Balancing Modern Medical Benefits And Risks

Towards a transactional medicine approach to combating global emerging pathogens: the case of COVID-19

When the COVID-19 pandemic struck and China reported the first case to the World Health Organization in December 2019, there was no evidence-based treatment to combat it. With the catastrophic situation that followed, materialised by a considerable number of deaths, researchers, doctors, traditional healers, and governments of all nations committed themselves to find therapeutic solutions, including preventive and curative. There are effective treatments offered both by modern medicine and traditional medicine for COVID-19 today. However, other therapeutic proposals have not been approved due to the lack of effectiveness and scientific rigour during their development process. Proponents of modern medicine prefer biomedical therapies while in some countries, traditional treatments are used regularly because of their availability, affordability and satisfaction they bring to the population. In this paper, we propose a transactional medicine approach where the interaction between traditional and modern medicine produces a change. With this approach, the promoters of traditional medicine and those of modern medicine will be able to acquire knowledge through the experience produced by their encounters. Transactional medicine aims to be a model for decolonising medicine and recognising the value of both traditional and modern medicine in the fight against COVID-19 and other global emerging pathogens.

Natural product remedies for COVID-19: A focus on safety

Infection by the novel coronavirus SARS-CoV-2 causing the coronavirus disease (COVID-19), is currently a global pandemic with more than two million deaths to date. Though a number of vaccines have recently been approved against the virus, availability remains a big challenge, and also acceptance by most people has become a big debate. This review discusses possible/proposed natural product remedies and some major conventional treatment options used to manage the infection and, safety concerns on the use of unproven or unapproved health products against COVID-19. An extensive literature review indicated that the influx of unproven and unapproved health products in the global market are on the rise, leading to various forms of self- medication. To this effect, there have been warnings by the United States Food and Drug Administration and the World Health Organisation against the use of such products. Conventional drugs such as remdesivir, chloroquine/hydroxychloroquine and dexamethasone are the major proposed drugs that are currently undergoing clinical trials for the management of this disease. Efforts are being made globally in the search for possible therapeutics which may be the best way to eradicating this disease. Some countries have approved the use of natural products in the management of COVID-19, despite little or no clinical evidence on their efficacy and safety. Natural products may hold a great potential in the fight against COVID-19 but without detailed clinical trials, their potency against the virus and their safe use cannot be established. To attain this goal, extensive research followed by clinical studies are needed. Collaborative efforts between researchers, clinicians, governments and traditional medicinal practitioners in the search and development of safe and effective therapeutics from natural products for the treatment of COVID-19 could be a potential option.

The effect of acculturation and harm beliefs on medication adherence on Middle Eastern hypertensive refugees and migrants in Australia

Background Different populations have different levels of acculturation, and beliefs about medications. Little is known about the differences between refugees and migrants regarding these various beliefs. Adherence to medications is influenced by many factors, including individuals' characteristics, acculturation, and their perceptions about medications. Having a thorough understanding of these beliefs contributes to understanding medication adherence in refugee and migrant populations. Objectives To evaluate the differences between Middle Eastern refugees and migrants in Australia regarding acculturation, beliefs about medications, and medication adherence, and to evaluate the association of acculturation and beliefs about medications and natural remedies with medication adherence. Setting Participants were recruited from various community groups and English language learning centres in Australia. Arabic Facebook community groups were also used to recruit participants for this study. Method A total of 320 Middle Eastern refugees and migrants with hypertension completed Arabic or English versions of the general Beliefs about Medicine Questionnaire (BMQ)-harm scale, a question about beliefs in natural remedies, six items about acculturation and the Medication Adherence Questionnaire. Two models of multiple mediation were applied. The first model examined the role of acculturation, length of residency, beliefs about natural remedies, and harm beliefs as mediators between migration status and medication adherence. The second model identified the role of acculturation, and beliefs about natural remedies as mediators between migration status and medication harm beliefs. Main outcome measure Medication adherence, harm beliefs about medication, acculturation, and beliefs about natural remedies. In addition, the differences between refugees and migrants regarding these beliefs and medication adherence. Results Differences were found between refugees and migrants for medication adherence and medication beliefs. Refugees were likely to have more harm beliefs towards medicine and were less acculturated than migrants (p = 0.0001). They were also less likely to adhere to medications (p = 0.0001), and perceived natural remedies to be safer than Western medications (p = 0.0001). Perceiving medications as harmful substances, and beliefs in natural remedies were mediators in the relationship between migration status and medication adherence. Beliefs in natural remedies and acculturation were mediators in the relationship between migration status and harm beliefs. Conclusion Beliefs about medications and natural remedies, and acculturation in refugees and migrants need to be better understood to enhance medication adherence and potentially overall health outcomes.

Approved CAR T cell therapies: ice bucket challenges on glaring safety risks and long-term impacts

Two autologous chimeric antigen receptor (CAR) T cell therapies (Kymriah™ and Yescarta™) were recently approved by the FDA. Kymriah™ is for the treatment of pediatric patients and young adults with refractory or relapse (R/R) B cell precursor acute lymphoblastic leukemia and Yescarta™ is for the treatment of adult patients with R/R large B cell lymphoma. In common, both are CD19-specific CAR T cell therapies lysing CD19-positive targets. Their dramatic efficacy in the short term has been highlighted by many media reports. By contrast, their glaring safety gaps behind the miracles remain much less addressed. Here, we focus on addressing the crucial challenges in relation to the gaps.

A formal risk-benefit framework for genomic tests: facilitating the appropriate translation of genomics into clinical practice

PURPOSE

Evaluation of genomic tests is often challenging because of the lack of direct evidence of clinical benefit compared with usual care and unclear evidence requirements. To address these issues, this study presents a risk-benefit framework for assessing the health-related utility of genomic tests.

METHODS

We incorporated approaches from a variety of established fields including decision science, outcomes research, and health technology assessment to develop the framework. Additionally, we considered genomic test stakeholder perspectives and case studies.

RESULTS

We developed a three-tiered framework: first, we use decision-analytic modeling techniques to synthesize data, project incidence of clinical events, and assess uncertainty. Second, we defined the health-related utility of genomic tests as improvement in health outcomes as measured by clinical event rates, life expectancy, and quality-adjusted life-years. Finally, we displayed results using a risk-benefit policy matrix to facilitate the interpretation and implementation of findings from these analyses.

CONCLUSION

A formal risk-benefit framework may accelerate the utilization and practice-based evidence development of genomic tests that pose low risk and offer plausible clinical benefit, while discouraging premature use of tests that provide little benefit or pose significant health risks compared with usual care.

Testing for qualitative interactions between stages in an adaptive study

I consider the underlying structure for a test of qualitative interaction of a treatment when assessing heterogeneity between stages in an adaptive trial. Since decisions about the clinical utility of a drug are based on the balance of risks and benefits, a quantitative interaction in treatment efficacy across different groups could lead to qualitatively different decisions. Thus, the difference between quantitative and qualitative interactions is not a true dichotomy. I show that the standard tests for qualitative interactions (Gail and Simon,Biometrics 1985; 41:361-372; Piantadosi and Gail, Statist. Med. 1993; 12:1239-1248) are very conservative in this application. Theoretical calculations in a simpler situation confirm that the published criteria are very conservative, which may help explain why the tests are known to have very low power to detect interaction. I introduce the concept of 'minimum detectable effect', which is the smallest effect that a study could identify as statistically significant. I propose that important heterogeneity between stages in an adaptive trial be identified when two criteria are met. First, at least one individual stage must be below the overall study mean by at least the minimum detectable effect. Second, using an appropriate critical value based on simulations, there must be statistically significant heterogeneity between the stages.