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de Jongh D, Massey EK, Cronin AJ, Schermer MHN, Bunnik EM. Early-Phase Clinical Trials of Bio-Artificial Organ Technology: A Systematic Review of Ethical Issues. Transpl Int 2022; 35:10751. [PMID: 36388425 PMCID: PMC9659568 DOI: 10.3389/ti.2022.10751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/07/2022] [Indexed: 01/25/2023]
Abstract
Regenerative medicine has emerged as a novel alternative solution to organ failure which circumvents the issue of organ shortage. In preclinical research settings bio-artificial organs are being developed. It is anticipated that eventually it will be possible to launch first-in-human transplantation trials to test safety and efficacy in human recipients. In early-phase transplantation trials, however, research participants could be exposed to serious risks, such as toxicity, infections and tumorigenesis. So far, there is no ethical guidance for the safe and responsible design and conduct of early-phase clinical trials of bio-artificial organs. Therefore, research ethics review committees will need to look to related adjacent fields of research, including for example cell-based therapy, for guidance. In this systematic review, we examined the literature on early-phase clinical trials in these adjacent fields and undertook a thematic analysis of relevant ethical points to consider for early-phase clinical trials of transplantable bio-artificial organs. Six themes were identified: cell source, risk-benefit assessment, patient selection, trial design, informed consent, and oversight and accountability. Further empirical research is needed to provide insight in patient perspectives, as this may serve as valuable input in determining the conditions for ethically responsible and acceptable early clinical development of bio-artificial organs.
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Affiliation(s)
- Dide de Jongh
- Department of Nephrology and Transplantation, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands,Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands,*Correspondence: Dide de Jongh,
| | - Emma K. Massey
- Department of Nephrology and Transplantation, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Antonia J. Cronin
- Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom,King’s College, London, United Kingdom
| | - Maartje H. N. Schermer
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Eline M. Bunnik
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
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Bach FC, Poramba-Liyanage DW, Riemers FM, Guicheux J, Camus A, Iatridis JC, Chan D, Ito K, Le Maitre CL, Tryfonidou MA. Notochordal Cell-Based Treatment Strategies and Their Potential in Intervertebral Disc Regeneration. Front Cell Dev Biol 2022; 9:780749. [PMID: 35359916 PMCID: PMC8963872 DOI: 10.3389/fcell.2021.780749] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/15/2021] [Indexed: 12/20/2022] Open
Abstract
Chronic low back pain is the number one cause of years lived with disability. In about 40% of patients, chronic lower back pain is related to intervertebral disc (IVD) degeneration. The standard-of-care focuses on symptomatic relief, while surgery is the last resort. Emerging therapeutic strategies target the underlying cause of IVD degeneration and increasingly focus on the relatively overlooked notochordal cells (NCs). NCs are derived from the notochord and once the notochord regresses they remain in the core of the developing IVD, the nucleus pulposus. The large vacuolated NCs rapidly decline after birth and are replaced by the smaller nucleus pulposus cells with maturation, ageing, and degeneration. Here, we provide an update on the journey of NCs and discuss the cell markers and tools that can be used to study their fate and regenerative capacity. We review the therapeutic potential of NCs for the treatment of IVD-related lower back pain and outline important future directions in this area. Promising studies indicate that NCs and their secretome exerts regenerative effects, via increased proliferation, extracellular matrix production, and anti-inflammatory effects. Reports on NC-like cells derived from embryonic- or induced pluripotent-stem cells claim to have successfully generated NC-like cells but did not compare them with native NCs for phenotypic markers or in terms of their regenerative capacity. Altogether, this is an emerging and active field of research with exciting possibilities. NC-based studies demonstrate that cues from developmental biology can pave the path for future clinical therapies focused on regenerating the diseased IVD.
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Affiliation(s)
- Frances C. Bach
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | | | - Frank M. Riemers
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
| | - Jerome Guicheux
- UMR 1229-RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, France
- UFR Odontologie, Université de Nantes, Nantes, France
- PHU4 OTONN, CHU Nantes, Nantes, France
| | - Anne Camus
- UMR 1229-RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, France
| | - James C. Iatridis
- Leni and Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Danny Chan
- School of Biomedical Sciences, The University of Hong Kong, Hong Kong SAR, China
| | - Keita Ito
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
- Department of Orthopedics, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Christine L. Le Maitre
- Biomolecular Sciences Research Centre, Sheffield Hallam University, Sheffield, United Kingdom
| | - Marianna A. Tryfonidou
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
- *Correspondence: Marianna A. Tryfonidou,
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de Windt TS, Niemansburg SL, Vonk LA, van Delden JM, Roes KCB, Dhert WJA, Saris DBF, Bredenoord AL. Ethics in musculoskeletal regenerative medicine; guidance in choosing the appropriate comparator in clinical trials. Osteoarthritis Cartilage 2019; 27:34-40. [PMID: 30243948 DOI: 10.1016/j.joca.2018.08.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/30/2018] [Accepted: 08/07/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Regenerative Medicine (RM) techniques aimed at the musculoskeletal system are increasingly translated to clinical trials and patient care. This revolutionary era in science raises novel ethical challenges. One of these challenges concerns the appropriate choice of the comparator in (randomized controlled) trials, including the ethically contentious use of sham procedures. To date, only general guidelines regarding the choice of the comparator exist. OBJECTIVE To provide specific guidelines for clinical trial comparator choice in musculoskeletal RM. METHODS In this manuscript, we discuss the ethics of comparator selection in RM trials. First, we make a classification of RM interventions according to different health states from disease prevention, return to normal health, postponing RM treatment, supplementing RM treatment, substituting RM treatment, improving RM outcome, and slowing progression. Subsequently, per objective, the accompanying ethical points to consider are evaluated with support from the available literature. RESULTS a sham procedure is demonstrated to be an ethically acceptable comparator in RM trials with certain objectives, but less appropriate for musculoskeletal RM interventions that aim at preventing disease or substituting a surgical treatment. The latter may be compared to 'standard of care'. CONCLUSION From a scientific perspective, choosing the correct comparator based on ethical guidelines is a step forward in the success of musculoskeletal RM.
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Affiliation(s)
- T S de Windt
- Department of Orthopaedics, University Medical Center, University Utrecht, The Netherlands.
| | - S L Niemansburg
- Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - L A Vonk
- Department of Orthopaedics, University Medical Center, University Utrecht, The Netherlands.
| | - J M van Delden
- Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - K C B Roes
- Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - W J A Dhert
- Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands.
| | - D B F Saris
- Department of Orthopaedics, University Medical Center, University Utrecht, The Netherlands; MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands; Department of Orthopedics, Mayo Clinic, Rochester, MN, USA.
| | - A L Bredenoord
- Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
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Thorpe AA, Bach FC, Tryfonidou MA, Le Maitre CL, Mwale F, Diwan AD, Ito K. Leaping the hurdles in developing regenerative treatments for the intervertebral disc from preclinical to clinical. JOR Spine 2018; 1:e1027. [PMID: 31463447 PMCID: PMC6686834 DOI: 10.1002/jsp2.1027] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 06/07/2018] [Accepted: 06/28/2018] [Indexed: 12/11/2022] Open
Abstract
Chronic back and neck pain is a prevalent disability, often caused by degeneration of the intervertebral disc. Because current treatments for this condition are less than satisfactory, a great deal of effort is being applied to develop new solutions, including regenerative strategies. However, the path from initial promising idea to clinical use is fraught with many hurdles to overcome. Many of the keys to success are not necessarily linked to science or innovation. Successful translation to clinic will also rely on planning and awareness of the hurdles. It will be essential to plan your entire path to clinic from the outset and to do this with a multidisciplinary team. Take advice early on regulatory aspects and focus on generating the proof required to satisfy regulatory approval. Scientific demonstration and societal benefits are important, but translation cannot occur without involving commercial parties, which are instrumental to support expensive clinical trials. This will only be possible when intellectual property can be protected sufficiently to support a business model. In this manner, commercial, societal, medical, and scientific partners can work together to ultimately improve patient health. Based on literature surveys and experiences of the co-authors, this opinion paper presents this pathway, highlights the most prominent issues and hopefully will aid in your own translational endeavors.
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Affiliation(s)
- Abbey A. Thorpe
- Biomolecular Sciences Research CentreSheffield Hallam UniversitySheffieldUK
| | - Frances C. Bach
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary MedicineUtrecht UniversityUtrechtthe Netherlands
| | - Marianna A. Tryfonidou
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary MedicineUtrecht UniversityUtrechtthe Netherlands
| | | | - Fackson Mwale
- Department of SurgeryMcGill UniversityMontrealCanada
| | - Ashish D. Diwan
- Spine Service, Department of Orthopaedic SurgerySt. George & Sutherland Clinical School, University of New South WalesSydneyAustralia
| | - Keita Ito
- Orthopaedic Biomechanics Division, Department of Biomedical EngineeringEindhoven University of TechnologyEindhoventhe Netherlands
- Department of OrthopedicsUniversity Medical Centre UtrechtUtrechtthe Netherlands
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Satalkar P, Elger BS, Shaw DM. Defining Nano, Nanotechnology and Nanomedicine: Why Should It Matter? SCIENCE AND ENGINEERING ETHICS 2016; 22:1255-1276. [PMID: 26373718 DOI: 10.1007/s11948-015-9705-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 09/10/2015] [Indexed: 06/05/2023]
Abstract
Nanotechnology, which involves manipulation of matter on a 'nano' scale, is considered to be a key enabling technology. Medical applications of nanotechnology (commonly known as nanomedicine) are expected to significantly improve disease diagnostic and therapeutic modalities and subsequently reduce health care costs. However, there is no consensus on the definition of nanotechnology or nanomedicine, and this stems from the underlying debate on defining 'nano'. This paper aims to present the diversity in the definition of nanomedicine and its impact on the translation of basic science research in nanotechnology into clinical applications. We present the insights obtained from exploratory qualitative interviews with 46 stakeholders involved in translational nanomedicine from Europe and North America. The definition of nanomedicine has implications for many aspects of translational research including: fund allocation, patents, drug regulatory review processes and approvals, ethical review processes, clinical trials and public acceptance. Given the interdisciplinary nature of the field and common interest in developing effective clinical applications, it is important to have honest and transparent communication about nanomedicine, its benefits and potential harm. A clear and consistent definition of nanomedicine would significantly facilitate trust among various stakeholders including the general public while minimizing the risk of miscommunication and undue fear of nanotechnology and nanomedicine.
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Affiliation(s)
- Priya Satalkar
- Institute for Biomedical Ethics (IBMB), University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.
| | - Bernice Simone Elger
- Institute for Biomedical Ethics (IBMB), University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - David M Shaw
- Institute for Biomedical Ethics (IBMB), University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
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Satalkar P, Elger BS, Hunziker P, Shaw D. Challenges of clinical translation in nanomedicine: A qualitative study. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2016; 12:893-900. [DOI: 10.1016/j.nano.2015.12.376] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 12/10/2015] [Accepted: 12/22/2015] [Indexed: 11/25/2022]
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Niemansburg SL, Habets MGJL, Dhert WJA, van Delden JJM, Bredenoord AL. Participant selection for preventive Regenerative Medicine trials: ethical challenges of selecting individuals at risk. JOURNAL OF MEDICAL ETHICS 2015; 41:914-916. [PMID: 26340912 DOI: 10.1136/medethics-2014-102625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 08/17/2015] [Indexed: 06/05/2023]
Abstract
The innovative field of Regenerative Medicine (RM) is expected to extend the possibilities of prevention or early treatment in healthcare. Increasingly, clinical trials will be developed for people at risk of disease to investigate these RM interventions. These individuals at risk are characterised by their susceptibility for developing clinically manifest disease in future due to the existence of degenerative abnormalities. So far, there has been little debate about the ethical appropriateness of including such individuals at risk in clinical trials. We discuss three main challenges of selecting this participant model for testing RM interventions: the challenge of achieving a proportional risk-benefit balance; complexities in the trial design in terms of follow-up and sample size; and the difficulty of obtaining informed consent due to the many uncertainties. We conclude that selecting the model is not ethically justifiable for first-in-man trials with RM interventions due to the high risks and uncertainties. However, the model can be ethically appropriate for testing the efficacy of RM interventions under the following conditions: interventions should be low risk; the degenerative abnormalities (and other risk factors) should be strongly related with disease within a short time frame; robust preclinical evidence of efficacy needs to be present; and the informed consent procedure should contain extra safeguards with regard to communication on uncertainties.
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Affiliation(s)
- Sophie L Niemansburg
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michelle G J L Habets
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wouter J A Dhert
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes J M van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Annelien L Bredenoord
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Niemansburg SL, Tempels TH, Dhert WJA, van Delden JJM, Bredenoord AL. Societal impacts of regenerative medicine: reflections on the views of orthopedic professionals. Regen Med 2015; 10:17-24. [PMID: 25562349 DOI: 10.2217/rme.14.69] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
As the amount of clinical studies in orthopedic regenerative medicine (RM) is increasing, it is time to take into account its impact on society. A total of 36 biomedical professionals working at the front row of orthopedic RM were interviewed to explore their attitudes, opinions and expectations regarding the societal impacts of RM. Professionals mainly recognized the societal impacts of counteraction of aging, prevention of disease and social justice. The 'soft' sides of these impacts were hardly mentioned. Whereas they did not perceive themselves in the position to mitigate these impacts, professionals should take up their role as actor and become involved in the societal debate. This is important as they can co-shape the societal impacts during the developmental process of technologies and thereby stimulate responsible innovation.
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Affiliation(s)
- Sophie L Niemansburg
- Department of Medical Humanities, Julius Center for Health Sciences & Primary Care, University Medical Center Utrecht, 3584CG Utrecht, The Netherlands
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Niemansburg SL, van Delden JJ, Dhert WJ, Bredenoord AL. Reconsidering the ethics of sham interventions in an era of emerging technologies. Surgery 2015; 157:801-10. [DOI: 10.1016/j.surg.2014.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 11/13/2014] [Accepted: 12/03/2014] [Indexed: 10/24/2022]
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Niemansburg SL, Teraa M, Hesam H, van Delden JJM, Verhaar MC, Bredenoord AL. Stem cell trials for cardiovascular medicine: ethical rationale. Tissue Eng Part A 2014; 20:2567-74. [PMID: 24164351 PMCID: PMC4195508 DOI: 10.1089/ten.tea.2013.0332] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 10/24/2013] [Indexed: 12/29/2022] Open
Abstract
Stem cell-based interventions provide new treatment prospects for many disease conditions, including cardiovascular disorders. Clinical trials are necessary to collect adequate evidence on (long-term) safety and efficacy of novel interventions such as stem cells, but the design and launch of clinical trials, from first-in-human studies to larger randomized controlled trials (RCTs), is scientifically and ethically challenging. Stem cells are different from traditional pharmaceuticals, surgical procedures, and medical devices in the following ways: the novelty and complexity of stem cells, the invasiveness of the procedures, and the novel aim of regeneration. These specifics, combined with the characteristics of the study population, will have an impact on the design and ethics of RCTs. The recently closed JUVENTAS trial will serve as an example to identify the (interwoven) scientific and ethical challenges in the design and launch of stem cell RCTs. The JUVENTAS trial has investigated the efficacy of autologous bone marrow cells in end-stage vascular patients, in a double-blind sham-controlled design. We first describe the choices, considerations, and experiences of the JUVENTAS team. Subsequently, we identify the main ethical and scientific challenges and discuss what is important to consider in the design of future stem cell RCTs: assessment of risks and benefits, the choice for outcome measures, the choice for the comparator, the appropriate selection of participants, and adequate informed consent. Additionally, the stem cell field is highly in the spotlight due to the (commercial) interests and expectations. This warrants a cautious pace of translation and scrupulous set up of clinical trials, as failures could put the field in a negative light. At the same time, knowledge from clinical trials is necessary for the field to progress. We conclude that in the scientifically and ethically challenging field of stem cell RCTs, researchers and clinicians have to maneuver between the Skylla of hyper accelerated translation without rigorously conducted RCTs and the Charybdis of the missed opportunity of valuable knowledge.
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Affiliation(s)
- Sophie L Niemansburg
- 1 Department of Medical Humanities, Julius Center, University Medical Center Utercht , The Netherlands
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Habets MGJL, van Delden JJM, Bredenoord AL. The inherent ethical challenge of first-in-human pluripotent stem cell trials. Regen Med 2014; 9:1-3. [PMID: 24350999 DOI: 10.2217/rme.13.83] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Michelle G J L Habets
- University Medical Center Utrecht, Julius Center, Department of Medical Humanities, Internal Post Str 6.131, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Koudstaal S, Niemansburg SL, Dib N, Wallet J, Doevendans PA, Bredenoord AL, Chamuleau SAJ. Placebo in autologous cell-based interventions: hard pill to swallow? J Am Coll Cardiol 2014; 63:2877-9. [PMID: 24794125 DOI: 10.1016/j.jacc.2014.03.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 03/28/2014] [Accepted: 03/30/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Stefan Koudstaal
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands; Interuniversity Cardiology Institute of the Netherlands (ICIN), Utrecht, the Netherlands
| | - Sophie L Niemansburg
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nabil Dib
- Clinical Cardiovascular Cell Therapy, University of California, San Diego, San Diego, California
| | - Justin Wallet
- Faculty of Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands; Interuniversity Cardiology Institute of the Netherlands (ICIN), Utrecht, the Netherlands
| | - Annelien L Bredenoord
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Steven A J Chamuleau
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands; Interuniversity Cardiology Institute of the Netherlands (ICIN), Utrecht, the Netherlands.
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Niemansburg SL, van Delden JJM, Oner FC, Dhert WJA, Bredenoord AL. Ethical implications of regenerative medicine in orthopedics: an empirical study with surgeons and scientists in the field. Spine J 2014; 14:1029-35. [PMID: 24184644 DOI: 10.1016/j.spinee.2013.10.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 09/23/2013] [Accepted: 10/17/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Regenerative medicine (RM) interventions, such as (stem) cell transplantation, scaffolds, gene transfer, and tissue engineering, are likely to change the field of orthopedics considerably. These strategies will significantly differ from treatments in current orthopedic practice, as they treat the underlying cause of disease and intervene at a biological level, preferably in an earlier stage. Whereas most of the RM interventions for orthopedics are still in the preclinical phase of research, the number of clinical studies is expected to increase rapidly in the future. The debate about the challenging scientific and ethical issues of translating these innovative interventions into (early) clinical studies is developing. However, no empirical studies that have systematically described the attitudes, opinions, and experiences of experts in the field of orthopedic RM concerning these challenges exist. PURPOSE The aim of this study was to identify ethical issues that experts in the area of RM for musculoskeletal disorders consider to be relevant to address so as to properly translate RM interventions into (early) clinical studies. STUDY DESIGN/SETTING In-depth qualitative interviews were conducted with 36 experts in the field, mainly spine surgeons and musculoskeletal scientists from The Netherlands and the United Kingdom. METHODS A topic list of open questions, based on existing literature and pilot interviews, was used to guide the interviews. Data analysis was based on the constant comparative method, which means going back and forth from the data to develop codes, concepts, and themes. RESULTS Four ethical themes emerged from the interview data. First, the risks to study participants. Second, the appropriate selection of study participants. Third, setting relevant goal(s) for measuring outcome, varying from regenerating tissue to improving well-being of patients. Finally, the need for evidence-based medicine and scientific integrity, which is considered challenging in orthopedics. DISCUSSION The overall attitude toward the development of RM was positive, especially because current surgical treatments for spine disorders lack satisfactory effectiveness. However, efforts should be taken to adequately address the ethical and scientific issues in the translation of RM interventions into clinical research. This is required to prevent unnecessary risks to study participants, to prevent exposure of future patients to useless clinical applications, as well as to prevent this young field from developing a negative reputation. Not only will the orthopedic RM field benefit from ethically and scientifically sound clinical studies, but the rise of RM also provides an opportunity to stimulate evidence-based practice in orthopedics and address hype- and profit-driven practices in orthopedics.
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Affiliation(s)
- Sophie L Niemansburg
- Department of Medical Humanities, Julius Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CG, Utrecht, The Netherlands.
| | - Johannes J M van Delden
- Department of Medical Humanities, Julius Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CG, Utrecht, The Netherlands
| | - F Cumhur Oner
- Department of Orthopedics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Wouter J A Dhert
- Department of Orthopedics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Annelien L Bredenoord
- Department of Medical Humanities, Julius Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CG, Utrecht, The Netherlands
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Bach FC, Willems N, Penning LC, Ito K, Meij BP, Tryfonidou MA. Potential regenerative treatment strategies for intervertebral disc degeneration in dogs. BMC Vet Res 2014; 10:3. [PMID: 24387033 PMCID: PMC3914844 DOI: 10.1186/1746-6148-10-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 12/31/2013] [Indexed: 01/07/2023] Open
Abstract
Pain due to spontaneous intervertebral disc (IVD) disease is common in dogs. In chondrodystrophic (CD) dogs, IVD disease typically develops in the cervical or thoracolumbar spine at about 3–7 years of age, whereas in non-chondrodystrophic (NCD) dogs, it usually develops in the caudal cervical or lumbosacral spine at about 6–8 years of age. IVD degeneration is characterized by changes in the biochemical composition and mechanical integrity of the IVD. In the degenerated IVD, the content of glycosaminoglycan (GAG, a proteoglycan side chain) decreases and that of denatured collagen increases. Dehydration leads to tearing of the annulus fibrosus (AF) and/or disc herniation, which is clinically characterized by pain and/or neurological signs. Current treatments (physiotherapy, anti-inflammatory/analgesic medication, surgery) for IVD disease may resolve neurological deficits and reduce pain (although in many cases insufficient), but do not lead to repair of the degenerated disc. For this reason, there is interest in new regenerative therapies that can repair the degenerated disc matrix, resulting in restoration of the biomechanical function of the IVD. CD dogs are considered a suitable animal model for human IVD degeneration because of their spontaneous IVD degeneration, and therefore studies investigating cell-, growth factor-, and/or gene therapy-based regenerative therapies with this model provide information relevant to both human and canine patients. The aim of this article is to review potential regenerative treatment strategies for canine IVD degeneration, with specific emphasis on cell-based strategies.
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Affiliation(s)
- Frances C Bach
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands.
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Niemansburg SL, Habets MGJL, van Delden JJM, Bredenoord AL. Disclosure of risks and uncertainties are especially vital in light of regenerative medicine. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:14-16. [PMID: 24730482 DOI: 10.1080/15265161.2014.889244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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