2020] [Accepted: 06/19/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine the average reported consent rate for published pediatric randomized controlled trials (RCTs) and whether this rate varies by trial characteristics. STUDY DESIGN A review of pediatric RCTs published in Medline in 2009, 2010, or 2015 was performed. Secondary analyses of prior trials, trials including adults, trials not requiring consent, or trials with missing or unclear consent data were excluded. Consent rate was defined as the number of patients enrolled divided by number of eligible patients where families were approached. Random effects meta-regression was conducted to determine the weighted average consent rate. RESULTS Of 2347 trials identified, 1651 were excluded. An additional 418 of 696 (60%) were excluded because the consent rate was missing or unclear. The average consent rate for 278 included RCTs was 82.6% (95% CI, 80.3%-84.8%) and was higher for vaccination compared with behavioral trials and for industry-funded compared with National Institutes of Health-funded or other government-funded trials. The average consent rate was <70% for 26% of included trials. Of these trials, US trials (28/77 [36.4%]) had a higher probability of a consent rate of <70% than non-US studies (35/64 [21.3%]) and multinational (9/37 [24.3%]) studies. There was slight variation by funding category. CONCLUSIONS Although the average consent rate for published trials was reasonably high, approximately one-quarter of trials had consent rates of <70%. Consent rates reporting has improved over time, but remains suboptimal. Our findings should assist with the planning of future pediatric RCTs, although consent data from unpublished trials are also needed.
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Affiliation(s)
| | | | - Swati Agarwal
- Department of Pediatrics, Inova Children's Hospital, Falls Church, VA
| | - Brian P Lucas
- The Dartmouth Institute of Health Policy & Clinical Practice, Hanover, NH
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Kim JP, Rostami M, Roberts LW. Attitudes of Mothers Regarding Willingness to Enroll Their Children in Research. J Empir Res Hum Res Ethics 2020; 15:452-464. [PMID: 32552481 DOI: 10.1177/1556264620927583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study assessed mothers' perspectives regarding research involvement by their children, factors that might affect perceptions of research risks, and attitudes regarding willingness to enroll children in research. Participants completed a survey on Amazon Mechanical Turk. Mothers were less inclined to enroll children in research involving procedures posing higher risk (regression coefficient = -0.51). Mothers without mental health issues with children without health issues were more sensitive to risk than mothers without mental health issues with children with health issues (estimated difference = 0.49). Mothers with mental health issues were more willing than mothers without mental health issues to enroll children in research (regression coefficient = -0.90). Among mothers with mental health issues, having a child with a health issue was associated with increased willingness to enroll in research, compared with having children without health issues (estimated difference = 0.65).
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Affiliation(s)
- Jane Paik Kim
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Maryam Rostami
- Stanford University School of Medicine, Palo Alto, CA, USA
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12
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Medvedev MM, Tumukunde V, Mambule I, Tann CJ, Waiswa P, Canter RR, Hansen CH, Ekirapa-Kiracho E, Katumba K, Pitt C, Greco G, Brotherton H, Elbourne D, Seeley J, Nyirenda M, Allen E, Lawn JE. Operationalising kangaroo Mother care before stabilisation amongst low birth Weight Neonates in Africa (OMWaNA): protocol for a randomised controlled trial to examine mortality impact in Uganda. Trials 2020; 21:126. [PMID: 32005286 PMCID: PMC6995072 DOI: 10.1186/s13063-019-4044-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 12/30/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND There are 2.5 million neonatal deaths each year; the majority occur within 48 h of birth, before stabilisation. Evidence from 11 trials shows that kangaroo mother care (KMC) significantly reduces mortality in stabilised neonates; however, data on its effect among neonates before stabilisation are lacking. The OMWaNA trial aims to determine the effect of initiating KMC before stabilisation on mortality within seven days relative to standard care. Secondary objectives include exploring pathways for the intervention's effects and assessing incremental costs and cost-effectiveness between arms. METHODS We will conduct a four-centre, open-label, individually randomised, superiority trial in Uganda with two parallel groups: an intervention arm allocated to receive KMC and a control arm receiving standard care. We will enrol 2188 neonates (1094 per arm) for whom the indication for KMC is 'uncertain', defined as receiving ≥ 1 therapy (e.g. oxygen). Admitted singleton, twin and triplet neonates (triplet if demise before admission of ≥ 1 baby) weighing ≥ 700-≤ 2000 g and aged ≥ 1-< 48 h are eligible. Treatment allocation is random in a 1:1 ratio between groups, stratified by weight and recruitment site. The primary outcome is mortality within seven days. Secondary outcomes include mortality within 28 days, hypothermia prevalence at 24 h, time from randomisation to stabilisation or death, admission duration, time from randomisation to exclusive breastmilk feeding, readmission frequency, daily weight gain, infant-caregiver attachment and women's wellbeing at 28 days. Primary analyses will be by intention-to-treat. Quantitative and qualitative data will be integrated in a process evaluation. Cost data will be collected and used in economic modelling. DISCUSSION The OMWaNA trial aims to assess the effectiveness of KMC in reducing mortality among neonates before stabilisation, a vulnerable population for whom its benefits are uncertain. The trial will improve understanding of pathways underlying the intervention's effects and will be among the first to rigorously compare the incremental cost and cost-effectiveness of KMC relative to standard care. The findings are expected to have broad applicability to hospitals in sub-Saharan Africa and southern Asia, where three-quarters of global newborn deaths occur, as well as important policy and programme implications. TRIAL REGISTRATION ClinicalTrials.gov, NCT02811432. Registered on 23 June 2016.
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Affiliation(s)
- Melissa M Medvedev
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
- Department of Paediatrics, University of California San Francisco, 550 16th Street, Box 1224, San Francisco, CA, 94158, USA.
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Victor Tumukunde
- Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, PO Box 49, Entebbe, Uganda
| | - Ivan Mambule
- Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, PO Box 49, Entebbe, Uganda
| | - Cally J Tann
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, PO Box 49, Entebbe, Uganda
- Department of Neonatal Medicine, University College London, 235 Euston Road, London, NW1 2BU, UK
| | - Peter Waiswa
- Centre of Excellence for Maternal, Newborn, and Child Health, School of Public Health, Makerere University, New Mulago Hill Road, Kampala, Uganda
- Department of Public Health Sciences, Karolinska Institutet, SE-171 77, Stockholm, Sweden
| | - Ruth R Canter
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Christian H Hansen
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, PO Box 49, Entebbe, Uganda
| | - Elizabeth Ekirapa-Kiracho
- Centre of Excellence for Maternal, Newborn, and Child Health, School of Public Health, Makerere University, New Mulago Hill Road, Kampala, Uganda
| | - Kenneth Katumba
- Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, PO Box 49, Entebbe, Uganda
| | - Catherine Pitt
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1E 7HT, UK
| | - Giulia Greco
- Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, PO Box 49, Entebbe, Uganda
- Centre of Excellence for Maternal, Newborn, and Child Health, School of Public Health, Makerere University, New Mulago Hill Road, Kampala, Uganda
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1E 7HT, UK
| | - Helen Brotherton
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Medical Research Council Unit The Gambia at LSHTM, PO Box 273, Fajara, The Gambia
| | - Diana Elbourne
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, PO Box 49, Entebbe, Uganda
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1E 7HT, UK
| | - Moffat Nyirenda
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Medical Research Council/Uganda Virus Research Institute and LSHTM Uganda Research Unit, PO Box 49, Entebbe, Uganda
| | - Elizabeth Allen
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive, & Child Health Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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13
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Aurich B, Vermeulen E, Elie V, Driessens MHE, Kubiak C, Bonifazi D, Jacqz-Aigrain E. Informed consent for neonatal trials: practical points to consider and a check list. BMJ Paediatr Open 2020; 4:e000847. [PMID: 33437878 PMCID: PMC7778778 DOI: 10.1136/bmjpo-2020-000847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/23/2020] [Accepted: 11/29/2020] [Indexed: 12/04/2022] Open
Abstract
Obtaining informed consent from parents of critically ill neonates can be challenging. The parental decision-making process is influenced by the severity of the child's condition, the benefit-risk balance, their emotional state and the quality of the relationship with the clinical team. Independent of local legislation, parents may prefer that consent is sought from both. Misconceptions about the absence of risks or unrealistic expectations about benefits should be openly addressed to avoid misunderstandings which may harm the relationship with the clinical team. Continuous consent can be sought where it is unclear whether the free choice of parental consent has been compromised. Obtaining informed consent is a dynamic process building on trusting relationships. It should include open and honest discussions about benefits and risks. Investigators may benefit from training in effective communication. Finally, involving parents in neonatal research including the development of the informed consent form and the process of obtaining consent should be considered standard practice.
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Affiliation(s)
- Beate Aurich
- Department of Paediatric Clinical Pharmacology and Pharmacogenetics, Robert Debré Hospital, 48 Boulevard Sérurier, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Eric Vermeulen
- Dutch patient association for rare and genetic diseases (VSOP), Soest, The Netherlands
| | - Valéry Elie
- Department of Paediatric Clinical Pharmacology and Pharmacogenetics, Robert Debré Hospital, 48 Boulevard Sérurier, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | | | - Christine Kubiak
- The European Clinical Research Infrastructure Network (ECRIN), 5-7 Rue Watt, Paris, France
| | - Donato Bonifazi
- Consorzio per le Valutazioni Biologiche e Farmacologiche, Via Nicolo Putignani, Bari, Italy.,TEDDY European Network of Excellence for Paediatric Research, Via Luigi Porta 14, Pavia, Italy
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Clinical Phramcology and Pharmacogenetics, Robert Debré Hospital, APHP, 48 Boulevard Sérurier, Paris, France.,Paris University, Paris, France
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14
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Kurin M, Katz J, Kodish E, Lashner B. Informed Consent in IBD Trials: Where We Are and Where We Need to Go. Inflamm Bowel Dis 2019; 25:1115-1119. [PMID: 30989217 DOI: 10.1093/ibd/izz067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Indexed: 12/09/2022]
Abstract
Patient enrollment is increasingly recognized as a major limiting factor to inflammatory bowel disease (IBD) clinical trial completion. Many IBD trials will fail to enroll enough patients to adequately power their study. This has led to a renewed multifaceted effort to encourage more patients to enroll in clinical trials. Although this is of clear importance, it is also important to ensure that all efforts to enroll patients in clinical trials do not compromise the quality and validity of the patient's/study participant's informed consent. Informed consent has 4 components: disclosure, voluntariness, understanding, and capacity. The application of informed consent to IBD clinical trials for biologic agents has not been previously studied. Yet the nature of clinical trials for biologics in IBD creates certain challenges to properly fulfilling the requirements of informed consent in the recruitment process that should be examined. In the following commentary, the components of informed consent are reviewed, challenges to their fulfillment in IBD trials are reviewed, and practical advice is offered.
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Affiliation(s)
- Michael Kurin
- Division of Gastroenterology and Liver Diseases, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jeffry Katz
- Division of Gastroenterology and Liver Diseases, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Eric Kodish
- Pediatrics Institute and Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Bret Lashner
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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15
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Beasant L, Brigden A, Parslow R, Apperley H, Keep T, Northam A, Wray C, King H, Langdon R, Mills N, Young B, Crawley E. Treatment preference and recruitment to pediatric RCTs: A systematic review. Contemp Clin Trials Commun 2019; 14:100335. [PMID: 30949611 PMCID: PMC6430075 DOI: 10.1016/j.conctc.2019.100335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 01/25/2019] [Accepted: 02/13/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Recruitment to pediatric randomised controlled trials (RCTs) can be a challenge, with ethical issues surrounding assent and consent. Pediatric RCTs frequently recruit from a smaller pool of patients making adequate recruitment difficult. One factor which influences recruitment and retention in pediatric trials is patient and parent preferences for treatment. PURPOSE To systematically review pediatric RCTs reporting treatment preference. METHODS Database searches included: MEDLINE, CINAHL, EMBASE, and COCHRANE.Qualitative or quantitative papers were eligible if they reported: pediatric population, (0-17 years) recruited to an RCT and reported treatment preference for all or some of the participants/parents in any clinical area. Data extraction included: Number of eligible participants consenting to randomisation arms, number of eligible patients not randomised because of treatment preference, and any further information reported on preferences (e.g., if parent preference was different from child). RESULTS Fifty-two studies were included. The number of eligible families declining participation in an RCT because of preference for treatment varied widely (between 2 and 70%) in feasibility, conventional and preference trial designs. Some families consented to trial involvement despite having preferences for a specific treatment. Data relating to 'participant flow and recruitment' was not always reported consistently, therefore numbers who were lost to follow-up or withdrew due to preference could not be extracted. CONCLUSIONS Families often have treatment preferences which may affect trial recruitment. Whilst children appear to hold treatment preferences, this is rarely reported. Further investigation is needed to understand the reasons for preference and the impact preference has on RCT recruitment, retention and outcome.
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Affiliation(s)
- L. Beasant
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, UK
| | - A. Brigden
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, UK
| | - R.M. Parslow
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, UK
| | - H. Apperley
- Department of Academic Paediatrics, Royal Alexandra Children's Hospital, Brighton and Sussex University Hospitals, UK
| | - T. Keep
- NHS Greater Glasgow and Clyde, UK
| | - A. Northam
- Department of Primary Care and Public Health, Royal Sussex County Hospital, Brighton and Sussex Medical School, UK
| | - C. Wray
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - H. King
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Trust, UK
| | - R. Langdon
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - N. Mills
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - B. Young
- Institute of Psychology, Health and Society, University of Liverpool, UK
| | - E. Crawley
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, UK
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16
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Soul JS, Pressler R, Allen M, Boylan G, Rabe H, Portman R, Hardy P, Zohar S, Romero K, Tseng B, Bhatt-Mehta V, Hahn C, Denne S, Auvin S, Vinks A, Lantos J, Marlow N, Davis JM. Recommendations for the design of therapeutic trials for neonatal seizures. Pediatr Res 2019; 85:943-954. [PMID: 30584262 PMCID: PMC6760680 DOI: 10.1038/s41390-018-0242-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 10/04/2018] [Accepted: 10/17/2018] [Indexed: 12/01/2022]
Abstract
Although seizures have a higher incidence in neonates than any other age group and are associated with significant mortality and neurodevelopmental disability, treatment is largely guided by physician preference and tradition, due to a lack of data from well-designed clinical trials. There is increasing interest in conducting trials of novel drugs to treat neonatal seizures, but the unique characteristics of this disorder and patient population require special consideration with regard to trial design. The Critical Path Institute formed a global working group of experts and key stakeholders from academia, the pharmaceutical industry, regulatory agencies, neonatal nurse associations, and patient advocacy groups to develop consensus recommendations for design of clinical trials to treat neonatal seizures. The broad expertise and perspectives of this group were invaluable in developing recommendations addressing: (1) use of neonate-specific adaptive trial designs, (2) inclusion/exclusion criteria, (3) stratification and randomization, (4) statistical analysis, (5) safety monitoring, and (6) definitions of important outcomes. The guidelines are based on available literature and expert consensus, pharmacokinetic analyses, ethical considerations, and parental concerns. These recommendations will ultimately facilitate development of a Master Protocol and design of efficient and successful drug trials to improve the treatment and outcome for this highly vulnerable population.
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Affiliation(s)
- Janet S Soul
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA.
| | - Ronit Pressler
- UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Geraldine Boylan
- INFANT Research Centre & Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Heike Rabe
- Brighton and Sussex Medical School, Brighton, England
| | | | | | - Sarah Zohar
- INSERM, UMRS1138, University Paris V and University Paris VI, Paris, France
| | | | | | - Varsha Bhatt-Mehta
- C.S.Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Cecil Hahn
- Division of Neurology, The Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Scott Denne
- Riley Children's Hospital, Indiana University, Indianapolis, Indiana, USA
| | - Stephane Auvin
- Pediatric Neurology Department & INSERM U1141, APHP, Robert Debré University Hospital, Paris, France
| | - Alexander Vinks
- College of Medicine & Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - John Lantos
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Neil Marlow
- UCL Institute for Women's Health, University College London, London, UK
| | - Jonathan M Davis
- The Floating Hospital for Children at Tufts Medical Center and the Tufts Clinical and Translational Science Institute, Boston, MA, USA
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17
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Walsh V, Oddie S, McGuire W. Ethical Issues in Perinatal Clinical Research. Neonatology 2019; 116:52-57. [PMID: 30947194 DOI: 10.1159/000494934] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 10/28/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Perinatal clinical research to improve the quality of care and outcomes for newborn infants relies on transparency, trust, and respect for the autonomy and well-being of study participants and their families. METHODS Here we consider the underpinning principles of ethical research with a focus on perinatal clinical research in the acute care or emergency setting where particular challenges to parental engagement and informed consent exist. RESULTS Several approaches to improving the validity of the consent process for perinatal research have been proposed and evaluated. These include consent waiver, antenatal consent, deferred consent preceded by verbal assent, and continuous consent. These have strengths and weaknesses and uncertainty remains about their validity and acceptability in certain research contexts. Prior exploration with parents and parent-advocacy groups of approaches to engagement and consent, and independent evaluation and ongoing monitoring of research studies, can enhance adherence to the ethical principles of justice and autonomy, and ensure that benefits to participants and their families exceed harm. CONCLUSIONS High-quality research and ethics are interdependent. Only research that meets ethical standards can be regarded as valid and applicable, and only research designs that are methodologically rigorous and appropriate can be regarded as ethical.
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Affiliation(s)
- Verena Walsh
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Sam Oddie
- Centre for Reviews and Dissemination, University of York, York, United Kingdom.,Neonatal Unit, Bradford Royal Infirmary, Bradford, United Kingdom
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, United Kingdom,
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18
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Horn R, Parker M. Health professionals' and researchers' perspectives on prenatal whole genome and exome sequencing: 'We can't shut the door now, the genie's out, we need to refine it'. PLoS One 2018; 13:e0204158. [PMID: 30240445 PMCID: PMC6150486 DOI: 10.1371/journal.pone.0204158] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 09/03/2018] [Indexed: 12/20/2022] Open
Abstract
The Prenatal Assessment of Genome and Exomes (PAGE) project is a UK-wide study aiming to gain a better understanding of genetic variants causing developmental problems during pregnancy. A further aim of the study is to provide an evidence-base for the introduction of prenatal whole genome and exome sequencing (PWGES) into prenatal diagnostics provided by the NHS, which is expected in 2018. This paper presents the findings of a qualitative interview study undertaken with 20 health professionals and researchers involved in the PAGE project, and explores their implications for understandings of 'good practice' in the uses of prenatal genomics clinically. A number of critical issues are identified that will need to be addressed in the development of a model of good ethical practice for prenatal genomics: consent, management of expectations, return of results, and professional duties in the context of PWGES. The analysis presented identifies and illustrates a great deal of complexity and qualitative richness in these issues as they arise in the day-to-day work of genomics professionals. Inclusive, critical discussion of these findings, together with the findings from other empirical studies, normative analysis and scientific discoveries resulting from PAGE, will be required to inform the development of appropriate guidelines of good ethical practice that address the needs and concerns to be encountered in daily clinical practice.
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Affiliation(s)
- Ruth Horn
- Department of Population Health, The Ethox Centre and Wellcome Trust Centre for Ethics and Humanities, University of Oxford, Headington, Oxford, United Kingdom
| | - Michael Parker
- Department of Population Health, The Ethox Centre and Wellcome Trust Centre for Ethics and Humanities, University of Oxford, Headington, Oxford, United Kingdom
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19
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Neyro V, Elie V, Thiele N, Jacqz-Aigrain E. Clinical trials in neonates: How to optimise informed consent and decision making? A European Delphi survey of parent representatives and clinicians. PLoS One 2018; 13:e0198097. [PMID: 29897934 PMCID: PMC5999079 DOI: 10.1371/journal.pone.0198097] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 05/14/2018] [Indexed: 11/27/2022] Open
Abstract
Objectives Parental consent for the participation of their neonate in neonatal research is influenced by the quality of the information delivered and the interaction between parents and investigators. Failure to provide important information may lead to difficulties in the decision making process of parents. This Delphi survey aims to establish a consensus between parent representatives of neonatal associations and healthcare professionals concerning the information deemed essential by both parties in order to improve the recruitment of neonates into clinical trials. Method This study was conducted in Europe among parent representatives and healthcare professionals. In this 3-phase study, 96 items were defined by the Scientific Committee (CS), composed of 11 clinicians (from 8 countries) and 1 parent representative of the European network of neonatal associations. Then the Committee of Experts (CE) composed of 16 clinicians were matched by country with 16 national parent representatives and evaluated these items in two rounds. The importance of each item was evaluated by each member of the CE on a scale between 1 and 9 based on their personal experience. Results Fifty eight items reached the second and final level of consensus. In contrast to clinicians, parent representatives preferred to be informed about the study by the physician in charge of their child. They also favoured additional support during the informed consent process and stated that both parents need to agree and sign. Conclusion The set of 58 items on which parents and clinicians reached consensus will be helpful to healthcare professionals seeking parental consent for the inclusion of a neonate in a clinical trial. Providing parents with information about the trial by the investigator in the presence of the patient’s neonatologist, developing closer contacts with parents and informing them of the available support by parents associations may be helpful for parents.
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Affiliation(s)
- Virginia Neyro
- Department of Paediatric Pharmacology and Pharmacogenetics, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Paris, France
- Doctoral School MTCI – Paris Descartes University, Paris, France
| | - Valéry Elie
- Department of Paediatric Pharmacology and Pharmacogenetics, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Paris, France
| | - Nicole Thiele
- European Foundation for the Care of Newborn Infants, EFCNI, Munich, Germany
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Assistance Publique des Hôpitaux de Paris, Robert Debré Hospital, Paris, France
- INSERM Clinical Investigations Center CIC1426, Robert Debré Hospital, Paris, France
- EA08 – Paris Diderot University, Paris, France
- * E-mail:
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20
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Safety, dosing, and pharmaceutical quality for studies that evaluate medicinal products (including biological products) in neonates. Pediatr Res 2017; 81:692-711. [PMID: 28248319 DOI: 10.1038/pr.2016.221] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/21/2016] [Indexed: 12/13/2022]
Abstract
The study of medications among pediatric patients has increased worldwide since 1997 in response to new legislation and regulations, but these studies have not yet adequately addressed the therapeutic needs of neonates. Additionally, extant guidance developed by regulatory agencies worldwide does not fully address the specificities of neonatal drug development, especially among extremely premature newborns who currently survive. Consequently, an international consortium from Canada, Europe, Japan, and the United States was organized by the Critical Path Institute to address the content of guidance. This group included neonatologists, neonatal nurses, parents, regulators, ethicists, clinical pharmacologists, specialists in pharmacokinetics, specialists in clinical trials and pediatricians working in the pharmaceutical industry. This group has developed a comprehensive, referenced White Paper to guide neonatal clinical trials of medicines - particularly early phase studies. Key points include: the need to base product development on neonatal physiology and pharmacology while making the most of knowledge acquired in other settings; the central role of families in research; and the value of the whole neonatal team in the design, implementation and interpretation of studies. This White Paper should facilitate successful clinical trials of medicines in neonates by informing regulators, sponsors, and the neonatal community of existing good practice.
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Clinicians' views and experiences of offering two alternative consent pathways for participation in a preterm intrapartum trial: a qualitative study. Trials 2017; 18:196. [PMID: 28446203 PMCID: PMC5406899 DOI: 10.1186/s13063-017-1940-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 04/11/2017] [Indexed: 11/15/2022] Open
Abstract
Background The Cord Pilot Trial compared alternative policies for timing of cord clamping at very preterm birth at eight UK hospitals. Preterm birth can be rapid and unexpected, allowing little time for the usual consent process. Therefore, in addition to the usual procedure for written consent, a two-stage pathway for consent for use when birth was imminent was developed. The aims of this study were to explore clinicians’ views and experiences of offering two consent pathways for recruitment to a randomised trial of timing of cord clamping at very preterm birth. Methods This was a qualitative study using semi-structured interviews. Clinicians from eight hospitals in the UK who had been involved in offering consent to the Cord Pilot Trial were invited to take part in an interview. Clinicians were interviewed in person or by telephone. Interviews were analysed using inductive systematic thematic analysis. Results Seventeen clinicians who had either offered usual written consent only (n = 6) or both the two-stage pathway (with oral assent before the birth and written consent after the birth) and usual written consent (n = 11) were interviewed. Six themes were identified: (1) team approach to offering participation; (2) consent form as a record; (3) consent and participation as a continual process; (4) different consent pathways for different trials; (5) balance between time, information, and understanding; and (6) validity of consent. Overall, clinicians were supportive of the two-stage consent pathway. Some clinicians felt that in time-critical situations oral assent presented an advantage over the usual written consent as they provided information on a “need to know” basis. However, there was some concern about how much information should be given for oral assent, and how this is understood by women when birth is imminent. Conclusions The two-stage pathway for consent developed for use in the Cord Pilot Trial when birth was imminent was acceptable to clinicians for comparable low-risk studies, although some concerns were raised about the practicalities of obtaining oral assent. Trial registration ISRCTN Registry, ISRCTN21456601. Registered on 28 February 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1940-5) contains supplementary material, which is available to authorized users.
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22
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Allmark P, Tod AM. Ethical challenges in conducting clinical research in lung cancer. Transl Lung Cancer Res 2016; 5:219-26. [PMID: 27413698 DOI: 10.21037/tlcr.2016.03.04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED The article examines ethical challenges that arise with clinical lung cancer research focusing on design, recruitment, conduct and dissemination. DESIGN problems related to equipoise can arise in lung cancer studies. Equipoise is an ethics precondition for RCTs and exists where there is insufficient evidence to decide which of two or more treatments is best. Difficulties arise in deciding what level of uncertainty constitutes equipoise and who should be in equipoise, for example, patients might not be even where clinicians are. Patient and public involvement (PPI) can reduce but not remove the problems. Recruitment: (I) lung cancer studies can be complex, making it difficult to obtain good quality consent. Some techniques can help, such as continuous consent. But researchers should not expect consent to be the sole protection for participants' welfare. This protection is primarily done elsewhere in the research process, for example, in ethics review; (II) the problem of desperate volunteers: some patients only consent to a trial because it gives them a 50/50 option of the treatment they want and can be disappointed or upset if randomised to the other arm. This is not necessarily unfair, given clinical equipoise. However, it should be avoided where possible, for example, by using alternative trial designs; (III) the so-called problem of therapeutic misconception: this is the idea that patients are mistaken if they enter trials believing this to be in their clinical best interest. We argue the problem is misconceived and relates only to certain health systems. Conduct: lung cancer trials face standard ethical challenges with regard to trial conduct. PPI could be used in decisions about criteria for stopping rules. DISSEMINATION as in other trial areas, it is important that all results, including negative ones, are reported. We argue also that the role of PPI with regard to dissemination is currently under-developed.
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Affiliation(s)
- Peter Allmark
- 1 Centre for Health and Social Care Research (CHSCR), Sheffield Hallam University, 32 Collegiate Crescent, Sheffield S10 2BP, UK ; 2 School of Nursing and Midwifery, University of Sheffield, Sheffield S10 2TN, UK
| | - Angela M Tod
- 1 Centre for Health and Social Care Research (CHSCR), Sheffield Hallam University, 32 Collegiate Crescent, Sheffield S10 2BP, UK ; 2 School of Nursing and Midwifery, University of Sheffield, Sheffield S10 2TN, UK
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Turner MA. Clinical trials of medicines in neonates: the influence of ethical and practical issues on design and conduct. Br J Clin Pharmacol 2015; 79:370-8. [PMID: 25041601 DOI: 10.1111/bcp.12467] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 06/24/2014] [Indexed: 01/03/2023] Open
Abstract
In the past, there has been a perception that ethical and practical problems limit the opportunities for research in neonates. This perception is no longer appropriate. It is now clear that research about the medicines used in neonates is an ethical requirement. It is possible to conduct high quality research in neonates if the research team adapt to the characteristics of this population. Good practice involves respecting the specific needs of newborn babies and their families by adopting relevant approaches to study design, recruitment, pharmacokinetic studies and safety assessment. Neonatal units have a unique culture that requires careful development in a research setting. Clinical investigators need to recognize the clinical and ethical imperative to conduct rigorous research. Industry needs to engage with neonatal networks early in the process of drug development, preferably before contacting regulatory agencies. Follow-up over 3-5 years is essential for the evaluation of medicines in neonates and explicit funding for this is required for the assessment of the benefit and risk of treatments given to sick newborn babies. The views of parents must be central to the development of studies and the research agenda. Ethical and practical problems are no longer barriers to research in neonates. The current challenges are to disseminate good practice and maximize capacity in order to meet the need for research among newborn babies.
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Affiliation(s)
- Mark A Turner
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Wilman E, Megone C, Oliver S, Duley L, Gyte G, Wright JM. The ethical issues regarding consent to clinical trials with pre-term or sick neonates: a systematic review (framework synthesis) of the empirical research. Trials 2015; 16:502. [PMID: 26537492 PMCID: PMC4634156 DOI: 10.1186/s13063-015-0957-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 09/14/2015] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Conducting clinical trials with pre-term or sick infants is important if care for this population is to be underpinned by sound evidence. Yet approaching parents at this difficult time raises challenges for the obtaining of valid informed consent to such research. This study asked: what light does the empirical literature cast on an ethically defensible approach to the obtaining of informed consent in perinatal clinical trials? METHODS A systematic search identified 49 studies. Analysis began by applying philosophical frameworks which were then refined in light of the concepts emerging from empirical studies to present a coherent picture of a broad literature. RESULTS Between them, studies addressed the attitudes of both parents and clinicians concerning consent in neonatal trials; the validity of the consent process in the neonatal research context; and different possible methods of obtaining consent. CONCLUSIONS Despite a variety of opinions among parents and clinicians there is a strongly and widely held view that it is important that parents do give or decline consent for neonatal participation in trials. However, none of the range of existing consent processes reviewed by the research is satisfactory. A significant gap is evaluation of the widespread practice of emergency 'assent', in which parents assent or refuse their baby's participation as best they can during the emergency and later give full consent to ongoing participation and follow-up. Emergency assent has not been evaluated for its acceptability, how such a process would deal with bad outcomes such as neonatal death between assent and consent, or the extent to which late parental refusal might bias results. This review of a large number of empirical papers, while not making fundamental changes, has refined and developed the conceptual framework from philosophy for examining informed consent in this context.
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MESH Headings
- Attitude of Health Personnel
- Clinical Trials as Topic/ethics
- Emergencies
- Emotions
- Gestational Age
- Health Knowledge, Attitudes, Practice
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/mortality
- Infant, Newborn, Diseases/therapy
- Infant, Premature
- Motivation
- Parental Consent/ethics
- Parents/psychology
- Research Design
- Risk Assessment
- Volition
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Affiliation(s)
- E Wilman
- Inter-Disciplinary Ethics Applied, University of Leeds, Leeds, UK.
| | - C Megone
- Inter-Disciplinary Ethics Applied, University of Leeds, Leeds, UK.
| | - S Oliver
- Social Science Research Unit and EPPI-Centre, Institute of Education, University of London, London, UK.
| | - L Duley
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, University of Nottingham, Nottingham, UK.
| | - G Gyte
- National Childbirth Trust, London, UK.
| | - J M Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
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Gallagher B, Berman AH, Bieganski J, Jones AD, Foca L, Raikes B, Schiratzki J, Urban M, Ullman S. National Human Research Ethics: A Preliminary Comparative Case Study of Germany, Great Britain, Romania, and Sweden. ETHICS & BEHAVIOR 2015; 26:586-606. [PMID: 27746664 PMCID: PMC5044765 DOI: 10.1080/10508422.2015.1096207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Although international research is increasing in volume and importance, there remains a dearth of knowledge on similarities and differences in “national human research ethics” (NHREs), that is, national ethical guidelines (NEGs), Institutional Review Boards (IRBs), and research stakeholder’ ethical attitudes and behaviors (EABs). We begin to address this situation by reporting upon our experiences in conducting a multinational study into the mental health of children who had a parent/carer in prison. The study was conducted in 4 countries: Germany, Great Britain, Romania, and Sweden. Data on NHREs were gathered via a questionnaire survey, two ethics-related seminars, and ongoing contact between members of the research consortium. There was correspondence but even more so divergence between countries in the availability of NEGs and IRBs and in researcher’ EABs. Differences in NHREs have implications particularly in terms of harmonization but also for ethical philosophy and practice and for research integrity.
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Affiliation(s)
| | - Anne H Berman
- Department of Clinical Neurosciences, Karolinska Institutet
| | | | - Adele D Jones
- School of Human and Health Sciences, University of Huddersfield
| | - Liliana Foca
- Department of Psychology, Asociația Alternative Sociale
| | - Ben Raikes
- Division of Social Work, University of Huddersfield
| | | | - Mirjam Urban
- Department of Medicine, Technische Universitaet Dresden
| | - Sara Ullman
- Department of Investigation, The Swedish Police
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Yang F, Jiang W, Bai Y, Han J, Liu X, Zhang G, Zhao G. Treatment of Rivaroxaban versus Aspirin for Non-disabling Cerebrovascular Events (TRACE): study protocol for a randomized controlled trial. BMC Neurol 2015; 15:195. [PMID: 26458895 PMCID: PMC4603584 DOI: 10.1186/s12883-015-0453-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 10/01/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transient ischemic attack (TIA) or minor ischemic stroke represents the largest group of cerebrovascular disease, and those patients have a high risk of early recurrent stroke. Over decades, anticoagulation therapy has been used prudently in them for likely increasing the risk of intra-/extra-cranial hemorrhagic complications. However, recently rivaroxaban, a new oral anticoagulant, is proved to be as effective as traditional anticoagulants, while carrying significantly less risk of intracranial hemorrhage. Therefore, we assumed that patients may benefit from rivaroxaban if treated soon after TIA or minor stroke, and designed this adequately powered randomized study, TRACE. METHODS AND DESIGN The Treatment of Rivaroxaban versus Aspirin in Non-disabling Cerebrovascular Events (TRACE) study is a randomized, double-blind clinical trial with a target enrollment of 4400 patients. A 14-days regimen of rivaroxaban 10 mg daily or a 14-days regimen of aspirin 100 mg daily will be administrated to randomized participants with acute TIA or minor stroke, defined as National Institute of Health Stroke Scale scores ≤ 3. The primary efficacy end point is percentage of patients with any stroke (ischemic or hemorrhage) at 14 days. Study visits will be performed at the day of randomization, day 14 and day 90. DISCUSSION Even though the new oral anticoagulants seem to be both safe and effective, few clinical trials have been carried out to test their effect on non-disabling cerebrovascular events. Treatment with rivaroxaban may prevent more cerebrovascular events with an acceptable risk profile after TIA or minor stroke, compared with aspirin, thus helping to improve the outcome of the disease. TRIAL REGISTRATION No. NCT01923818.
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Affiliation(s)
- Fang Yang
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
| | - Wenrui Jiang
- Emergency Department, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
| | - Ya Bai
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
| | - Junliang Han
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
| | - Xuedong Liu
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
| | - Guangyun Zhang
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
| | - Gang Zhao
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China.
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27
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Jansen-van der Weide MC, Caldwell PHY, Young B, de Vries MC, Willems DL, Van't Hoff W, Woolfall K, van der Lee JH, Offringa M. Clinical Trial Decisions in Difficult Circumstances: Parental Consent Under Time Pressure. Pediatrics 2015; 136:e983-92. [PMID: 26416935 DOI: 10.1542/peds.2014-3402] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Treatments and interventions used to care for children in emergencies should be based on strong evidence. Well-designed clinical trials investigating these interventions for children are therefore indispensable. Parental informed consent is a key ethical requirement for the enrollment of children in such studies. However, if time is limited because of an urgent need for intervention, there are additional ethical challenges to adequately support the informed consent process. The acute situation and associated psychological impact may compromise the ability of parents to give informed consent. Little evidence exists to guide the process of consent seeking for a child's research participation when time is limited. It is also unclear in what circumstances alternatives to prospective informed consent could be applied. This article describes possible options to manage the informed consent process in an appropriate, practical, and, we believe, ethical way when time is limited.
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Affiliation(s)
| | - Patrina H Y Caldwell
- Discipline of Paediatrics and Child Health, University of Sydney, Sydney, Australia
| | - Bridget Young
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, United Kingdom
| | - Martine C de Vries
- Departments of Pediatrics, Medical Ethics and Law, Leiden University Medical Center, Leiden, Netherlands
| | - Dick L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Center/University of Amsterdam, Amsterdam, Netherlands
| | - William Van't Hoff
- Clinical Research Facility, Great Ormond Street Hospital, London, United Kingdom; and
| | - Kerry Woolfall
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, United Kingdom
| | - Johanna H van der Lee
- Pediatric Clinical Research Office, Emma Children's Hospital, Academic Medical Center, Amsterdam, Netherlands
| | - Martin Offringa
- Child Health Evaluative Sciences, SickKids Research Institute, University of Toronto, Toronto, Ontario, Canada
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28
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Vain NE, Musante GA, Mariani GL. Meconium Stained Newborns: Ethics for Evidence in Resuscitation. J Pediatr 2015; 166:1109-12. [PMID: 25720365 DOI: 10.1016/j.jpeds.2015.01.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 01/28/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Nestor E Vain
- Department of Pediatrics, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina; FUNDASAMIN (Fundación para la Salud Materno Infantil), Buenos Aires, Argentina; Department of Neonatology, Hospitals Sanatorio de la Trinidad Palermo and San Isidro, Buenos Aires, Argentina.
| | - Gabriel A Musante
- Department of Pediatrics, Facultad de Ciencias Biomédicas, Universidad Austral, Argentina; Department of Maternal and Child Health, Hospital Universitario Austral, Pilar, Argentina
| | - Gonzalo L Mariani
- Department of Pediatrics, School of Medicine, University Institute, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Neonatology Division, Hospital Italiano, Buenos Aires, Argentina
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Ayers S, Sawyer A, Düring C, Rabe H. Parents report positive experiences about enrolling babies in a cord-related clinical trial before birth. Acta Paediatr 2015; 104:e164-70. [PMID: 25639827 DOI: 10.1111/apa.12922] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 08/06/2014] [Accepted: 01/07/2015] [Indexed: 12/01/2022]
Abstract
AIM The aim of this study was to evaluate parents' perceptions when they were asked to enrol their unborn preterm infant in a randomised trial involving delayed cord clamping or cord milking. METHODS The parents of 58 infants were asked to take part in a qualitative study using semi-structured interviews to provide feedback about how they felt about their infants being included in the research project. A total of 37 parents - 15 fathers and 22 mothers - agreed to take part. RESULTS Parents were generally positive about their experiences of their baby taking part in the trial, but the findings raised some concerns about the validity of the consent obtained before delivery, as it was given in a hurry, and some participants had difficulty remembering that they had agreed to take part. Four themes were identified from the interviews: implications of taking part, reasons for enrolling infants, experiences of recruitment and suggestions for improvement. CONCLUSION Overall, the parents were positive about their baby taking part in the trial, but the consent process could be improved, by providing information about relevant trials earlier in the pregnancy or implementing continuous consent at key points in the trial.
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Affiliation(s)
- Susan Ayers
- Centre for Maternal and Child Health Research; City University London; London UK
| | - Alexandra Sawyer
- Centre for Maternal and Child Health Research; City University London; London UK
| | | | - Heike Rabe
- Brighton and Sussex Medical School and University Hospitals; Brighton UK
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Schreiner MS, Feltman D, Wiswell T, Wootton S, Arnold C, Tyson J, Lantos JD. When is waiver of consent appropriate in a neonatal clinical trial? Pediatrics 2014; 134:1006-12. [PMID: 25287456 PMCID: PMC4533281 DOI: 10.1542/peds.2014-0207] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
It is difficult to do scientifically rigorous research on treatments that must be administered urgently or emergently. Therefore, such treatments are often provided without a strong evidence base. Research would be facilitated if it were permissible to waive the requirement for parental consent. However, that raises a different set of concerns. Federal regulations allow waiver of the requirement for consent but only if studies meet certain conditions. Institutional review boards must decide whether those conditions are met. Sometimes, reasonable people disagree. We present and analyze a protocol for which investigators request a waiver of consent.
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Affiliation(s)
- Mark S. Schreiner
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania;,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dalia Feltman
- Northshore Evanston Hospital, Evanston, Illinois;,University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | | | | | - Cody Arnold
- University of Texas at Houston, Houston, Texas
| | - Jon Tyson
- University of Texas at Houston, Houston, Texas
| | - John D. Lantos
- University of Missouri–Kansas City, Kansas City, Missouri; and,Children’s Mercy Hospital, Kansas City, Missouri
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Yang F, Lei H, Jiang W, Jiang W, Han J, Zhao G. Initial 3-weeks' Apixaban Versus Dual-antiplatelet Therapy (Clopidogrel and Aspirin) followed by Clopidogrel alone in high-risk patients with Acute Non-Disabling Cerebrovascular Events (ADANCE): study protocol for a randomized controlled trial. Clin Drug Investig 2014; 34:755-61. [PMID: 25200142 PMCID: PMC4210645 DOI: 10.1007/s40261-014-0228-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background
Nondisabling cerebrovascular events represent the largest group of cerebrovascular disease with a high risk of recurrent stroke. A recent trial demonstrated that dual-antiplatelet therapy (clopidogrel and aspirin), compared with aspirin monotherapy, reduced the risk of recurrent stroke and was not associated with increased risk of hemorrhagic events. Apixaban, a new oral anticoagulant, has been proven to be as safe and effective as traditional anticoagulants while carrying significantly less risk of intracranial hemorrhage. Patients with transient ischemic attack (TIA)/minor stroke might benefit from apixaban treatment; therefore, an adequately powered randomized study is needed. Methods and Results The ADANCE [Apixaban Versus Dual-antiplatelet Therapy (Clopidogrel and Aspirin) in Acute Non-disabling Cerebrovascular Events] study is a randomized, double-blind clinical trial with a target enrollment of 5,500 patients. A 21-day regimen of apixaban or of clopidogrel with aspirin followed by clopidogrel on days 22 through 90 will be administered to randomized participants with acute TIA or minor ischemic stroke. The primary efficacy endpoint is the percentage of patients with any new stroke (ischemic or hemorrhage), including fatal stroke, at day 21. Study visits will be performed on the day of randomization, and at days 7, 22, and 90. Discussion The novel oral anticoagulant apixaban has been widely used with fewer adverse effects than traditional anticoagulants. We designed the ADANCE trial to observe the effects of apixaban on recurrent stroke after TIA or minor stroke. The results should better guide the selection of anticoagulant or dual-antiplatelet therapy for patients with acute TIA or minor ischemic stroke.
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Affiliation(s)
- Fang Yang
- Department of Neurology, Xijing Hospital, No. 15 West Changle Road, Xi'an, 710032, China,
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Mothers of babies enrolled in a randomized trial immediately after birth report a positive experience. J Perinatol 2014; 34:280-3. [PMID: 24480902 DOI: 10.1038/jp.2013.183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 12/12/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Randomized trials are essential for improving outcomes, but researchers can be hesitant about undertaking clinical trials in newborn babies because of perceived vulnerability of the baby and risk of increasing parental anxiety. There is a paucity of evidence about the parental experience. We investigated mothers' experiences of having their newborn baby participate in a randomized double-blind placebo-controlled trial soon after birth. STUDY DESIGN Eligible mothers had consented to their baby's participation in the Sugar Babies Study. Mothers of potentially eligible babies were invited to join the study antenatally, but others were approached postnatally. Babies were enrolled in the study soon after birth and remained in the study for 48 h. After 2 weeks the birth mothers were interviewed by phone about their experience. RESULT Four hundred and eighty-one mothers were enrolled, of whom 310 (64%) gave consent antenatally. All mothers were contacted and 477 (99%) were interviewed. The majority of mothers (458, 96%) reported they would consent to participating again, if they had another eligible baby, and 460 mothers (96%) reported they would recommend participation to family and friends. Nineteen mothers (4%) reported they did not like the heel lance blood tests, which were part of routine clinical care and not part of the trial protocol. CONCLUSION Most mothers reported the experience of having their newborn baby participate in a clinical trial as positive. Most negative responses were related to aspects of routine care rather than the trial protocol.
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Abstract
OBJECTIVES US regulations allow local institutional review boards to approve greater than minimal risk, no-benefit research when the research enrolls children with the condition under study but not when it enrolls healthy children. We aim to describe the opinions of parents regarding higher-hazard, no-benefit research METHODS Quantitative and qualitative interviews with parents of children without heart disease or chronic medical conditions (no heart disease [noHD], n = 30), children with fully correctable heart disease (FCHD, n = 30), and children with life-altering heart disease (LAHD, n = 30). RESULTS Parents of children with heart disease endorse higher-hazard, no-benefit heart disease research more strongly than noHD parents. Eight of 30 noHD parents, 19 of 30 FCHD parents, and 26 of 30 LAHD parents reported willingness to enroll their children in a heart disease research study involving an otherwise unnecessary chest radiograph (P < .01). There was no difference among groups in willingness to enroll their children in a similar study focused on childhood cancer. Twenty-two of 30 FCHD and 30 of 30 LAHD parents reported that parents have a responsibility to enroll their children in medical research to help future children with heart disease. Twenty-one of 30 noHD parents, 29 of 30 FCHD parents, and 30 of 30 LAHD parents feel able to evaluate the risks of medical research (P = .01). CONCLUSIONS Parental opinions regarding higher-hazard, no-benefit research align with federal regulations. Parental willingness to enroll their children in higher-hazard, no-benefit research is driven in part by a sense of obligation to a community of families affected by childhood heart disease.
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Affiliation(s)
- Tanya Sachdeva
- Department of Pediatrics, Children's Hospital of New York, 3959 Broadway, CHN 10-24, New York, NY 10032.
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Rose D, Russo J, Wykes T. Taking part in a pharmacogenetic clinical trial: assessment of trial participants understanding of information disclosed during the informed consent process. BMC Med Ethics 2013; 14:34. [PMID: 24025622 PMCID: PMC3847084 DOI: 10.1186/1472-6939-14-34] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 08/20/2013] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND This study is the first to examine the understandings that participants have of the consent process in a pharmacogenetic trial of anti-depressant medication. METHODS This was a qualitative cross sectional study. There were 76 participants residing in London, Mannheim, Arhuus and Poznan. RESULTS Only one quarter of participants (none in Poznan) could articulate the concept of pharmacogenetics. Heritability and testing medication were also given as the purpose of the trial. Most participants had not appreciated harms that could derive from the trial. Even when shown the consent sheet, participants were confused about DNA profiling. There was evidence that participants appreciated weekly contact with researchers. Most said they would participate in a trial again but would like choice over the intervention they were assigned to. CONCLUSION Participants in this study showed a poor level of informed consent. Although this is not the first time this argument has been made, it is in the case of a pharmacogenetic trial. Further work should investigate the associations between extraneous factors such as information and social support on beneficial or untoward outcomes of antidepressant treatment.
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Affiliation(s)
- Diana Rose
- Institute of Psychiatry, King's College London, de Crespigny Park, London SE5 8AF, UK
| | - Jasna Russo
- Institute of Psychiatry, King's College London, de Crespigny Park, London SE5 8AF, UK
| | - Til Wykes
- Institute of Psychiatry, King's College London, de Crespigny Park, London SE5 8AF, UK
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Roth-Cline M, Nelson RM. Parental permission and child assent in research on children. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2013; 86:291-301. [PMID: 24058304 PMCID: PMC3767214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Grounded on the ethical principle of respect for persons, parental permission and child assent function together to protect the child and to foster the development of the child's self-determination. Although both parental permission and child assent involve the same components of information sharing, comprehension, and voluntariness, how these three components are understood and operationalized should differ depending on the developmental level of the child. For example, the amount of information that a child must comprehend to provide meaningful and developmentally appropriate child assent (or dissent) should be allowed to vary with the age and maturity of the child. By understanding child assent together with the important protections of parental permission, child assent does not need to be burdened with the same informational and process requirements. As a result, the age (as a proxy for developmental stage) at which a child is deemed capable of assent would be lower (i.e., 5 to 7 years old). By assuming a lack of capacity, the potential arises to dishonor and disregard a child's wishes by failing to solicit meaningful assent or dissent. Further research needs to be done on how best to obtain truly informed and voluntary parental permission and child assent for research participation.
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Affiliation(s)
- Michelle Roth-Cline
- Office of Pediatric Therapeutics, Food and Drug Administration, Silver Spring,
Maryland
| | - Robert M. Nelson
- Office of Pediatric Therapeutics, Food and Drug Administration, Silver Spring,
Maryland
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Woolfall K, Shilling V, Hickey H, Smyth RL, Sowden E, Williamson PR, Young B. Parents' agendas in paediatric clinical trial recruitment are different from researchers' and often remain unvoiced: a qualitative study. PLoS One 2013; 8:e67352. [PMID: 23844006 PMCID: PMC3701006 DOI: 10.1371/journal.pone.0067352] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 05/17/2013] [Indexed: 11/19/2022] Open
Abstract
Ensuring parents make an informed decision about their child's participation in a clinical trial is a challenge for practitioners as a parent's comprehension of a trial may differ from that intended by the practitioners responsible for recruitment. We explored what issues parents consider important when making a decision about participation in a paediatric clinical trial and their comprehension of these issues to inform future recruitment practice. This qualitative interview and observational study examined recruitment in four placebo-controlled, double-blind randomised clinical trials of medicines for children. Audio-recorded trial recruitment discussions between practitioners and parents (N = 41) were matched with semi-structured interviews with parents (N = 41). When making a decision about trial entry parents considered clinical benefit, child safety, practicalities of participation, research for the common good, access to medication and randomisation. Within these prioritised issues parents had specific misunderstandings, which had the potential to influence their decisions. While parents had many questions and concerns about trial participation which influenced their decision-making, they rarely voiced these during discussions about the trials with practitioners. Those involved in the recruitment of children to clinical trials need to be aware of parents' priorities and the sorts of misunderstandings that can arise with parents. Providing trial information that is tailored to what parents consider important in making a decision about a clinical trial may improve recruitment practice and ultimately benefit evidence-based paediatric medicine.
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Affiliation(s)
- Kerry Woolfall
- Department of Psychological Sciences, University of Liverpool, Liverpool, United Kingdom.
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Molyneux S, Njue M, Boga M, Akello L, Olupot-Olupot P, Engoru C, Kiguli S, Maitland K. 'The words will pass with the blowing wind': staff and parent views of the deferred consent process, with prior assent, used in an emergency fluids trial in two African hospitals. PLoS One 2013; 8:e54894. [PMID: 23408950 PMCID: PMC3569446 DOI: 10.1371/journal.pone.0054894] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 12/17/2012] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To document and explore the views and experiences of key stakeholders regarding the consent procedures of an emergency research clinical trial examining immediate fluid resuscitation strategies, and to discuss the implications for similar trials in future. METHODS A social science sub-study of the FEAST (Fluid Expansion As Supportive Therapy) trial. Interviews were held with trial team members (n = 30), health workers (n = 15) and parents (n = 51) from two purposively selected hospitals in Soroti, Uganda, and Kilifi, Kenya. FINDINGS Overall, deferred consent with prior assent was seen by staff and parents as having the potential to protect the interests of both patients and researchers, and to avoid delays in starting treatment. An important challenge is that the validity of verbal assent is undermined when inadequate initial information is poorly understood. This concern needs to be balanced against the possibility that full prior consent on admission potentially causes harm through introducing delays. Full prior consent also potentially imposes worries on parents that clinicians are uncertain about how to proceed and that clinicians want to absolve themselves of any responsibility for the child's outcome (some parents' interpretation of the need for signed consent). Voluntariness is clearly compromised for both verbal assent and full prior consent in a context of such vulnerability and stress. Further challenges in obtaining verbal assent were: what to do in the absence of the household decision-maker (often the father); and how medical staff handle parents not giving a clear agreement or refusal. CONCLUSION While the challenges identified are faced in all research in low-income settings, they are magnified for emergency trials by the urgency of decision making and treatment needs. Consent options will need to be tailored to particular studies and settings, and might best be informed by consultation with staff members and community representatives using a deliberative approach.
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Affiliation(s)
- Sassy Molyneux
- Health Systems and Social Science Research Group, Kenya Medical Research Institute-ellcome Trust Research Programme, Kilifi, Kenya.
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Han J, Yang F, Jiang W, Zhang G, Liu Z, Liu X, Xia F, Bai Y, He J, Chao M, Zhao G. Hydroxyethyl starch 130/0.4 and sodium chloride injection as adjunctive therapy in patients with cerebral hypoperfusion. BMC Neurol 2012; 12:127. [PMID: 23110412 PMCID: PMC3557161 DOI: 10.1186/1471-2377-12-127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Accepted: 09/26/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Both severe stenosis and completed occlusion in internal carotid artery or its distal branches have been considered the main reasons of cerebral hypoperfusion, which contributes to the washout disturbances of embolism in low perfusion territories distal to stenosis. An aggravated hypoperfusion state in certain brain region may induce ischemic stroke and further cognitive decline. However, the effective medication for cerebral hypoperfusion is largely unsettled. METHODS/DESIGN By using computed tomography perfusion (CTP) imaging, the trial will evaluate the effectiveness, safety and tolerability of hydroxyethyl starch (HES) 130/0.4 for patients with extra-/intra-cranial artery stenosis and cerebral hypoperfusion. From 5 neurological inpatient wards, 300 patients will be randomly recruited for administered routine medications plus intravascular volume therapies using the equal volume of HES 130/0.4 or 0.9% sodium chloride solution. Cerebral hypoperfusion state after 7-day intervention is the primary outcome measure. The secondary outcome measures includes, impaired renal function, abnormal heart function, hematological changes, neurological dysfunctions and cerebrovascular events in peri-intervention period and/or 3-month follow-up. The sample size will allow the detection of a two-sided 5% significance level between groups in the endpoint with a power of 80%. DISCUSSION The trial would provide important efficacy and safety data on the intravascular administration of HES 130/0.4 in patients with unilateral cerebral hypoperfusion. The effects on kidney function, heart function, coagulation, neurological function and cerebralvascular events will be assessed. TRIAL REGISTRATION ClinicalTrials.gov (Identifier: NCT01192581).
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Affiliation(s)
- Junliang Han
- Department of Neurology, Xijing Hospital, No, 15 West Changle Road, Xi'an, China, 710032
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Cartwright K, Mahoney L, Ayers S, Rabe H. Parents' perceptions of their infants' participation in randomized controlled trials. J Obstet Gynecol Neonatal Nurs 2012; 40:555-65. [PMID: 22273412 DOI: 10.1111/j.1552-6909.2011.01276.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To explore parents' perceptions of their infants' participation in randomized control trials (RCTs) and the implications of the RCT for their infant and themselves. DESIGN A qualitative study using semistructured interviews. SETTING Participants were identified from neonatal intensive care unit (NICU) clinical registers and from responses to an advertisement put on the website of United Kingdom special care baby charity, BLISS. Interviews were conducted with parents face-to-face in their homes or over the telephone. PARTICIPANTS Sixteen parents of 12 infants born prematurely or with complications at full term and who had participated in one of three RCTs while receiving intensive care in one of seven NICUs. METHODS Interviews were audio-taped or digitally recorded, transcribed verbatim, and analyzed using systematic thematic analysis using WinMax qualitative software. RESULTS Five main themes emerged from the data. The themes were parents' immediate reactions to being approached about RCT enrollment, interactions between parents and clinicians upon the approach of enrollment and during the RCT, making the decision to enroll their infants, implications of the RCT for parents, and effects of the RCT on the infants. CONCLUSIONS Clinicians should be encouraged to approach parents about enrollment of their infants in clinical research given that parents reported mostly positive experiences related to this participation. However, appropriate measures should be taken to ensure that the individual needs of parents are being met throughout the entire research process from enrollment to follow-up.
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Affiliation(s)
- Kim Cartwright
- Developmental Brain Behaviour Laboratory, School of Psychology, University of Southampton, Highfield, Southampton, UK.
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Bromage DI, Lim J, ter Meulen R, Ramcharitar S. Improving informed consent in percutaneous coronary revascularisation. EUROINTERVENTION 2012; 8:146-54. [DOI: 10.4244/eijv8i1a22] [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] [Indexed: 11/23/2022]
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Wulf F, Krasuska M, Bullinger M. Determinants of decision-making and patient participation in paediatric clinical trials: A literature review. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/ojped.2012.21001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Perceptions of informed consent for care practices: hospitalized patients and nurses. Appl Nurs Res 2011; 24:276-80. [DOI: 10.1016/j.apnr.2009.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2009] [Revised: 12/10/2009] [Accepted: 12/16/2009] [Indexed: 11/21/2022]
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Blanco D. Presente y futuro de la neuroprotección con hipotermia. An Pediatr (Barc) 2011; 75:295-7. [DOI: 10.1016/j.anpedi.2011.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 07/18/2011] [Accepted: 07/18/2011] [Indexed: 11/28/2022] Open
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Blanco D, García-Alix A, Valverde E, Tenorio V, Vento M, Cabañas F. [Neuroprotection with hypothermia in the newborn with hypoxic-ischaemic encephalopathy. Standard guidelines for its clinical application]. An Pediatr (Barc) 2011; 75:341.e1-20. [PMID: 21925984 DOI: 10.1016/j.anpedi.2011.07.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 07/18/2011] [Accepted: 07/18/2011] [Indexed: 01/24/2023] Open
Abstract
Standardisation of hypothermia as a treatment for perinatal hypoxic-ischaemic encephalopathy is supported by current scientific evidence. The following document was prepared by the authors on request of the Spanish Society of Neonatology and is intended to be a guide for the proper implementation of this therapy. We discuss the difficulties that may arise when moving from the strict framework of clinical trials to clinical daily care: early recognition of clinical encephalopathy, inclusion and exclusion criteria, hypothermia during transport, type of hypothermia (selective head or systemic cooling) and side effects of therapy. The availability of hypothermia therapy has changed the prognosis of children with hypoxic-ischaemic encephalopathy and our choices of therapeutic support. In this sense, it is especially important to be aware of the changes in the predictive value of the neurological examination and the electroencephalographic recording in cooled infants. In order to improve neuroprotection with hypothermia we need earlier recognition of to recognise earlier the infants that may benefit from cooling. Biomarkers of brain injury could help us in the selection of these patients. Every single infant treated with hypothermia must be included in a follow up program in order to assess neurodevelopmental outcome.
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Affiliation(s)
- D Blanco
- Servicio de Neonatología, Hospital Universitario Gregorio Marañón, Madrid, España.
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Robertson NJ, Hagmann CF, Acolet D, Allen E, Nyombi N, Elbourne D, Costello A, Jacobs I, Nakakeeto M, Cowan F. Pilot randomized trial of therapeutic hypothermia with serial cranial ultrasound and 18-22 month follow-up for neonatal encephalopathy in a low resource hospital setting in Uganda: study protocol. Trials 2011; 12:138. [PMID: 21639927 PMCID: PMC3127769 DOI: 10.1186/1745-6215-12-138] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 06/04/2011] [Indexed: 11/26/2022] Open
Abstract
Background There is now convincing evidence that in industrialized countries therapeutic hypothermia for perinatal asphyxial encephalopathy increases survival with normal neurological function. However, the greatest burden of perinatal asphyxia falls in low and mid-resource settings where it is unclear whether therapeutic hypothermia is safe and effective. Aims Under the UCL Uganda Women's Health Initiative, a pilot randomized controlled trial in infants with perinatal asphyxia was set up in the special care baby unit in Mulago Hospital, a large public hospital with ~20,000 births in Kampala, Uganda to determine: (i) The feasibility of achieving consent, neurological assessment, randomization and whole body cooling to a core temperature 33-34°C using water bottles (ii) The temperature profile of encephalopathic infants with standard care (iii) The pattern, severity and evolution of brain tissue injury as seen on cranial ultrasound and relation with outcome (iv) The feasibility of neurodevelopmental follow-up at 18-22 months of age Methods/Design Ethical approval was obtained from Makerere University and Mulago Hospital. All infants were in-born. Parental consent for entry into the trial was obtained. Thirty-six infants were randomized either to standard care plus cooling (target rectal temperature of 33-34°C for 72 hrs, started within 3 h of birth) or standard care alone. All other aspects of management were the same. Cooling was performed using water bottles filled with tepid tap water (25°C). Rectal, axillary, ambient and surface water bottle temperatures were monitored continuously for the first 80 h. Encephalopathy scoring was performed on days 1-4, a structured, scorable neurological examination and head circumference were performed on days 7 and 17. Cranial ultrasound was performed on days 1, 3 and 7 and scored. Griffiths developmental quotient, head circumference, neurological examination and assessment of gross motor function were obtained at 18-22 months. Discussion We will highlight differences in neonatal care and infrastructure that need to be taken into account when considering a large safety and efficacy RCT of therapeutic hypothermia in low and mid resource settings in the future. Trial registration Current controlled trials ISRCTN92213707
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Affiliation(s)
- Nicola J Robertson
- Institute for Women's Health, 86-96 Chenies Mews, University College London, London, UK.
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Abstract
Informed consent is a communication process of providing the patient/parents/guardians with relevant information regarding the treatment and the diagnosis, so that they can make informed decisions. The process of informed consent in pediatric patients is not well understood. The amount of information to be disclosed in an informed consent is a matter of debate. There are four basic elements to the content of informed consent form: nature of procedure, risks, benefits and alternatives. The article delineates the essential elements and legal implications of informed consent in pediatric practice.
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Affiliation(s)
- Jaya Shankar Kaushik
- Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India.
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Does Informed Consent Have an Expiry Date? A Critical Reappraisal of Informed Consent as a Process. Camb Q Healthc Ethics 2011; 20:85-92. [DOI: 10.1017/s0963180110000642] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Informed consent is central to modern research ethics. Informed consent procedures have mainly been justified in terms of respect for autonomy, the core idea being that it should be every competent individual’s right to decide for herself whether or not to participate in scientific studies. A number of conditions are normally raised with regard to morally valid informed consent. These include that potential research subjects get adequate information, understand those aspects that are relevant to them, and, based on that information, make a voluntary decision whether or not to participate. These conditions are meant to guarantee that participation is genuinely the individual’s own choice and is coherent with his or her authentic interests.
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Abstract
OBJECTIVE Some commentators argue that informed consent for clinical research should be an on-going process, which begins, rather than ends, with participants' initial consent. Lacking, however, are empirical data on whether there is a need for 'on-going consent'. DESIGN Two self-administered surveys - a baseline survey at initial consent and a follow-up survey 2-3 years later - to assess whether participants remain informed over time. METHODS Respondents were adults with HIV disease from Argentina, Brazil and Thailand enrolled in a long-term clinical trial. RESULTS Respondents overall were well informed at baseline. At follow-up, many reported being not informed about aspects of the study central to their on-going participation. With respect to the possibility of withdrawal, 38.5% of respondents at follow-up reported being 'not at all' informed. At follow-up, 71.1% wanted more information. Yet, 62.8% had not asked any questions during the entire study. Reasons for not asking questions included not having an opportunity (16.4%) and not knowing whom to ask (15.5%). CONCLUSIONS The standard consent process resulted in participants being well informed at enrollment. Yet, this process was not sufficient to keep them informed about aspects of the study central to their on-going participation. In addition, participants who wanted more information often did not ask for it. These findings provide empirical support for recommendations that clinical trials should consider including a process of 'on-going consent'.
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Abstract
Hypothermia is the first effective neuroprotective intervention for newborns who are critically ill following a life-threatening asphyxial insult. It is not surprising that it has raised complex and controversial ethical dilemmas for investigators and clinicians. Given the history of iatrogenic disasters in neonatology, there has been an understandable reluctance to incorporate hypothermia into routine clinical practice until there is persuasive evidence from high quality randomised trials. This article reviews ethical issues that arose during the design of the original clinical trials, the implications of accumulating evidence of safety and efficacy, and the problems of ensuring informed parental participation in treatment decisions.
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Affiliation(s)
- John S Wyatt
- Institute for Women's Health, University College London, 5 University Street, London WC1E 6JJ, UK.
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Vallely A, Lees S, Shagi C, Kasindi S, Soteli S, Kavit N, Vallely L, McCormack S, Pool R, Hayes RJ. How informed is consent in vulnerable populations? Experience using a continuous consent process during the MDP301 vaginal microbicide trial in Mwanza, Tanzania. BMC Med Ethics 2010; 11:10. [PMID: 20540803 PMCID: PMC2893460 DOI: 10.1186/1472-6939-11-10] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2009] [Accepted: 06/13/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV prevention trials conducted among disadvantaged vulnerable at-risk populations in developing countries present unique ethical dilemmas. A key concern in bioethics is the validity of informed consent for trial participation obtained from research subjects in such settings. The purpose of this study was to investigate the effectiveness of a continuous informed consent process adopted during the MDP301 phase III vaginal microbicide trial in Mwanza, Tanzania. METHODS A total of 1146 women at increased risk of HIV acquisition working as alcohol and food vendors or in bars, restaurants, hotels and guesthouses have been recruited into the MDP301 phase III efficacy and safety trial in Mwanza. During preparations for the trial, participatory community research methods were used to develop a locally-appropriate pictorial flipchart in order to convey key messages about the trial to potential participants. Pre-recorded audio tapes were also developed to facilitate understanding and compliance with gel-use instructions. A comprehension checklist is administered by clinical staff to all participants at screening, enrolment, 12, 24, 40 and 50 week follow-up visits during the trial. To investigate women's perceptions and experiences of the trial, including how well participants internalize and retain key messages provided through a continuous informed consent process, a random sub-sample of 102 women were invited to participate in in-depth interviews (IDIs) conducted immediately after their 4, 24 and 52 week follow-up visits. RESULTS 99 women completed interviews at 4-weeks, 83 at 24-weeks, and 74 at 52 weeks (a total of 256 interviews). In all interviews there was evidence of good comprehension and retention of key trial messages including that the gel is not currently know to be effective against HIV; that this is the key reason for conducting the trial; and that women should stop using gel in the event of pregnancy. CONCLUSIONS Providing information to trial participants in a focussed, locally-appropriate manner, using methods developed in consultation with the community, and within a continuous informed-consent framework resulted in high levels of comprehension and message retention in this setting. This approach may represent a model for researchers conducting HIV prevention trials among other vulnerable populations in resource-poor settings. TRIAL REGISTRATION Current Controlled Trials ISRCTN64716212.
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Affiliation(s)
- Andrew Vallely
- London School of Hygiene & Tropical Medicine, London, UK.
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