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Kremer S, Shakhnovich V, Riffel AK, Harvey L, Borges CR. Delta-S-Cys-Albumin as a Marker of Pediatric Biospecimen Integrity. Biopreserv Biobank 2024. [PMID: 38651617 DOI: 10.1089/bio.2023.0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
Blood plasma storage is a crucial element of pediatric biobanking. Improperly stored or handled specimens (e.g., at > -30°C) can result in altered biomolecular compositions that no longer reflects in vivo reality. We report application of a previously developed assay in adults-the ΔS-Cys-Albumin assay, which facilitates estimation of plasma and serum exposure to thawed conditions-to a population of pediatric EDTA plasma samples from patients aged 3-18 years to determine the assay's applicability, estimate its reference range for pediatric samples, and assess the impact of pre-centrifugation delay at 0°C. In addition, the effect of plasma thawed-state exposure to a range of times at 23°C, 4°C, and -20°C on ΔS-Cys-Albumin was evaluated. Using 98 precollected and processed pediatric EDTA plasma specimens, no difference was found in ΔS-Cys-Albumin under conditions of pre-centrifugation delay for up to 10 hours at 0°C. This lack of change allowed us to estimate a pediatric reference range for ΔS-Cys-Albumin of 7.0%-22.5% (mean of 12.8%) with a modest Pearson correlation between ΔS-Cys-Albumin and age (p = 0.0037, R2 = 0.29). ΔS-Cys-Albumin stability in six specimens at 23°C, 4°C, and -20°C was also evaluated. Plateaus in the decay curves were reached by 1 day, 7 days, and 14-28 days at these respective temperatures. The estimated pediatric reference range observed in children was lower than that previously observed in 180 adults of 12.3%-30.6% (mean of 20.0%), and the slope of the age correlation in children was twice as steep as that from adults. ΔS-Cys-Albumin decay curves at 23°C, 4°C, and -20°C were similar to those previously observed in adults. The data reported here support the use of ΔS-Cys-Albumin in evaluating the integrity and overall exposure of pediatric EDTA plasma specimens to thawed conditions. In doing so, they add an important quality control tool to the biobanker's arsenal.
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Affiliation(s)
- Schuyler Kremer
- School of Molecular Sciences, Arizona State University, Tempe, Arizona, USA
- The Biodesign Institute at Arizona State University, Tempe, Arizona, USA
| | - Valentina Shakhnovich
- Children's Mercy Hospital, Kansas City, Missouri, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
- Ironwood Pharmaceuticals, Boston, Massachusetts, USA
| | | | - Lisa Harvey
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Chad R Borges
- School of Molecular Sciences, Arizona State University, Tempe, Arizona, USA
- The Biodesign Institute at Arizona State University, Tempe, Arizona, USA
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Murdoch B, Jandura A, Caulfield T. Reconsenting paediatric research participants for use of identifying data. JOURNAL OF MEDICAL ETHICS 2023; 49:106-109. [PMID: 35046134 PMCID: PMC9887363 DOI: 10.1136/medethics-2021-107958] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/30/2021] [Indexed: 06/14/2023]
Abstract
When a minor research participant reaches the age of majority or the level of maturity necessary to be granted legal decision-making capacity, reconsent can be required for ongoing participation in research or use of health information and banked biological materials. Despite potential logistical concerns with implementation and ethical questions about the trade-offs between maximising respect for participant agency and facilitating research that may generate benefits, reconsent is the approach most consistent with both law and research ethics.Canadian common law consent requirements are expansive and likely compel reconsent on obtaining capacity. Common law doctrine recognises that children are entitled to decision-making authority that reflects their evolving intelligence and understanding. Health consent legislation varies by province but generally either compels reconsent on obtaining capacity or delegates the ability to determine reconsent to research ethics boards. These boards largely rely on the Canada's national ethics policy, the Tri-Council Policy Statement, which states that, with few exceptions, reconsent for continued participation is required when minors gain capacity that would allow them to consent to the research in which they participate. A strict interpretation of this policy could require researchers to perform frequent capacity assessments, potentially presenting feasibility concerns. In addition, Canadian policy and law are generally consistent with the core principles of key international ethical standards from the United Nations and elsewhere.In sum, reconsent of paediatric participants upon obtaining capacity should be explicit and informed in Canada, and should not be presumed from continued participation alone.
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Affiliation(s)
- Blake Murdoch
- Faculty of Law, University of Alberta, Edmonton, Alberta, Canada
| | - Allison Jandura
- Faculty of Law, University of Alberta, Edmonton, Alberta, Canada
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Munung NS, Nembaware V, Osei-Tutu L, Treadwell M, Chide OE, Bukini D, Tutuba H, Wonkam A. Assent, parental consent and reconsent for health research in Africa: thematic analysis of national guidelines and lessons from the SickleInAfrica registry. BMC Med Ethics 2022; 23:130. [PMID: 36482457 PMCID: PMC9730625 DOI: 10.1186/s12910-022-00843-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 10/18/2022] [Indexed: 12/13/2022] Open
Abstract
The enrolment of children and adolescents in health research requires that attention to be paid to specific assent and consent requirements such as the age range for seeking assent; conditions for parental consent (and waivers); the age group required to provide written assent; content of assent forms; if separate assent and parental consent forms should be used, consent from emancipated young adults; reconsent at the age of adulthood when a waiver of assent requirements may be appropriate and the conditions for waiving assent requirements. There is however very little available information for researchers and ethics committees on how to navigate these different issues. To provide guidance to research initiatives, the SickleInAfrica consortium conducted a thematic analysis of a sample of research ethics guidelines and procedures in African countries, to identify guidance for assent requirements in health research. The thematic analysis revealed that 12 of 24 African countries specified the age group for which assent is required. The minimum age for written assent varied across the countries. Five countries, Algeria, Botswana, Cameroon, Nigeria and The Democratic Republic of Congo require consent from both parents/family council in certain circumstances. Botswana, Nigeria, South Africa and Uganda have specific assent/consent requirements for research with emancipated minors. South Africa and Algeria requires re-consent at onset of adulthood. Five countries (Botswana, Cameroon, Nigeria, South Africa and Tanzania) specified conditions for waiving assent requirements. The CIOMS and the ICH-GCP guidelines had the most comprehensive information on assent requirements compared to other international guidelines. An interactive map with assent requirements for different African countries is provided. The results show a major gap in national regulations for the inclusion of minors in health research. The SickleInAfrica experience in setting up a multi-country SCD registry in Africa highlights the need for developing and harmonising national and international guidelines on assent and consent requirements for research involving minors. Harmonisation of assent requirements will help facilitate collaborative research across countries.
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Affiliation(s)
- Nchangwi Syntia Munung
- grid.7836.a0000 0004 1937 1151Division of Human Genetics, University of Cape Town, Cape Town, South Africa
| | - Victoria Nembaware
- grid.7836.a0000 0004 1937 1151Division of Human Genetics, University of Cape Town, Cape Town, South Africa
| | | | - Marsha Treadwell
- grid.266102.10000 0001 2297 6811Department of Pediatrics, School of Medicine, University of California San Francisco, San Francisco, CA USA
| | - Okocha Emmanuel Chide
- grid.470111.20000 0004 1783 5514Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra Nigeria
| | - Daima Bukini
- grid.25867.3e0000 0001 1481 7466Sickle Cell Program, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Hilda Tutuba
- grid.25867.3e0000 0001 1481 7466Sickle Cell Program, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | | | - Ambroise Wonkam
- grid.7836.a0000 0004 1937 1151Division of Human Genetics, University of Cape Town, Cape Town, South Africa ,grid.469474.c0000 0000 8617 4175McKusick-Nathans Institute and Department of Genetic Medicine, Johns Hopkins Medicine, Baltimore, MD USA
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Patrinos D, Knoppers BM, Laplante DP, Rahbari N, Wazana A. Sharing and Safeguarding Pediatric Data. Front Genet 2022; 13:872586. [PMID: 35795212 PMCID: PMC9251179 DOI: 10.3389/fgene.2022.872586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/30/2022] [Indexed: 11/21/2022] Open
Abstract
Data sharing is key to advancing our understanding of human health and well-being. While issues related to pediatric research warrant strong ethical protections, overly protectionist policies may serve to exclude minors from data sharing initiatives. Pediatric data sharing is critical to scientific research concerning health and well-being, to say nothing of understanding human development generally. For example, large-scale pediatric longitudinal studies, such as those in the DREAM-BIG Consortium, on the influence of prenatal adversity factors on child psychopathology, will provide prevention data and generate future health benefits. Recent initiatives have formulated sound policy to help enable and foster data sharing practices for pediatric research. To help translate these policy initiatives into practice, we discuss how model consent clauses for pediatric research can help address some of the issues and challenges of pediatric data sharing, while enabling data sharing.
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Affiliation(s)
- Dimitri Patrinos
- Centre of Genomics and Policy, School of Biomedical Sciences, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
- *Correspondence: Dimitri Patrinos,
| | - Bartha Maria Knoppers
- Centre of Genomics and Policy, School of Biomedical Sciences, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - David P. Laplante
- Lady Davis Institute (LDI), Montreal, QC, Canada
- Centre for Child Development and Mental Health, Jewish General Hospital, Montreal, QC, Canada
| | - Noriyeh Rahbari
- Lady Davis Institute (LDI), Montreal, QC, Canada
- Centre for Child Development and Mental Health, Jewish General Hospital, Montreal, QC, Canada
| | - Ashley Wazana
- Lady Davis Institute (LDI), Montreal, QC, Canada
- Centre for Child Development and Mental Health, Jewish General Hospital, Montreal, QC, Canada
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Patrinos D, Knoppers BM, Kleiderman E, Rahbari N, Laplante DP, Wazana A. Re-contact Following Withdrawal of Minors from Research. CANADIAN JOURNAL OF BIOETHICS 2022. [DOI: 10.7202/1087202ar] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Snell K, Tarkkala H. "Here comes Bio-me": An analysis of a biobank campaign targeted at children. PUBLIC UNDERSTANDING OF SCIENCE (BRISTOL, ENGLAND) 2021; 30:913-926. [PMID: 34148459 PMCID: PMC8488646 DOI: 10.1177/09636625211022648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Finnish biobanks have started to recruit children. The national supervising authority has emphasized the centrality of providing children with age-appropriate information. We analyzed one such campaign. We argue that by simplifying the complex socio-technical arrangements of biobanking with the introduction of a new metaphor-like concept, "Bio-me," the campaign presents a misleading and reductionist picture of data-driven biomedicine and biobank participation. First, the Bio-me character seems to bear similarities to the seventeenth-century explanations of embryological development. Second, the focus in the campaign is on biological material while crucial connections to different sorts of data are ignored. Third, we point to the absence of verbal references to genes and DNA, although the prevailing visualization comprises the double helix. We argue that the campaign has potential to contribute to public misunderstanding of science by introducing a new term that has little connection to actual biology or scientific practices it tries to promote.
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Affiliation(s)
- Karoliina Snell
- Karoliina Snell, Sociology, Faculty of Social Sciences, University of Helsinki, PO Box 18, University of Helsinki 00014, Finland.
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Kasperbauer TJ, Halverson C. Adolescent Assent and Reconsent for Biobanking: Recent Developments and Emerging Ethical Issues. Front Med (Lausanne) 2021; 8:686264. [PMID: 34307413 PMCID: PMC8301072 DOI: 10.3389/fmed.2021.686264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/17/2021] [Indexed: 11/13/2022] Open
Abstract
Research biobanks that enroll minors face important practical, ethical, and regulatory challenges in reconsenting participants when they reach the age of 18. Federal regulations governing research in the United States provide minimal guidance and allow for a range of practices, including waiving the requirement to obtain reconsent. Some commentators have argued that institutional review boards should indeed grant such waivers, given the low risks of biobank-based research and the impracticality of contacting all participants when they turn 18. There is also significant ethical debate about the age at which adolescents can make authentic, autonomous decisions regarding their research participation. This paper reviews these issues in detail, describes the current state of the ethical discussion, and outlines evidence-based policies for enrolling minors into research biobanks.
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Affiliation(s)
- T J Kasperbauer
- Indiana University Center for Bioethics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Colin Halverson
- Indiana University Center for Bioethics, Indiana University School of Medicine, Indianapolis, IN, United States
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Boers SN, de Winter-de Groot KM, Noordhoek J, Gulmans V, van der Ent CK, van Delden JJM, Bredenoord AL. Mini-guts in a dish: Perspectives of adult Cystic Fibrosis (CF) patients and parents of young CF patients on organoid technology. J Cyst Fibros 2018. [PMID: 29523474 DOI: 10.1016/j.jcf.2018.02.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Organoid technology enables the cultivation of human tissues in a dish. Its precision medicine potential could revolutionize the Cystic Fibrosis (CF) field. We provide a first thematic exploration of the patient perspective on organoid technology to set the further research agenda, which is necessary for responsible development of this ethically challenging technology. METHODS 23 semi-structured qualitative interviews with 14 Dutch adult CF patients and 12 parents of young CF patients to examine their experiences, opinions, and attitudes regarding organoid technology. RESULTS Four themes emerged: (1) Respondents express a close as well as a distant relationship to organoids; (2) the open-endedness of organoid technology sparks hopes and concerns, (3) commercial use evokes cautiousness. (4) Respondents mention the importance of sound consent procedures, long-term patient engagement, responsible stewardship, and stringent conditions for commercial use. CONCLUSIONS The precision medicine potential of organoid technology can only be realized if the patient perspective is taken adequately into account.
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Affiliation(s)
- Sarah N Boers
- Julius Center for Health Sciences and Primary Care, Department of Medical Humanities, University Medical Center Utrecht, Internal post Str. 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
| | - Karin M de Winter-de Groot
- Department of Pediatric Pulmonology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Internal post KH.01.419.0, P.O. Box 85090, 3508 AB Utrecht, The Netherlands.
| | - Jacquelien Noordhoek
- Dutch Cystic Fibrosis Foundation (NCFS), Dr. A. Schweitzerweg 3A, 3744 MG Baarn, The Netherlands.
| | - Vincent Gulmans
- Dutch Cystic Fibrosis Foundation (NCFS), Dr. A. Schweitzerweg 3A, 3744 MG Baarn, The Netherlands.
| | - Cornelis K van der Ent
- Department of Pediatric Pulmonology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Internal post KH.01.419.0, P.O. Box 85090, 3508 AB Utrecht, The Netherlands.
| | - Johannes J M van Delden
- Julius Center for Health Sciences and Primary Care, Department of Medical Humanities, University Medical Center Utrecht, Internal post Str. 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
| | - Annelien L Bredenoord
- Julius Center for Health Sciences and Primary Care, Department of Medical Humanities, University Medical Center Utrecht, Internal post Str. 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
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Abstract
From a research perspective, the interest in biobanking continues to intensify. Governments and industry have invested heavily in biobanks, as exemplified by initiatives like the United Kingdom Biobank and United States' Precision Medicine Initiative. But despite this enthusiasm, many profound legal and ethical challenges remain unresolved. Indeed, there continues to be disagreements about how best to obtain consent and the degree and nature of control that research participants retain over donated samples and health information. Emerging social trends-including concerns about commercialization and perceived rights of continuing control ("biorights")-seem likely to intensify these issues.
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Affiliation(s)
- Timothy Caulfield
- Health Law Institute, Faculty of Law, University of Alberta, Edmonton, Alberta, Canada
| | - Blake Murdoch
- Health Law Institute, Faculty of Law, University of Alberta, Edmonton, Alberta, Canada
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Chen SC, Berkman BE, Hull SC. Recontacting participants for expanded uses of existing samples and data: a case study. Genet Med 2017; 19:883-889. [PMID: 28125076 PMCID: PMC6097706 DOI: 10.1038/gim.2016.207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/16/2016] [Indexed: 11/09/2022] Open
Abstract
Purpose: Facilitating genomic research may require the use of samples and data collected via consent processes that did not include specific descriptions of secondary uses. We explore whether a waiver of consent with notification and the option to withdraw (WNOW) is a viable alternative to written informed consent for secondary uses of samples and data. Methods: We developed a retrospective case study of a rare disease protocol involving 1978 participants that implemented WNOW for genomic data-sharing activities. We analyzed Institutional Review Board and investigator records and conducted in-depth semi-structured interviews with key staff members. Results: WNNOW was largely successful at achieving its goals in this case, although the re-contact effort, relative to proceeding with a waiver, decreased participation in genomic data-sharing by 13.8% (n=253), primarily because 224 letters were returned as undeliverable. A small number of participants responded (n=89), and some of them expressed confusion and frustration. In the pediatric arm of the study, the research may have been practicable without a waiver, given the relationship between the pediatric clinicians and families. Conclusion: The practicability of conducting research on existing specimens without a waiver of informed consent, and whether WNOW is a viable alternative, depend on contextual factors, including a reliable way to communicate with participants.
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Affiliation(s)
- Stephanie C Chen
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Benjamin E Berkman
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA.,National Human Genome Research Institute, Bethesda, Maryland, USA
| | - Sara Chandros Hull
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA.,National Human Genome Research Institute, Bethesda, Maryland, USA
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Giesbertz NAA, Melham K, Kaye J, van Delden JJM, Bredenoord AL. Personalized assent for pediatric biobanks. BMC Med Ethics 2016; 17:59. [PMID: 27733160 PMCID: PMC5062866 DOI: 10.1186/s12910-016-0142-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 09/29/2016] [Indexed: 12/22/2022] Open
Abstract
Pediatric biobanking is considered important for generating biomedical knowledge and improving (pediatric) health care. However, the inclusion of children’s samples in biobanks involves specific ethical issues. One of the main concerns is how to appropriately engage children in the consent procedure. We suggest that children should be involved through a personalized assent procedure, which means that both the content and the process of assent are adjusted to the individual child. In this paper we provide guidance on how to put personalized assent into pediatric biobanking practice and consider both the content and process of personalized assent. In the discussion we argue that the assent procedure itself is formative. Investing in the procedure should be a requirement for pediatric biobank research. Although personalized assent will require certain efforts, the pediatric (biobank) community must be aware of its importance. The investment and trust earned can result in ongoing engagement, important longitudinal information, and stability in/for the research infrastructure, as well as increased knowledge among its participants about research activity. Implementing personalized assent will both respect the child and support biobank research.
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Affiliation(s)
- Noor A A Giesbertz
- Department of Medical Humanities, Division Julius Center, University Medical Center Utrecht, Office Stratenum 6.131, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands. .,Department of Genetics, Division Biomedical Genetics, University Medical Center Utrecht, KC.04.084.2, P.O. Box 85090, 3508 AB, Utrecht, The Netherlands.
| | - Karen Melham
- Clinical Trials & Research Governance (CTRG) University of Oxford Joint Research Office, Block 60, Churchill Hospital, Headington, Oxford, OX3 7LE, United Kingdom
| | - Jane Kaye
- Nuffield Department of Population Health, HeLEX-Centre for Health, Law and Emerging Technologies at Oxford, University of Oxford, Ewert House, Ewert Place, Banbury Road, Summertown, Oxford, OX2 7DD, UK
| | - Johannes J M van Delden
- Department of Medical Humanities, Division Julius Center, University Medical Center Utrecht, Office Stratenum 6.131, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Annelien L Bredenoord
- Department of Medical Humanities, Division Julius Center, University Medical Center Utrecht, Office Stratenum 6.131, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
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A template for broad consent in biobank research. Results and explanation of an evidence and consensus-based development process. Eur J Med Genet 2016; 59:295-309. [PMID: 27130428 DOI: 10.1016/j.ejmg.2016.04.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/15/2016] [Accepted: 04/25/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Biobanks increasingly presume long-term storage of biomaterials and data that shall be used for future research projects which are today unspecified. Appropriate consent documents for sample donors must therefore explain the breadth of consent and other elements of the biobank governance framework. Recent reviews demonstrated high variability in what issues these documents mention or not and how the issues are explained. This might undermine the protection of sample donors, complicate networked biobank research, create research waste and impact on public trust. METHODS A systematic analysis of international research guidelines and existing broad consent templates was performed. Based on this information an interdisciplinary expert group from the AKMEK (Permanent Working Party of German RECs) developed a draft template and organized a comprehensive stakeholder consultation. After revision the final template was consented by all 53 German RECs. RESULTS This paper briefly explores the spectrum of potentially relevant issues for broad consent forms. It then elaborates the template and how it was designed to be applicable in different types of biobanks. DISCUSSION To further improve the validity and applicability of broad consent forms in biobank and other big data research, practice evaluations are needed. We hope that in this regard the presented template supports the development of new consent forms as well as the evaluation and revision of existing ones.
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