Optimizing expert and patient input in pediatric trial design: Lessons learned and recommendations from a collaboration between conect4children and European Patient-CEntric ClinicAl TRial PLatforms.

Advice from multiple stakeholders is required to design the optimal pediatric clinical trial. We present recommendations for acquiring advice from trial experts and patients/caregivers, derived from advice meetings that were performed through a collaboration of the Collaborative Network for European Clinical Trials for Children (c4c) and the European Patient-CEntric ClinicAl TRial PLatforms (EU-PEARL). Three advice meetings were performed: (1) an advice meeting for clinical and methodology experts, (2) an advice meeting for patients/caregivers, and (3) a combined meeting with both experts and patients/caregivers. Trial experts were recruited from c4c database. Patients/caregivers were recruited through a patient organization. Participants were asked to provide input on a trial protocol, including endpoints, outcomes, and the assessment schedule. Ten experts, 10 patients, and 13 caregivers participated. The advice meetings resulted in modification of eligibility criteria and outcome measures. We have provided recommendations for the most effective meeting type per protocol topic. Topics with limited options for patient input were most efficiently discussed in expert advice meetings. Other topics benefit from patient/caregiver input, either through a combined meeting with experts or a patients/caregivers-only advice meeting. Some topics, such as endpoints and outcome measures, are suitable for all meeting types. Combined sessions profit from synergy between experts and patients/caregivers, balancing input on protocol scientific feasibility and acceptability. Both experts and patients/caregivers provided critical input on the presented protocol. The combined meeting was the most effective methodology for most protocol topics. The presented methodology can be used effectively to acquire expert and patient feedback.

Role of Patients and Parents in Pediatric Drug Development.

Patient engagement in health care has been an emerging priority in the global effort and move toward the consideration of patients as experts of their own conditions. However, the input of pediatric patients and their families have not been consistently requested nor regarded as valuable when deriving protocols for, as well as assessing the outcomes of, pediatric clinical trials. Extending this mutual collaboration further upstream is important, especially in the area of pediatric drug development where the lack of formalized trials for children and adolescents result in the increased use of off-label prescribing and risk of adverse effects. While recent changes to European and North American legislation contributed to the inclusion of children and youth in pediatric drug development, the lack of systematic guidelines and methodologies in literature serve as barriers for practical application. When combined with the work of external pediatric advocacy and patient advisory groups, the hope is that pediatric patient voices can be brought forward for the future. This article brings together international experts to review current best practices, progress from regulatory agencies, as well as global advocacy efforts to involve patients and families in the pursuit of drug development processes that value the voice of children and youth.

Involving children and young people in clinical research through the forum of a European Young Persons' Advisory Group: needs and challenges.

Children and young people are seen as fundamental to the design and delivery of clinical research as active and reflective participants. In Europe, involvement of children and young people in clinical research is promoted extensively in order to engage young people in research as partners and to give them a voice to raise their own issues or opinions and for their involvement in planning and decision making in addition to learning research skills. Children and young people can be trained in clinical research through participation in young person advisory groups (YPAGs). Members of YPAGs assist other children and young people to learn about clinical research and share their experience and point of view with researchers, thereby possibly influencing all phases of research including the development and prioritization of research questions, design and methods, recruitment plans, and strategies for results dissemination. In the long term, the expansion of YPAGs in Europe will serve as a driving force for refining pediatric clinical research. It will help in a better definition of research projects according to the patients' needs. Furthermore, direct engagement of children and young people in research will be favorable to both researchers and young people.

A trial of an iPad™ intervention targeting social communication skills in children with autism.

This study evaluated a technology-based early intervention for social communication skills in pre-schoolers in a randomised controlled trial. Participants were 54 children aged under 6 years with a diagnosis of autism, assigned to either intervention or control conditions. The app engaged children, who played consistently, regardless of developmental level, and was rated highly by parents. There were no significant group differences in parent-report measures post-intervention, nor in a measure of parent-child play at follow-up. Therefore, this intervention did not have an observable impact on real-world social communication skills and caution is recommended about the potential usefulness of iPad(™) apps for amelioration of difficulties in interaction. However, positive attitudes among participants, lack of harms and the potential of apps to deliver therapeutic content at low economic cost suggest this approach is worth pursuing further, perhaps targeting other skill domains.

iCAN: Providing a Voice for Children and Families in Pediatric Research.

Research and innovation are critical to improving the health and well-being of the world's children; clinical trials yield important information on a medical product's safety, dosing, and effectiveness. While the prescribing information available to pediatric providers has substantially improved, approximately 50% of medicines still do not have data on their labels to guide their appropriate use in children. Regulatory bodies have recently taken measures to ensure, if drugs have a potential pediatric indication, that the safety and efficacy clinical trials include the pediatric population. However, there are significant challenges with pediatric trials, including study design and feasibility, suitable formulations, and patient recruitment and retention. The authors propose that these challenges can be addressed by actively involving young people and families in study design so their insights can inform successful trial implementation. As the volume of pediatric research increases, there needs to be a concomitant effort for researchers and providers to seek input from patients and families in the development of their work, which can lead to a transformation of the cultural and regulatory environment of pediatric medicine. The benefits of patient and public involvement in research have been well documented. In 2006, the National Institute for Health Research Clinical Research Network: Children started its first Young Persons' Advisory Group in an effort to include young people in the design and delivery of pediatric research. Since their initial efforts, the youth advisory concept has grown into a global effort known as the International Children's Advisory Network (iCAN). This article describes the foundational building blocks of iCAN and provides tools to investigators and practitioners in an effort to increase the instances of children and families being invited to share their unique point of view in medicine.

Brominated dioxins (PBDD/Fs) and PBDEs in marine shellfish in the UK.

The occurrence of brominated dioxins (PBDD/Fs) and polybrominated diphenyl ethers (PBDEs) was investigated in commonly consumed species of marine shellfish in the UK. Individual samples of Pacific oysters (Crassostrea gigas), native oysters (Ostrea edulis), mussels (Mytilus edulis), scallops (Pecten maximus), and cockles (Cerastoderma edule) were collected from different coastal regions between 2006 and 2007. Samples of a particular species from each site were composited and 60 samples were analysed. Polybrominated dibenzofurans (PBDFs) occurred more frequently and generally at a higher level than polybrominated dibenzodioxins (PBDDs), except for 237-TriBDD, which was the predominant PBDD/F congener in some species, notably oysters. This profile may reflect the environmental distribution of these compounds and the effects of removal mechanisms, such as degradation, selective uptake and metabolism. PBDEs were detected in all samples. The dominant congeners were BDEs 47, 49, 99 and 100 and, to a lesser extent, BDEs 66 and 154. The occurrence of BDE-209 was observed in most samples and appears to be species selective, with the highest values occurring almost exclusively in mussels and cockles. Among the species studied, oysters and mussels displayed relatively higher levels of both sets of contaminants; native oysters, in particular, showed elevated levels of 237-TriBDD (up to 14.5 ng/kg). In general, contaminant levels appeared to be consistent with the extent of local industrialisation with lower levels observed in more remote areas such as the north of Scotland. Polybrominated biphenyls (PBBs) were also measured, and PBBs 49, 52 and 77 were the most frequently detected, although levels were very low. Dietary intakes, estimated for PBDD/Fs, showed that 237-TriBDD from single portions of oysters constituted a high proportion of the total dietary intake of the congener but, otherwise, dietary intakes of PBDD/Fs from shellfish were relatively low.

Determination of brominated flame retardants in food by LC-MS/MS: diastereoisomer-specific hexabromocyclododecane and tetrabromobisphenol A.

The levels of the brominated flame retardants (BFRs) hexabromocyclododecane (alpha, beta and gammaHBCD diastereoisomers) and tetrabromobisphenol A (TBBPA) have been determined in two studies using LC-MS/MS. The methodology developed was validated in-house and used to analyse UK 2004 Total Diet Study (TDS) samples and shellfish (oysters, mussels and scallops) collected from Scotland. HBCD was detected in most samples; in both studies the alphaHBCD diastereoisomer was generally the most abundant as opposed to the gamma diastereoisomer that tends to dominate in environmental samples and manufactured products. It is reported that selective metabolism or biotransformation of the beta and gamma diastereoisomers may be taking place. TBBPA was not detected in any samples above the limit of detection, which was as low as 0.05 microg kg(-1). This may be because TBBPA, unlike HBCD, is chemically bound to the polymer matrix during manufacture and not readily leached. The UK Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) concluded that the concentrations of HBCD and TBBPA detected in the TDS study did not raise toxicological concerns and, as levels in the shellfish samples were in a similar concentration range, it was concluded that exposure to the BFRs measured is not significant when compared to exposure from the rest of the diet.

Brominated and chlorinated dioxins, PCBs and brominated flame retardants in Scottish shellfish: methodology, occurrence and human dietary exposure.

The most commonly consumed shellfish species produced in Scotland - mussels, oysters and scallops - were investigated for the occurrence of a range of brominated and chlorinated contaminants in order to establish current levels and estimate human dietary exposure. Flesh from individual sub-samples was representatively pooled and 35 composites were analysed for brominated and chlorinated dioxins (PBDD/Fs, PCDD/Fs), brominated and chlorinated biphenyls (PBBs, PCBs), polybrominated diphenyl ethers (PBDEs), hexabromocyclododecanes (HBCDs) and tetrabromobisphenol A (TBBPA). The analytical methodology used (13)C(12) labelled surrogates of the target compounds, with GC coupled to (usually) high resolution MS, and LC-MS/MS for HBCD and TBBPA analysis. Positive identifications were made in the majority of samples for most analytes with the exception of TBBPA and most PBDD congeners measured. None of the levels detected for PCDD/F and PCB were above the maximum permitted levels specified in European Union regulations. The levels of brominated furans predominated over brominated dioxins, reflecting the environmental distribution and source emission profiles of these contaminants, and relatively high levels of the tri-brominated congeners were observed. Levels of the flame retardant chemicals reflected current and legacy use, with appreciable concentrations of PBDEs and HBCDs (predominantly alpha-HBCD) but far lower levels of PBBs. TBBPA was not detected in any of the species. In general, mussels and oysters displayed relatively higher levels of contamination than scallops, although the gonad tissue of the latter showed significant levels of brominated dioxins. The estimated adult dietary intakes of PCDD/Fs and PCBs arising from the consumption of a typical portion of these foods in combination with an otherwise average UK diet were in the range 0.5-0.6 pg World Health Organisation (WHO)-toxic equivalent (TEQ)(2005)/kg bodyweight per day. These estimated dietary intakes are well within the Tolerable Daily Intake for dioxins and dioxin-like PCBs of 2 pg WHO-TEQ(2005)/kg bodyweight/day endorsed by the independent expert Committee on Toxicology of Chemicals in Food, Consumer Products and the Environment. The corresponding intakes for sumPBDEs and sumHBCDs were 5.6-6.1 and 5.9-7.9 ng/kg bodyweight/day respectively.