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Bozzi LM, Jacobson MH, Yost E, Sheahan A, Cafone J, Komatsu Y, Schwartz L, Levitan B, Nelson RM. A Benefit-Risk Conceptual Framework for Biologic Use During Pregnancy: A Mini-Review. Clin Pharmacol Ther 2024; 115:1251-1257. [PMID: 38506485 DOI: 10.1002/cpt.3239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/19/2024] [Indexed: 03/21/2024]
Abstract
Recent reports related to in utero exposure of marketed immunosuppressive biologics led to clinical recommendations to delay live vaccinations for infants due to the concern of reduced vaccine effectiveness and/or increased risk of vaccine-related disease. These delays can increase the risk of children contracting vaccine preventable diseases, yet the alternative cessation of biologics during pregnancy may result in increased autoimmune disease activity for the pregnant person, raising complex benefit-risk (B-R) considerations and trade-offs. Our goal is to develop a conceptual framework for B-R assessment based on the key benefits and risks pregnant people would consider for themselves and their children when continuing (vs. discontinuing) a biologic during pregnancy. The proposed framework defines the decision contexts, key domains and attributes for potential benefits, and risks of biologic use during pregnancy, informed by a literature review of indications for biologics and refined with key clinical stakeholders. The framework includes both the pregnant person taking the biologic and the infant potentially exposed to the biologic in utero, with potential benefit and risk domains and attributes for each participant. To advance this conceptual framework, there are considerations of potential biases and uncertainty of available data that will be imperative to address when quantifying the B-R framework. For these reasons, we recommend the formation of a consortium to ensure development of a robust, validated framework that can be adopted in the healthcare setting.
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Affiliation(s)
- Laura M Bozzi
- Janssen Research & Development, Raritan, New Jersey, USA
| | | | - Emily Yost
- Janssen Research & Development, Horsham, Pennsylvania, USA
| | - Anna Sheahan
- Janssen Research & Development, Horsham, Pennsylvania, USA
| | - Joseph Cafone
- Janssen Research & Development, Spring House, Pennsylvania, USA
| | - Yosuke Komatsu
- Janssen Research & Development, Spring House, Pennsylvania, USA
| | - Lisa Schwartz
- Janssen Research & Development, Raritan, New Jersey, USA
| | | | - Robert M Nelson
- Janssen Research & Development, Spring House, Pennsylvania, USA
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2
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Schanberg LE, Mulugeta LY, Akinlade B, Brunner HI, Chen J, Colbert RA, Delgaizo V, Gastonguay MR, Glaser R, Imundo L, Lovell DJ, Leu JH, Mostafa NM, Nelson RM, Nigrovic PA, Nikolov NP, Rider LG, Rothwell R, Sahajwalla C, Singh R, Sinha V, Yancey CL, Yao L. Therapeutic Development in Polyarticular Course Juvenile Idiopathic Arthritis: Extrapolation, Dose Selection, and Clinical Trial Design. Arthritis Rheumatol 2023; 75:1856-1866. [PMID: 37067688 DOI: 10.1002/art.42534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/15/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023]
Abstract
OBJECTIVE Stakeholders met to address persistent challenges facing the development of therapeutics for polyarticular juvenile idiopathic arthritis (pJIA), which result in fewer approved therapies for children with pJIA than adults with rheumatoid arthritis (RA) and long lag times from adult RA approval to pediatric labeling. Ensuring that new medications are authorized in a timely manner to meet the needs of JIA patients worldwide is critically important to multiple stakeholders. METHODS The Food and Drug Administration in collaboration with the University of Maryland Center for Regulatory Science and Innovation held a public workshop entitled "Accelerating Drug Development for pJIA" on October 2, 2019, to address challenges surrounding access to new medications for children and adolescents with pJIA. Regulatory, academic, and industry stakeholders, as well as patient representatives, participated in the workshop, which consisted of 4 sessions, including panel discussions. RESULTS The workshop facilitated broad public discussion of challenges facing the development of pJIA therapeutics, highlighting areas of need and outlining opportunities to expedite development, while underscoring the necessity of close collaboration between all stakeholders, including patients and families. CONCLUSION This report summarizes key aspects of the workshop, including the appropriate application of innovative approaches to the development of pJIA therapeutics, including extrapolation, to address current challenges and provide timely access to newer safe and effective treatments. Long-term safety assessment is of pressing concern to stakeholders and cannot be fully extrapolated from adult studies but requires consistent postmarketing long-term follow-up.
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Affiliation(s)
- Laura E Schanberg
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Lily Yeruk Mulugeta
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Jianmeng Chen
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Robert A Colbert
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Rachel Glaser
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Lisa Imundo
- Columbia University Irving Medical Center, New York, New York
| | - Daniel J Lovell
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jocelyn H Leu
- Janssen Research and Development, Spring House, Pennsylvania
| | | | | | - Peter A Nigrovic
- Division of Immunology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Nikolay P Nikolov
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Lisa G Rider
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, NIH, Bethesda, Maryland
| | - Rebecca Rothwell
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Chandrahas Sahajwalla
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Renu Singh
- Gilead Sciences, Foster City, California
| | - Vikram Sinha
- Novartis Pharmaceutical Corporation, One Health Plaza, East Hanover NJ, 07936, USA
| | - Carolyn L Yancey
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Lynne Yao
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
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Bucci-Rechtweg C, Siapkara A, An Haack Bonnet K, Corriol Rohou S, Haf Davies E, Dehlinger Kremer M, Gamalo M, Moreno C, Nelson RM, Thomas Turner R. Strategies to facilitate adolescent access to medicines: Improving regulatory guidance. Clin Trials 2023; 20:13-21. [PMID: 36341541 DOI: 10.1177/17407745221132302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Historically, pediatric medicines are developed after adult trials are completed, even when identical drug targets and disease similarities exist across the populations. This has resulted in significant delays in the authorization of medicines for adolescent use, limiting access to beneficial drugs. This study sought to understand how adolescent inclusion in adult trials is positioned in regulatory guidance documents as they set critical expectations for trial design and regulatory decision-making. METHODS This study utilized a qualitative analysis approach. Guidance documents were identified via Food and Drug Administration and European Medicines Agency websites. Utilizing a blinded adjudication process, the documents were classified as permissive, exclusionary, or silent regarding recommendations about adolescent inclusion in adult clinical trials. A post hoc analysis of similarities and differences between the Food and Drug Administration and European Medicines Agency guidance documents was conducted to assess the possible role of regional pediatric research laws on age-inclusive trial methodologies as well as emergent themes by therapeutic area. RESULTS In total, 96 Food and Drug Administration (1977 to 2019) and 106 European Medicines Agency (1987 to 2019) guidance documents were identified for analysis. The guidance contained explicit or implicit recommendations supporting adolescent inclusion in adult trials in 32% of Food and Drug Administration and 15% of European Medicines Agency documents, while 14% and 21%, respectively, were found to be exclusionary. A large number of guidance documents were silent regarding the applicability of adolescent-inclusive trial designs (53% and 64%, Food and Drug Administration and European Medicines Agency, respectively). Analysis by therapeutic area revealed the most permissive of adolescent inclusion in Food and Drug Administration guidance for infectious diseases and conditions requiring blood products in European Medicines Agency guidance. A more holistic approach to age-inclusive trial design was identified in disease guidance published by the Food and Drug Administration Oncology Center of Excellence. DISCUSSION There are many influences on the development and/or revision of regulatory guidance documents. Substantial scientific knowledge and regulatory precedence for the inclusion of adolescents within adult trials are available to inform research approaches. Our study has identified important opportunities for the enhancement of guidance. For example, contextualization of developmental factors influencing adolescent disease progression provides insights into the role of adolescent inclusion. If addressed, guidance documents can facilitate broader acceptance of age-inclusive trial methodologies and accelerate adolescent access to medicines.
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Affiliation(s)
| | | | | | | | | | | | | | - Carmen Moreno
- Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, Madrid, Spain
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Leu JH, Shiff NJ, Clark M, Bensley K, Lomax KG, Berezny K, Nelson RM, Zhou H, Xu Z. Intravenous Golimumab in Patients with Polyarticular Juvenile Idiopathic Arthritis and Juvenile Psoriatic Arthritis and Subcutaneous Ustekinumab in Patients with Juvenile Psoriatic Arthritis: Extrapolation of Data from Studies in Adults and Adjacent Pediatric Populations. Paediatr Drugs 2022; 24:699-714. [PMID: 36171515 PMCID: PMC9592662 DOI: 10.1007/s40272-022-00533-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To describe the extrapolation approaches used to support intravenous (IV) golimumab for polyarticular juvenile idiopathic arthritis (pJIA) and juvenile psoriatic arthritis (jPsA) and subcutaneous (SC) ustekinumab for jPsA. METHODS Pharmacokinetic, clinical response, and safety data from trials of IV golimumab and SC ustekinumab in polyarticular-course JIA (pc-JIA) (GO-VIVA) or pediatric psoriasis (PsO) (CADMUS and CADMUS Jr) and data from pivotal, phase 3 trials of these agents in adults with similar diseases were used to support extrapolation in pJIA and jPsA. In the phase 3 GO-VIVA trial, patients with pc-JIA aged 2 to < 18 years received IV golimumab 80 mg/m2 at weeks 0, 4, then every 8 weeks (Q8W). In the phase 3, randomized, placebo-controlled CADMUS trial, patients with PsO aged ≥ 12 to < 18 years received ustekinumab at weeks 0, 4, then Q12W. In the phase 3 CADMUS Jr trial, patients with PsO aged ≥ 6 to < 12 years received ustekinumab at weeks 0, 4, then Q12W. The ustekinumab analyses used data only from patients who received the standard ustekinumab dosing regimen (≤ 60 kg: 0.75 mg/kg; > 60 to ≤ 100 kg: 45 mg; > 100 kg: 90 mg). RESULTS In the 127 patients with pc-JIA treated with IV golimumab (GO-VIVA), pharmacokinetic and exposure-response results were similar to those in adults with rheumatoid arthritis treated with IV golimumab. Additionally, pharmacokinetic and clinical response data from five patients with jPsA in GO-VIVA were comparable to those in adults with PsA treated with IV golimumab. No new safety signals were observed in GO-VIVA. Pharmacokinetic and clinical response data observed in the four pediatric patients with PsO and jPsA treated with ustekinumab in CADMUS and CADMUS Jr were similar to those in the 91 pediatric patients with PsO without jPsA in these trials and to those in adults with PsA treated with ustekinumab. Safety was extrapolated from CADMUS or CADMUS Jr; no new signals were observed. CONCLUSIONS These three sets of analyses corroborate similar exposure and efficacy of IV golimumab in pediatric patients with pc-JIA or jPsA and SC ustekinumab in patients with jPsA to support extrapolation of established adult efficacy. The overall safety profiles of IV golimumab in pediatric patients with pc-JIA or jPsA and SC ustekinumab in pediatric patients with PsO with or without jPsA were consistent with the safety profiles of these agents in the context of their clinical programs and cumulative use. Based on these analyses, the US Food and Drug Administration approved IV golimumab for polyarticular JIA and active PsA in patients 2 years and older and SC ustekinumab for pediatric PsA in patients 6 years and older, highlighting how use of an extrapolation approach can help streamline drug development for pediatric patient populations in whom larger clinical trials are not feasible. CLINICAL TRIAL REGISTRATION GO-VIVA (NCT02277444) was registered at clinicaltrials.gov on 29 October 2014; CADMUS (NCT01090427) was registered on 22 March 2010; and CADMUS Jr (NCT02698475) was registered on 3 March 2016.
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Affiliation(s)
- Jocelyn H. Leu
- grid.497530.c0000 0004 0389 4927Janssen Research & Development, LLC, 1400 McKean Road, Spring House, PA 19477 USA
| | - Natalie J. Shiff
- grid.497530.c0000 0004 0389 4927Janssen Scientific Affairs, LLC, Horsham, PA USA ,grid.25152.310000 0001 2154 235XAdjunct, Department of Community Health & Epidemiology, University of Saskatchewan, Saskatoon, SK Canada
| | - Michael Clark
- grid.497530.c0000 0004 0389 4927Janssen Research & Development, LLC, 1400 McKean Road, Spring House, PA 19477 USA
| | - Karen Bensley
- grid.497530.c0000 0004 0389 4927Janssen Research & Development, LLC, 1400 McKean Road, Spring House, PA 19477 USA
| | - Kathleen G. Lomax
- grid.497530.c0000 0004 0389 4927Janssen Research & Development, LLC, 1400 McKean Road, Spring House, PA 19477 USA
| | - Katherine Berezny
- grid.497530.c0000 0004 0389 4927Janssen Research & Development, LLC, 1400 McKean Road, Spring House, PA 19477 USA
| | | | - Honghui Zhou
- grid.497530.c0000 0004 0389 4927Janssen Research & Development, LLC, 1400 McKean Road, Spring House, PA 19477 USA
| | - Zhenhua Xu
- grid.497530.c0000 0004 0389 4927Janssen Research & Development, LLC, 1400 McKean Road, Spring House, PA 19477 USA
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Noel GJ, Nelson RM, Bucci-Rechtweg C, Portman R, Miller T, Green DJ, Snyder D, Moreno C, Hovinga C, Connor E. Inclusion of Adolescents in Adult Clinical Trials: Report of the Institute for Advanced Clinical Trials for Children's Pediatric Innovation Research Forum. Ther Innov Regul Sci 2021; 55:773-778. [PMID: 33811302 PMCID: PMC8018511 DOI: 10.1007/s43441-021-00283-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/17/2021] [Indexed: 01/22/2023]
Abstract
Including adolescents in adult clinical trials can play an important role in making innovative new medicines available to children in a timelier fashion. Stakeholders involved in the processes leading to regulatory approval and labeling of new drugs recognize that challenges exist in involving adolescents and older children in clinical trials before the safety and efficacy of these drugs are established for adults. However, it has been possible to design and execute phase 3 trials that combine adults with adolescents which are medically and scientifically sound and ethically justified. Based on this experience and considerations of the medical and scientific, ethical, and operation-related matters, the 2019 Pediatric Innovation Research Forum advocated for the position that adolescents routinely be considered for enrollment in phase 3 clinical trials. The Forum also concluded that exclusion of adolescents in adult pivotal trials occur only when a thorough evaluation of the target disease and the potential benefit and risks of the study intervention supports a delay in their involvement until after completion of clinical trials in adults.
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Affiliation(s)
- Gary J Noel
- The Institute for Advanced Clinical Trials for Children, 9211 Corporate Blvd. Suite 260, Rockville, MD, 20850, USA.
- Weill-Cornell Medical College, New York, NY, USA.
| | | | | | - Ronald Portman
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | - Donna Snyder
- US Food and Drug Administration, Silver Spring, MD, USA
| | - Carmen Moreno
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Collin Hovinga
- The Institute for Advanced Clinical Trials for Children, 9211 Corporate Blvd. Suite 260, Rockville, MD, 20850, USA
| | - Edward Connor
- The Institute for Advanced Clinical Trials for Children, 9211 Corporate Blvd. Suite 260, Rockville, MD, 20850, USA
- George Washington School of Medicine, Washington, DC, USA
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7
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Gamalo-Siebers M, Hampson L, Kordy K, Weber S, Nelson RM, Portman R. Incorporating Innovative Techniques Toward Extrapolation and Efficient Pediatric Drug Development. Ther Innov Regul Sci 2019; 53:567-578. [DOI: 10.1177/2168479019842541] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Wendler D, Nelson RM, Lantos JD. The Potential Benefits of Research May Justify Certain Research Risks. Pediatrics 2019; 143:peds.2018-1703. [PMID: 30787097 PMCID: PMC10081016 DOI: 10.1542/peds.2018-1703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 11/24/2022] Open
Abstract
US regulations allow institutional review boards to approve pediatric clinical trials only when the risks are minimal or (in some cases) a minor increase over minimal, or when the risks are justified by a potential for direct benefit to the participants. But how should an institutional review board determine if the risks of pediatric clinical trials are justified by a potential for participant benefit? In this Ethics Rounds article, we consider which potential benefits can justify which research risks with a focus on randomized clinical trials.
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Affiliation(s)
- David Wendler
- Department of Bioethics, National Institutes of Health, Bethesda, Maryland
| | - Robert M Nelson
- Child Health Innovation Leadership Department, Johnson & Johnson, Raritan, New Jersey; and
| | - John D Lantos
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
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Snyder DL, Nelson RM. A Framework for Evaluating a Minor's Involvement in Medical Decision Making. Am J Bioeth 2018; 18:10-12. [PMID: 29466124 PMCID: PMC5997482 DOI: 10.1080/15265161.2017.1418938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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10
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Snyder DL, Nelson RM. The Food and Drug Administration's Federal Review of a Pediatric Muscular Dystrophy Protocol. IRB 2018; 40:18-20. [PMID: 29910527 PMCID: PMC6002149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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11
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Hume M, Lewis LL, Nelson RM. Meeting the goal of concurrent adolescent and adult licensure of HIV prevention and treatment strategies. J Med Ethics 2017; 43:857-860. [PMID: 28507222 PMCID: PMC5685924 DOI: 10.1136/medethics-2016-103600] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 03/23/2017] [Accepted: 04/18/2017] [Indexed: 06/07/2023]
Abstract
The ability of adolescents to access safe and effective new products for HIV prevention and treatment is optimised by adolescent licensure at the same time these products are approved and marketed for adults. Many adolescent product development programmes for HIV prevention or treatment products may proceed simultaneously with adult phase III development programmes. Appropriately implemented, this strategy is not expected to delay licensure as information regarding product efficacy can often be extrapolated from adults to adolescents, and pharmacokinetic properties of drugs in adolescents are expected to be similar to those in adults. Finally, adolescents enrolled in therapeutic HIV prevention and treatment research can be considered adults, based on US Food and Drug Administration (FDA) regulations and the appropriate application of state law. The FDA permits local jurisdictions to apply state and local HIV/sexually transmitted infection minor treatment laws so that adolescents who are HIV-positive or at risk of contracting HIV may be enrolled in therapeutic or prevention trials without obtaining parental permission.
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Affiliation(s)
- Michelle Hume
- Department of Psychiatry, University of Wisconsin, Madison, Wisconsin, USA
| | - Linda L Lewis
- Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Robert M Nelson
- Office of Pediatric Therapeutics, Office of the Commissioner, Food and Drug Administration, Silver Spring, Maryland, USA
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Abstract
Despite more than thirty years of debate, disagreement persists among research ethicists about the most appropriate way to interpret the U.S. regulations on pediatric research, specifically the categories of "minimal risk" and a "minor increase over minimal risk." Focusing primarily on the definition of "minimal risk," we argue in this article that the continued debate about the pediatric risk categories is at least partly because their conceptual status is seldom considered directly. Once this is done, it becomes clear that the most popular strategy for interpreting "minimal risk"-defining it as a specific set of risks-is indefensible and, from a pragmatic perspective, unlikely to resolve disagreement. Primarily this is because judgments about minimal risk are both normative and heavily intuitive in nature and thus cannot easily be captured by reductions to a given set of risks. We suggest instead that a more defensible approach to evaluating risk should incorporate room for reflection and deliberation. This dispositional, deliberative framework can nonetheless accommodate a number of intellectual resources for reducing reliance on sheer intuition and improving the quality of risk evaluations.
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Affiliation(s)
- John Rossi
- Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Robert M. Nelson
- Office of Pediatric Therapeutics (OPT), Office of the Commissioner (OC), United States Food and Drug Administration (FDA), Silver Spring, Maryland, USA
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Sable CA, Ivy DD, Beekman RH, Clayton-Jeter HD, Jenkins KJ, Mahle WT, Morrow WR, Murphy MD, Nelson RM, Rosenthal GL, Stockbridge N, Wessel DL. 2017 ACC/AAP/AHA Health Policy Statement on Opportunities and Challenges in Pediatric Drug Development: Learning From Sildenafil. Circ Cardiovasc Qual Outcomes 2017; 10:HCQ.0000000000000026. [DOI: 10.1161/hcq.0000000000000026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Craig A. Sable
- American College of Cardiology Representative. US Food and Drug Administration Representative. American Academy of Pediatrics Representative. US Food and Drug Administration Representative. Retired from the US Food and Drug Administration during the development of this statement
| | - D. Dunbar Ivy
- American College of Cardiology Representative. US Food and Drug Administration Representative. American Academy of Pediatrics Representative. US Food and Drug Administration Representative. Retired from the US Food and Drug Administration during the development of this statement
| | - Robert H. Beekman
- American College of Cardiology Representative. US Food and Drug Administration Representative. American Academy of Pediatrics Representative. US Food and Drug Administration Representative. Retired from the US Food and Drug Administration during the development of this statement
| | - Helene D. Clayton-Jeter
- American College of Cardiology Representative. US Food and Drug Administration Representative. American Academy of Pediatrics Representative. US Food and Drug Administration Representative. Retired from the US Food and Drug Administration during the development of this statement
| | - Kathy J. Jenkins
- American College of Cardiology Representative. US Food and Drug Administration Representative. American Academy of Pediatrics Representative. US Food and Drug Administration Representative. Retired from the US Food and Drug Administration during the development of this statement
| | - William T. Mahle
- American College of Cardiology Representative. US Food and Drug Administration Representative. American Academy of Pediatrics Representative. US Food and Drug Administration Representative. Retired from the US Food and Drug Administration during the development of this statement
| | - William R. Morrow
- American College of Cardiology Representative. US Food and Drug Administration Representative. American Academy of Pediatrics Representative. US Food and Drug Administration Representative. Retired from the US Food and Drug Administration during the development of this statement
| | - Mary Dianne Murphy
- American College of Cardiology Representative. US Food and Drug Administration Representative. American Academy of Pediatrics Representative. US Food and Drug Administration Representative. Retired from the US Food and Drug Administration during the development of this statement
| | - Robert M. Nelson
- American College of Cardiology Representative. US Food and Drug Administration Representative. American Academy of Pediatrics Representative. US Food and Drug Administration Representative. Retired from the US Food and Drug Administration during the development of this statement
| | - Geoffrey L. Rosenthal
- American College of Cardiology Representative. US Food and Drug Administration Representative. American Academy of Pediatrics Representative. US Food and Drug Administration Representative. Retired from the US Food and Drug Administration during the development of this statement
| | - Norman Stockbridge
- American College of Cardiology Representative. US Food and Drug Administration Representative. American Academy of Pediatrics Representative. US Food and Drug Administration Representative. Retired from the US Food and Drug Administration during the development of this statement
| | - David L. Wessel
- American College of Cardiology Representative. US Food and Drug Administration Representative. American Academy of Pediatrics Representative. US Food and Drug Administration Representative. Retired from the US Food and Drug Administration during the development of this statement
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Sable CA, Ivy DD, Beekman RH, Clayton-Jeter HD, Jenkins KJ, Mahle WT, Morrow WR, Murphy MD, Nelson RM, Rosenthal GL, Stockbridge N, Wessel DL. 2017 ACC/AAP/AHA Health Policy Statement on Opportunities and Challenges in Pediatric Drug Development: Learning From Sildenafil. J Am Coll Cardiol 2017; 70:495-503. [PMID: 28669447 DOI: 10.1016/j.jacc.2017.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Wang J, Johnson T, Sahin L, Tassinari MS, Anderson PO, Baker TE, Bucci-Rechtweg C, Burckart GJ, Chambers CD, Hale TW, Johnson-Lyles D, Nelson RM, Nguyen C, Pica-Branco D, Ren Z, Sachs H, Sauberan J, Zajicek A, Ito S, Yao LP. Evaluation of the Safety of Drugs and Biological Products Used During Lactation: Workshop Summary. Clin Pharmacol Ther 2017; 101:736-744. [PMID: 28510297 DOI: 10.1002/cpt.676] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/22/2017] [Accepted: 02/27/2017] [Indexed: 12/15/2022]
Abstract
This report serves as a summary of a 2-day public workshop sponsored by the US Food and Drug Administration (FDA) to discuss the safety of drugs and biological products used during lactation. The aim of the workshop was to provide a forum to discuss the collection of data to inform the potential risks to breastfed infants with maternal use of medications during lactation. Discussions included the review of current approaches to collect data on medications used during lactation, and the considerations for future approaches to design and guide clinical lactation studies. This workshop is part of continuing efforts to raise the awareness of the public for women who choose to breastfeed their infants.
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Affiliation(s)
- J Wang
- Office of Drug Evaluation IV, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - T Johnson
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - L Sahin
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - M S Tassinari
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - P O Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
| | - T E Baker
- Infantrisk Center, Texas Tech University Health Sciences Center Amarillo, Amarillo, Texas, USA
| | - C Bucci-Rechtweg
- Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, New Jersey, USA
| | - G J Burckart
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - C D Chambers
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | - T W Hale
- Infantrisk Center, Texas Tech University Health Sciences Center Amarillo, Amarillo, Texas, USA
| | - D Johnson-Lyles
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - R M Nelson
- Office of Pediatric Therapeutics, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - C Nguyen
- Division of Bone, Reproductive, and Urologic Products, Office of Drug Evaluation III, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - D Pica-Branco
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Z Ren
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institute of Health, Bethesda, Maryland, USA
| | - H Sachs
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - J Sauberan
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California, USA
| | - A Zajicek
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institute of Health, Bethesda, Maryland, USA
| | - S Ito
- Division of Clinical Pharmacology & Toxicology, Department of Pediatrics, Hospital For Sick Children, Toronto, Ontario, Canada
| | - L P Yao
- Division of Pediatric and Maternal Health, Office of Drug Evaluation IV, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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Abstract
The natural history of spinal muscular atrophy type I (SMA-I) has changed as improved medical support has become available. With investigational drugs for spinal muscular atrophy now in clinical trials, efficient trial design focuses on enrolling recently diagnosed infants, providing best available supportive care, and minimizing subject variation. The quandary has arisen whether it is ethically appropriate to specify a predefined level of nutritional and/or ventilation support for spinal muscular atrophy type I subjects while participating in these studies. We conducted a survey at 2 spinal muscular atrophy investigator meetings involving physician investigators, clinical evaluators, and study coordinators from North America, Europe, and Asia-Pacific. Each group endorsed the concept that having a predefined degree of nutritional and ventilation support was warranted in this context. We discuss how autonomy, beneficence/non-maleficence, noncoercion, social benefit, and equipoise can be maintained when a predefined level of supportive care is proposed, for participation in a clinical trial.
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Affiliation(s)
- Richard S Finkel
- 1 Division of Neurology, Nemours Children's Hospital, Orlando, FL, USA
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Sun H, Stockbridge N, Ariagno RL, Murphy D, Nelson RM, Rodriguez W. Reliable and developmentally appropriate study end points are needed to achieve drug development for treatment of pediatric pulmonary arterial hypertension. J Perinatol 2016; 36:1029-1033. [PMID: 27416322 PMCID: PMC5585871 DOI: 10.1038/jp.2016.103] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 03/29/2016] [Accepted: 04/11/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To identify suitable end points and surrogates for pediatric pulmonary arterial hypertension (PAH) as the lack of developmentally appropriate end point and clinical trials contribute to the unmet medical need. STUDY DESIGN Reviewed the efficacy end points and surrogates for all trials (1995 to 2013) that were submitted to the Food and Drug Administration (FDA) to support the approval of PAH therapy and conducted literature search. RESULTS An increase in the 6 min walking distance (6MWD) was used as a primary end point in 8/9 adult PAH trials. This end point is not suitable for infants and young children because of performance limitations and lack of control data. One adult PAH trial used time to the first morbidity or mortality event as a primary end point, which could potentially be used in pediatric PAH trials. In the sildenafil pediatric PAH trial, the change in pulmonary vascular resistance index or mean pulmonary artery pressure was used as a surrogate for the 6MWD to assess exercise capacity. However, two deaths and three severe adverse events during the catheterizations made this an unacceptably high-risk surrogate. The INOmax persistent pulmonary hypertension of the newborn trial used a reduction in initiation of extracorporeal membrane oxygenation treatment as a primary end point, which is not feasible for other pediatric PAH trials. A Literature review revealed none of the existing noninvasive markers are fully validated as surrogates to assess PAH efficacy and long-term safety. CONCLUSIONS For pediatric PAH trials, clinical end points are acceptable, and novel validated surrogates would be helpful. FDA seeks collaboration with academia, industry and parents to develop other suitable and possibly more efficient efficacy end points to facilitate pediatric PAH drug development.
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Affiliation(s)
- H Sun
- Office of Pediatric Therapeutics/Office of Commissioner, Food and Drug Administration, Silver Spring, Maryland, USA
| | - N Stockbridge
- Division of Cardiovascular and Renal Products, Food and Drug Administration, Silver Spring, Maryland, USA
| | - RL Ariagno
- Stanford University, Division of Neonatal & Developmental Medicine, Palo Alto, California, USA,Senior Oak Ridge Institute for Science and Education, Silver Spring, Maryland, USA
| | - D Murphy
- Office of Pediatric Therapeutics/Office of Commissioner, Food and Drug Administration, Silver Spring, Maryland, USA
| | - RM Nelson
- Office of Pediatric Therapeutics/Office of Commissioner, Food and Drug Administration, Silver Spring, Maryland, USA
| | - W Rodriguez
- Office of Pediatric Therapeutics/Office of Commissioner, Food and Drug Administration, Silver Spring, Maryland, USA
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Offringa M, Davis JM, Turner MA, Ward R, Bax R, Maldonado S, Sinha V, McCune SK, Zajicek A, Benjamin DK, Bucci-Rechtweg C, Nelson RM. Applying Regulatory Science to Develop Safe and Effective Medicines for Neonates: Report of the US Food and Drug Administration First Annual Neonatal Scientific Workshop, October 28–29, 2014. Ther Innov Regul Sci 2015; 49:623-631. [DOI: 10.1177/2168479015597730] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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21
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Nelson RM. The author replies. Hastings Cent Rep 2015; 45:4. [PMID: 25944196 DOI: 10.1002/hast.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Affiliation(s)
- M Roth-Cline
- Office of Pediatric Therapeutics; FDA; Silver Spring Maryland USA
| | - RM Nelson
- Office of Pediatric Therapeutics; FDA; Silver Spring Maryland USA
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Affiliation(s)
- David J. Howard
- Department of Psychology, University of South Florida, Tampa, Florida
| | - Sally A. Coovert
- Office of Children's Health, University of South Florida, Tampa, Florida
| | | | - Robert M. Nelson
- Office of Children's Health, University of South Florida, Tampa, Florida
- Department of Pediatrics, University of Texas, Rio Grande Valley, Harlingen, Texas
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Nelson RM, Roth-Cline M, Prohaska K, Cox E, Borio L, Temple R. Right job, wrong tool: a commentary on designing clinical trials for Ebola virus disease. Am J Bioeth 2015; 15:33-6. [PMID: 25856596 DOI: 10.1080/15265161.2015.1010018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
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Sun H, Vesely R, Nelson RM, Taminiau J, Szitanyi P, Isaac M, Klein A, Uzu S, Griebel D, Mulberg AE. Steps toward harmonization for clinical development of medicines in pediatric ulcerative colitis-a global scientific discussion, part 2: data extrapolation, trial design, and pharmacokinetics. J Pediatr Gastroenterol Nutr 2014; 58:684-8. [PMID: 24866782 DOI: 10.1097/mpg.0000000000000322] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To facilitate global drug development, the International Pediatric Inflammatory Bowel Disease Working Group (i-IBD Working Group) discussed data extrapolation, trial design, and pharmacokinetic (PK) considerations for drugs intended to treat pediatric ulcerative colitis (UC), and considered possible approaches toward harmonized drug development. METHODS Representatives from the US Food and Drug Administration, European Medicines Agency, Health Canada, and the Pharmaceuticals and Medical Devices Agency of Japan convened monthly to explore existing regulatory approaches, reviewed the results of a literature search, and provided perspectives on pediatric UC drug development based on the available medical literature. RESULTS Although pediatric UC, when compared with UC in adults, has a similar disease progression and response to intervention, the similarity of the exposure-response relation has not been adequately established. Consequently, clinical endpoints should be selected to optimally assess efficacy in children. The inclusion of a placebo control in pediatric trials to assure assay sensitivity may be appropriate under limited circumstances. In clinical studies, although the drug under investigation could provide possible direct benefit, placebo treatment should present no more than a minor increase over minimal risk to children with UC. CONCLUSIONS Partial extrapolation of efficacy from informative adult studies may be appropriate. Placebo-controlled efficacy trials are scientifically and ethically appropriate for pediatric UC given appropriate patient selection and the use of early escape. Clinical studies in pediatric UC may include initial dose-finding studies and exposure-response modeling followed by an efficacy and safety study to further explore the exposure-response relation.
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Affiliation(s)
- Haihao Sun
- *US Food and Drug Administration, Silver Spring, MD †European Medicines Agency, London, UK ‡Health Canada, Ottawa, Ontario, Canada §Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
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Roth-Cline M, Nelson RM. Parental permission and child assent in research on children. Yale J Biol Med 2013; 86:291-301. [PMID: 24058304 PMCID: PMC3767214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Bright PL, Nelson RM. A capacity-based approach for addressing ancillary care needs: implications for research in resource limited settings. J Med Ethics 2012; 38:672-676. [PMID: 22562947 DOI: 10.1136/medethics-2011-100205] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
A paediatric clinical trial conducted in a developing country is likely to encounter conditions or illnesses in participants unrelated to the study. Since local healthcare resources may be inadequate to meet these needs, research clinicians may face the dilemma of deciding when to provide ancillary care and to what extent. The authors propose a model for identifying ancillary care obligations that draws on assessments of urgency, the capacity of the local healthcare infrastructure and the capacity of the research infrastructure. The model lends itself to a decision tree that can be adapted to the local context and resources so as to provide procedural guidance. This approach can help in planning and establishing organisational policies that govern the provision of ancillary care.
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Abstract
Determining whether a research risk meets or exceeds a regulatory standard of risk acceptability is difficult. Recently a framework called the systematic evaluation of research risks (SERR) has been proposed as a method of comparing research risks with predetermined standards of acceptability. SERR purports to offer a systematic and largely determinate (definite) way to compare risks and say whether a specific research risk falls below or above an acknowledged standard of acceptable risk. Here the authors review some philosophical problems with this framework, which they take to be representative of determinate approaches to risk comparison, and conclude that it should not be used in a stand-alone or determinate fashion. Instead, the authors suggest that a deliberative approach may be a more viable candidate for future development. Such an approach could be informed by methods such as SERR without being rigidly bound to them.
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Affiliation(s)
- John Rossi
- Community Health and Prevention, Drexel University School of Public Health, 1505 Race Street, Bellet Building, 11th Floor, Philadelphia, PA 19102, USA.
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Abstract
OBJECTIVE The aim of the current study was to examine demographic and contextual correlates of voluntariness in parents making research or treatment decisions for their children with cancer. METHODS Participants included 184 parents of children with cancer who made a decision about enrolling the child in a research or treatment protocol within the previous 10 days. Parents completed questionnaires that assessed voluntariness, external influence by others, concern that the child's care would be negatively affected if the parent did not agree, time pressure, information adequacy, and demographics. RESULTS Lower perceived voluntariness was associated with lower education, male gender, minority status, and not having previous experience with a similar decision. Parents who reported lower voluntariness also perceived more external influence and time pressure, had more concern about the child's care being negatively affected if they declined, and perceived that they had either too much or not enough information about the decision. In a multivariate regression, education, minority status, gender, external influence, and too little information remained significantly associated with voluntariness. CONCLUSIONS Several groups of parents appear to be at risk for decreased voluntariness when making research or treatment decisions for their seriously ill children, including fathers, nonwhite parents, and those with less education. Parental voluntariness may be enhanced by helping parents to mitigate the effects of unhelpful or unwanted influences by others and ensuring that their information needs are met.
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Affiliation(s)
- Victoria A. Miller
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Robert M. Nelson
- Office of Pediatric Therapeutics, Office of the Commissioner, Food and Drug Administration, Rockville, Maryland
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31
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Affiliation(s)
- Robert M Nelson
- US Food and Drug Administration, Silver Spring, MD 20993, USA.
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Abstract
Our primary focus is on analysis of the concept of voluntariness, with a secondary focus on the implications of our analysis for the concept and the requirements of voluntary informed consent. We propose that two necessary and jointly sufficient conditions must be satisfied for an action to be voluntary: intentionality, and substantial freedom from controlling influences. We reject authenticity as a necessary condition of voluntary action, and we note that constraining situations may or may not undermine voluntariness, depending on the circumstances and the psychological capacities of agents. We compare and evaluate several accounts of voluntariness and argue that our view, unlike other treatments in bioethics, is not a value-laden theory. We also discuss the empirical assessment of individuals' perceptions of the degrees of noncontrol and self-control. We propose use of a particular Decision Making Control Instrument. Empirical research using this instrument can provide data that will help establish appropriate policies and procedures for obtaining voluntary consent to research.
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Affiliation(s)
- Robert M Nelson
- US Food and Drug Administration, Silver Spring, MD 20993, USA.
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Miller VA, Luce MF, Nelson RM. Relationship of external influence to parental distress in decision making regarding children with a life-threatening illness. J Pediatr Psychol 2011; 36:1102-12. [PMID: 21693541 DOI: 10.1093/jpepsy/jsr033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To examine the relationship of external influence to parental distress when making a decision about research or treatment for a child with a life-threatening illness and to test potential moderators of this relationship. METHODS Parents (n = 219) who made a decision about research or treatment for a child completed measures of external influence, distress, decision-making preference, and coping. RESULTS More external influence was associated with more hostility, uncertainty, and confusion. Decision-making preference and coping style moderated the relationship between external influence and distress: More external influence was associated with more distress when decision-making preference was low and task-focused coping was high. CONCLUSIONS External influence appears to be related to distress in parents making research and treatment decisions for children with life-threatening illnesses. However, it is important to consider parent characteristics, such as decision-making preference and coping style, when examining the effects of contextual factors on distress during decision making.
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Affiliation(s)
- Victoria A Miller
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Nelson RM. A relative standard for minimal risk is unnecessary and potentially harmful to children: lessons from the Phambili trial. Am J Bioeth 2011; 11:14-16. [PMID: 21678206 DOI: 10.1080/15265161.2011.568588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Robert M Nelson
- U.S. Food and Drug Administration, Office of Pediatric Therapeutics, Silver Spring 20993-0002, USA.
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Miller VA, Ittenbach RF, Harris D, Reynolds WW, Beauchamp TL, Luce MF, Nelson RM. The decision making control instrument to assess voluntary consent. Med Decis Making 2011; 31:730-41. [PMID: 21402793 DOI: 10.1177/0272989x11398666] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The decision to participate in a research intervention or to undergo medical treatment should be both informed and voluntary. OBJECTIVE The aim of the present study was to develop an instrument to measure the perceived voluntariness of parents making decisions for their seriously ill children. METHODS A total of 219 parents completed questionnaires within 10 days of making such a decision at a large, urban tertiary care hospital for children. Parents were presented with an experimental form of the Decision Making Control Instrument (DMCI), a measure of the perception of voluntariness. Data obtained from the 28-item form were analyzed using a combination of both exploratory and confirmatory factor analytic techniques. RESULTS The 28 items were reduced to 9 items representing 3 oblique dimensions: Self-Control, Absence of Control, and Others' Control. The hypothesis that the 3-factor covariance structure of our model was consistent with that of the data was supported. Internal consistency for the scale as a whole was high (0.83); internal consistency for the subscales ranged from 0.68 to 0.87. DMCI scores were associated with measures of affect, trust, and decision self-efficacy, supporting the construct validity of the new instrument. CONCLUSION The DMCI is an important new tool that can be used to inform our understanding of the voluntariness of treatment and research decisions in medical settings.
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Affiliation(s)
- Victoria A Miller
- Department of Anesthesiology and Critical Care Medicine, the Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine (VAM)
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center (RFI)
| | - Diana Harris
- Center for the Integration of Genetic Healthcare Technologies, University of Pennsylvania School of Medicine (DH)
| | | | | | | | - Robert M Nelson
- Office of Pediatric Therapeutics, Office of the Commissioner, Food and Drug Administration (RMN)
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Abstract
The critical need for pediatric research on drugs and biological products underscores the responsibility to ensure that children are enrolled in clinical research that is both scientifically necessary and ethically sound. In this chapter, we review key ethical considerations concerning the participation of children in clinical research. We propose a basic ethical framework to guide pediatric research, and suggest how this framework might be operationalized in linking science and ethics. Topics examined include: the status of children as a vulnerable population; the appropriate balance of risk and potential benefit in research; ethical considerations underlying study design, including clinical equipoise, placebo controls, and non-inferiority designs; the use of data monitoring committees; compensation; and parental permission and child assent to participate in research. We incorporate selected national (USA) and international guidelines, as well as regulatory approaches to pediatric studies that have been adopted in the USA, Canada, and Europe.
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Affiliation(s)
- Michelle Roth-Cline
- U.S. Department of Health and Human Services, Food and Drug Administration, Office of the Commissioner, Office of Pediatric Therapeutics, Silver Spring, MD 2011, USA
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Abstract
At the time of this writing, a widely publicized, waived-consent trial is underway. Sponsored by Northfield Laboratories, Inc. (Evanston, IL) the trial is intended to evaluate the emergency use of PolyHeme®, an oxygen-carrying resuscitative fluid that might prevent deaths from uncontrolled bleeding. The protocol allows patients in hemorrhagic shock to be randomized between PolyHeme® and saline in the field and, still without consent, randomized between PolyHeme® and blood after arrival at an emergency department. The Federal regulations that govern the waiver of consent restrict its applicability to circumstances where proven, satisfactory treatments are unavailable. Blood-the standard treatment for hemorrhagic shock-is not available in ambulances but is available in hospitals. The authors argue that the in-hospital stage of the study fails to meet ethical and regulatory standards.
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Ross LF, Loup A, Nelson RM, Botkin JR, Kost R, Smith GR, Gehlert S. Human subjects protections in community-engaged research: a research ethics framework. J Empir Res Hum Res Ethics 2010; 5:5-17. [PMID: 20235860 PMCID: PMC2946318 DOI: 10.1525/jer.2010.5.1.5] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the 30 years since the Belmont Report, the role of the community in research has evolved and has taken on greater moral significance. Today, more and more translational research is being performed with the active engagement of individuals and communities rather than merely upon them. This engagement requires a critical examination of the range of risks that may arise when communities become partners in research. In attempting to provide such an examination, one must distinguish between established communities (groups that have their own organizational structure and leadership and exist regardless of the research) and unstructured groups (groups that may exist because of a shared trait but do not have defined leadership or internal cohesiveness). In order to participate in research as a community, unstructured groups must develop structure either by external means (by partnering with a Community-Based Organization) or by internal means (by empowering the group to organize and establish structure and leadership). When groups participate in research, one must consider risks to well-being due to process and outcomes. These risks may occur to the individual qua individual, but there are also risks that occur to the individual qua member of a group and also risks that occur to the group qua group. There are also risks to agency, both to the individual and the group. A 3-by-3 grid including 3 categories of risks (risks to well-being secondary to process, risks to well-being secondary to outcome and risks to agency) must be evaluated against the 3 distinct agents: individuals as individual participants, individuals as members of a group (both as participants and as nonparticipants) and to communities as a whole. This new framework for exploring the risks in community-engaged research can help academic researchers and community partners ensure the mutual respect that community-engaged research requires.
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Ross LF, Loup A, Nelson RM, Botkin JR, Kost R, Smith GR, Gehlert S. Nine key functions for a human subjects protection program for community-engaged research: points to consider. J Empir Res Hum Res Ethics 2010; 5:33-47. [PMID: 20235862 PMCID: PMC2963647 DOI: 10.1525/jer.2010.5.1.33] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The ethical conduct of Community-Engaged Research (CEnR), of which the Community-Based Participatory Research (CBPR) model is the partnership model most widely discussed in the CEnR literature and is the primary model we draw upon in this discussion, requires an integrated and comprehensive human subjects protection (HSP) program that addresses the additional concerns salient to CEnR where members of a community are both research partners and participants. As delineated in the federal regulations, the backbone of a HSP program is the fulfillment of nine functions: (1) minimize risks; (2) reasonable benefit-risk ratio; (3) fair subject selection; (4) adequate monitoring; (5) informed consent; (6) privacy and confidentiality; (7) conflicts of interest; (8) address vulnerabilities; and (9) HSP training. The federal regulations, however, do not consider the risks and harms that may occur to groups, and these risks have not traditionally been included in the benefit: risk analysis nor have they been incorporated into an HSP framework. We explore additional HSP issues raised by CEnR within these nine ethical functions. Various entities exist that can provide HSP---the investigator, the Institutional Review Board, the Conflict of Interest Committee, the Research Ethics Consultation program, the Research Subject Advocacy program, the Data and Safety Monitoring Plan, and the Community Advisory Board. Protection is best achieved if these entities are coordinated to ensure that no gaps exist, to minimize unnecessary redundancy, and to provide checks and balances between the different entities of HSP and the nine functions that they must realize. The document is structured to provide a "points-to-consider" roadmap for HSP entities to help them adequately address the nine key functions necessary to provide adequate protection of individuals and communities in CEnR.
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Ross LF, Loup A, Nelson RM, Botkin JR, Kost R, Smith GR, Gehlert S. Human subjects protections in community-engaged research: a research ethics framework. J Empir Res Hum Res Ethics 2010. [PMID: 20235860 DOI: 10.1525/jer.2010.5.1.5.human] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
In the 30 years since the Belmont Report, the role of the community in research has evolved and has taken on greater moral significance. Today, more and more translational research is being performed with the active engagement of individuals and communities rather than merely upon them. This engagement requires a critical examination of the range of risks that may arise when communities become partners in research. In attempting to provide such an examination, one must distinguish between established communities (groups that have their own organizational structure and leadership and exist regardless of the research) and unstructured groups (groups that may exist because of a shared trait but do not have defined leadership or internal cohesiveness). In order to participate in research as a community, unstructured groups must develop structure either by external means (by partnering with a Community-Based Organization) or by internal means (by empowering the group to organize and establish structure and leadership). When groups participate in research, one must consider risks to well-being due to process and outcomes. These risks may occur to the individual qua individual, but there are also risks that occur to the individual qua member of a group and also risks that occur to the group qua group. There are also risks to agency, both to the individual and the group. A 3-by-3 grid including 3 categories of risks (risks to well-being secondary to process, risks to well-being secondary to outcome and risks to agency) must be evaluated against the 3 distinct agents: individuals as individual participants, individuals as members of a group (both as participants and as nonparticipants) and to communities as a whole. This new framework for exploring the risks in community-engaged research can help academic researchers and community partners ensure the mutual respect that community-engaged research requires.
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Ross LF, Loup A, Nelson RM, Botkin JR, Kost R, Smith GR, Gehlert S. The challenges of collaboration for academic and community partners in a research partnership: points to consider. J Empir Res Hum Res Ethics 2010; 5:19-31. [PMID: 20235861 PMCID: PMC2946316 DOI: 10.1525/jer.2010.5.1.19] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The philosophical underpinning of Community-Engaged Research (CEnR) entails a collaborative partnership between academic researchers and the community. The Community-Based Participatory Research (CBPR) model is the partnership model most widely discussed in the CEnR literature and is the primary model we draw upon in this discussion of the collaboration between academic researchers and the community. In CPBR, the goal is for community partners to have equal authority and responsibility with the academic research team, and that the partners engage in respectful negotiation both before the research begins and throughout the research process to ensure that the concerns, interests, and needs of each party are addressed. The negotiation of a fair, successful, and enduring partnership requires transparency and understanding of the different assets, skills and expertise that each party brings to the project. Delineating the expectations of both parties and documenting the terms of agreement in a memorandum of understanding or similar document may be very useful. This document is structured to provide a "points- to-consider" roadmap for academic and community research partners to establish and maintain a research partnership at each stage of the research process.
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Nathan AT, Hoehn KS, Ittenbach RF, Gaynor JW, Nicolson S, Wernovsky G, Nelson RM. Assessment of parental decision-making in neonatal cardiac research: a pilot study. J Med Ethics 2010; 36:106-110. [PMID: 20133406 DOI: 10.1136/jme.2009.030676] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To assess parental permission for a neonate's research participation using the MacArthur competence assessment tool for clinical research (MacCAT-CR), specifically testing the components of understanding, appreciation, reasoning and choice. STUDY DESIGN Quantitative interviews using study-specific MacCAT-CR tools. HYPOTHESIS Parents of critically ill newborns would produce comparable MacCAT-CR scores to healthy adult controls despite the emotional stress of an infant with critical heart disease or the urgency of surgery. Parents of infants diagnosed prenatally would have higher MacCAT-CR scores than parents of infants diagnosed postnatally. There would be no difference in MacCAT-CR scores between parents with respect to gender or whether they did or did not permit research participation. PARTICIPANTS Parents of neonates undergoing cardiac surgery who had made decisions about research participation before their neonate's surgery. METHODS The MacCAT-CR. RESULTS 35 parents (18 mothers; 17 fathers) of 24 neonates completed 55 interviews for one or more of three studies. Total scores: magnetic resonance imaging (mean 36.6, SD 7.71), genetics (mean 38.8, SD 3.44), heart rate variability (mean 37.7, SD 3.30). Parents generally scored higher than published subject populations and were comparable to published control populations with some exceptions. CONCLUSIONS The MacCAT-CR can be used to assess parental permission for neonatal research participation. Despite the stress of a critically ill neonate requiring surgery, parents were able to understand study-specific information and make informed decisions to permit their neonate's participation.
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Affiliation(s)
- Aruna T Nathan
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Pennsylvania, USA.
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Miller VA, Reynolds WW, Ittenbach RF, Luce MF, Beauchamp TL, Nelson RM. Challenges in measuring a new construct: perception of voluntariness for research and treatment decision making. J Empir Res Hum Res Ethics 2009; 4:21-31. [PMID: 19754231 DOI: 10.1525/jer.2009.4.3.21] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
RELIABLE AND VALID MEASURES OF RELEVANT constructs are critical in the developing field of the empirical study of research ethics. The early phases of scale development for such constructs can be complex. We describe the methodological challenges of construct definition and operationalization and how we addressed them in our study to develop a measure of perception of voluntariness. We also briefly present our conceptual approach to the construct of voluntariness, which we defined as the perception of control over decision making. Our multifaceted approach to scale development ensured that we would develop a construct definition of sufficient breadth and depth, that our new measure of voluntariness would be applicable across disciplines, and that there was a clear link between our construct definition and items. The strategies discussed here can be adapted by other researchers who are considering a scale development study related to the empirical study of ethics.
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Affiliation(s)
- Victoria A Miller
- The Children's Hospital of Philadelphia, Civic Center, Philadelphia, PA 19104, USA.
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Hoehn KS, Nathan A, White LE, Ittenbach RF, Reynolds WW, Gaynor JW, Wernovsky G, Nicolson S, Nelson RM. Parental perception of time and decision-making in neonatal research. J Perinatol 2009; 29:508-11. [PMID: 19194453 DOI: 10.1038/jp.2009.5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the impact of time on parental decision-making for research participation for neonates with congenital heart disease. STUDY DESIGN Interviews were conducted with 37 parents of 19 neonates with congenital heart disease who were eligible for three different studies: genetic etiology of congenital heart disease, heart rate variability (HRV) and structural and functional cranial magnetic resonance imaging (MRI). All parents were asked the same questions: (1) 'Did you have adequate time to make a decision about research?' and (2) 'Why?' Differences between groups (reporting adequate and inadequate time) were evaluated using Fisher's exact tests; central themes were examined using qualitative analysis. RESULT Of those parents who reported having adequate time to make their decision (22 of 37), the majority chose to participate when compared to those who reported inadequate time (genetics study, P<0.01; HRV, P=0.05; MRI, P<0.01). For the parents reporting inadequate time, consistent themes emerged: insufficient time to make an educated choice (n=10), consideration of study logistics (n=8), spouse not present at the time of decision (n=7) and insufficient time to discuss the studies (n=4). CONCLUSION Parental perception of adequate time to decide about research participation was associated with parental willingness to enroll the child in research. Despite any time limitations, parents were satisfied with the decisions they made. Optimizing the time available for the parental permission process could enhance research participation in the neonatal period.
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Affiliation(s)
- K S Hoehn
- Department of Pediatrics, University of Chicago School of Medicine, Chicago, IL 60608, USA.
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Borasino S, Morrison W, Silberman J, Nelson RM, Feudtner C. Physicians' contact with families after the death of pediatric patients: a survey of pediatric critical care practitioners' beliefs and self-reported practices. Pediatrics 2008; 122:e1174-8. [PMID: 19015203 DOI: 10.1542/peds.2008-0952] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Although research with bereaved families has shown that they appreciate contact with clinicians after the child's death, this realm of clinical practice remains empirically uncharted. The objective of this study was to describe pediatric critical care practitioners' attitudes and self-reported practices regarding contacting families after a patient's death. METHODS A total of 376 board-certified members of the American Academy of Pediatrics Section of Critical Care received e-mail invitations to complete a Web-based questionnaire; 204 members responded (effective response rate: 54.3%). RESULTS Most (95%) participants reported 0 to 1 patient deaths per week. A total of 79% of the respondents reported contacting families at least sometimes, 71.9% had attended funerals, and only 2.5% thought that it was inappropriate for clinicians to attend funerals. A total of 75.9% agreed that follow-up contact helps the family, whereas 47.3% agreed that follow-up contact helps the physicians. The most common methods of follow-up contact included the passive measures of providing contact information; active methods such as meeting with the family, calling them by telephone, or writing a letter or note were used less often. In multivariable analysis, respondents were more likely to report contact with a family after the death of a child when they affirmed the belief that such contact was useful to the family or to the physician or when they were female physicians. Regarding reported funeral attendance after the death of a patient, multivariable analysis revealed similar patterns of association but to an attenuated and nonstatistically significant degree. CONCLUSIONS A high proportion of pediatric critical care physicians have contacted bereaved families and attended funerals after the death of a child patient. These practices were consistently associated with the belief that such follow-up contact helps the family or the practitioner.
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Affiliation(s)
- Santiago Borasino
- University of Alabama at Birmingham, Pediatric Critical Care Medicine, ACC 504, 1600 7th Ave S, Birmingham, AL 35233-1711, USA.
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Nelson RM. Institutional review boards lack the moral legitimacy to reinterpret subpart D. Am J Bioeth 2008; 8:37-39. [PMID: 18576252 DOI: 10.1080/15265160802147264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Robert M Nelson
- United States Food and Drug Administration, Rockville, MD 20057, USA.
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Reynolds WW, Nelson RM. Empirical data and the acceptability of research risk: a commentary on the charitable participation standard. Arch Pediatr Adolesc Med 2008; 162:88-90. [PMID: 18180419 DOI: 10.1001/archpediatrics.2007.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Moses B, Nelson RM, Nelson AJ, Cheifetz P. The relationship between skin temperature and neuronal characteristics in the median, ulnar and radial nerves of non-impaired individuals. Electromyogr Clin Neurophysiol 2007; 47:351-360. [PMID: 18051629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The purpose of this study was to evaluate the relationship between the nerve conduction characteristics in the median, ulnar and radial nerves and presenting skin temperature in non-impaired individuals as they were subjected to electrophysiological testing. Previous researchers artificially manipulated the skin temperature and demonstrated that there was a positive relationship between temperature and nerve conduction velocity and a negative correlation between distal latency and evoked motor action potential (EMAP). The sample population was 50 non-impaired individuals derived from a venue in the New York City and Long Island region. The independent variable was skin temperature. The dependent variables were: motor nerve conduction velocity, motor distal latency, EMAP of median and ulnar nerves, sensory distal latency and sensory nerve action potential (SNAP) of median, ulnar and radial nerves. The data were analyzed using descriptive statistics, the Bonferroni correction factor and correlation statistics. The study showed significant correlation in median motor distal latency, ulnar motor distal latency, ulnar sensory distal latency, median sensory amplitude, and ulnar sensory amplitude. The NCV, the distal latency and the amplitude of the median, ulnar and radial nerves were similar in values to other researchers' normal values.
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Affiliation(s)
- B Moses
- Electrophysiology Program, Rocky Mountain University of Health Professions, Provo, UT, USA
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Abstract
According to the rational choice model, informed consent should consist of a systematic, step-by-step evaluation of all information pertinent to the treatment or research participation decision. Research shows that people frequently deviate from this normative model, however, employing decision-making shortcuts, or heuristics. In this paper we report findings from a qualitative study of 32 adolescents and (their) 31 parents who were recruited from two Northeastern US hospitals and asked to consider the risks of and make hypothetical decisions about research participation. The purpose of this study was to increase our understanding of how diabetic and at-risk adolescents (i.e., those who are obese and/or have a family history of diabetes) and their parents perceive risks and make decisions about research participation. Using data collected from adolescents and parents, we identify heuristic decision processes in which participant perceptions of risk magnitude, which are formed quickly and intuitively and appear to be based on affective responses to information, are far more prominent and central to the participation decision than are perceptions of probability. We discuss participants' use of decision-making heuristics in the context of recent research on affect and decision processes, and we consider the implications of these findings for researchers.
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Affiliation(s)
- William W Reynolds
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Center for Research Integrity, CHOP North Room 1511, 3405 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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