The ethics of a clinical trial when the protocol clashes with international guidelines.

Due to their nature and complexity, clinical trials often take some time to launch after the protocol has been designed and ethics approval obtained. During this time, there may be changes in international treatment guidelines and recommendations that result in a conflict between study protocol and recommended international best practice. Here, we describe the situation that arose in a pharmacokinetic study on the use of two different doses of rifabutin in patients with human immunodeficiency virus-associated tuberculosis who initiated antiretroviral therapy (ART) with a lopinavir-ritonavir-based regimen in South Africa and Viet Nam. The study protocol specified that ART should be started 10 weeks after the start of anti-tuberculosis treatment. The study in South Africa was approved in June 2008, went ahead as scheduled and was completed in August 2010. The study in Viet Nam was approved in October 2008 and was started in June 2010. A few weeks later, the World Health Organization released their 2010 guidelines for adult ART; one of its strong recommendations (with moderate quality of evidence) was that ART should be started 2-8 weeks after the start of anti-tuberculosis treatment. Emerging scientific evidence also supported this recommendation. The investigators felt that the Viet Nam study protocol was in conflict with recommended international best practice, and the trial was stopped in October 2010. An amended study protocol in which ART was started at 2 weeks was developed and implemented. The ethics issues around this decision and the need to change the study protocol are discussed in this article.

Du fait de la nature et de la complexité des études cliniques, leur mise en œuvre est souvent longue après l'élaboration du protocole et son approbation éthique. Pendant cette période, il peut y avoir un changement des lignes directrices internationales de traitement et des recommandations qui provoquent un conflit entre le protocole et les meilleures pratiques recommandées internationalement. Nous décrivons ici la situation apparue dans une étude pharmacocinétique portant sur l'utilisation de deux doses différentes de rifabutin chez des patients atteints de tuberculose (TB) associée au virus de l'immunodéficience humaine et commençant un traitement antirétroviral (ART) à base de lopinavir-ritonavir en Afrique du Sud et au Viet Nam. Le protocole de l'étude spécifiait de commencer l'ART 10 semaines après le début de la thérapie antituberculeuse. En Afrique du Sud, l'étude a été approuvée en juin 2008, s'est déroulée comme prévu et a été achevée en juin 2010. Au Viet Nam, l'étude a été approuvée en octobre 2008 et a démarré en juin 2010. Quelques semaines après, l'Organisation Mondiale de la Santé a publié ses lignes directrices de 2010 pour l'utilisation de l'ART chez les adultes, dont l'une des vives recommandations (basée sur des données de qualité modérée) était de commencer l'ART entre 2 et 8 semaines après le début du traitement de la TB. L'arrivée de nouvelles preuves scientifiques est aussi venue à l'appui de cette recommandation. Les investigateurs ont eu le sentiment que le protocole d'étude au Viet Nam était en conflit avec les meilleures pratiques internationales et l'étude a été arrêtée en octobre 2010. Un protocole d'étude amendé a été développé et mis en œuvre. Les problèmes éthiques entourant cette décision et la nécessité de changer le protocole sont discutés dans ce papier.

Los ensayos clínicos, dadas sus características y su complejidad, suelen exigir mucho tiempo desde la elaboración del protocolo y la aprobación por parte del comité de ética hasta su realización. Durante este lapso, pueden surgir modificaciones en las recomendaciones y las directrices terapéuticas internacionales, lo cual genera un conflicto entre el protocolo del estudio y las prácticas óptimas recomendadas. A continuación se describe la situación que se presentó en Suráfrica y Viet Nam durante un estudio de farmacocinética sobre el uso de dos dosificaciones diferentes de rifabutina, en pacientes aquejados de tuberculosis (TB) asociada con la infección por el virus de la inmunodeficiencia humana (HIV), quienes habían comenzado el tratamiento antirretrovírico (ART) con un régimen basado en la asociación lopinavir y ritonavir. El protocolo del estudio precisaba que el ART se debía comenzar 10 semanas después de haber iniciado el tratamiento antituberculoso. En Suráfrica, el estudio recibió la aprobación en junio del 2008, comenzó en el tiempo previsto y se completó en agosto del 2010. En Viet Nam, se obtuvo la aprobación del estudio en octubre del 2008 y se comenzó en junio del 2010. A las pocas semanas, la Organización Mundial de Salud publicó sus directrices del ART en los adultos del 2010, una de cuyas recomendaciones más firmes consistía en que el ART se debía iniciar entre 2 y 8 semanas después de haber comenzado el tratamiento antituberculoso (con una calidad probatoria moderada). Algunos resultados científicos de aparición reciente respaldaban igualmente esta recomendación. Los investigadores consideraron que el protocolo del estudio en Viet Nam entraba en conflicto con las prácticas óptimas internacionales recomendadas e interrumpieron su realización en octubre del 2010. Se introdujeron modificaciones al protocolo, según las cuales el ART se comenzaría a las 2 semanas y se puso en práctica el estudio. En el presente artículo se analizan los aspectos éticos en torno a esta decisión y a la necesidad de modificar el protocolo del estudio.

Improving the diagnosis of pulmonary tuberculosis in HIV-infected individuals in Ho Chi Minh City, Viet Nam.

SETTING: District 6, An Hoa Clinic in Ho Chi Minh City (HCMC), Viet Nam. OBJECTIVE: To evaluate the performance of various algorithms in tuberculosis (TB) screening and diagnosis in a human immunodeficiency virus (HIV) infected population in HCMC, Viet Nam. DESIGN: A cross-sectional study of 397 consecutive HIV-infected patients seeking care at the An Hoa Clinic from August 2009 to June 2010. Data on participant demographics, clinical status, chest radiography (CXR) and laboratory results were collected. A multiple logistic regression model was developed to assess the association of covariates and pulmonary TB (PTB). RESULTS: The prevalence of sputum culture-confirmed PTB, acid-fast bacilli (AFB) positive TB, and multidrugresistant TB among the 397 HIV-infected patients was respectively 7%, 2%, and 0.3%. Adjusted odds ratios for low CD4+ cell count, positive sputum smear, and CXR to positive sputum culture were respectively 3.17, 32.04 and 4.28. Clinical findings alone had poor sensitivity, but combining CD4+ cell count, AFB sputum smear and CXR had a more accurate diagnostic performance. CONCLUSION: Results suggest that symptom screening had poor clinical performance, and support the routine use of sputum culture to improve the detection of TB disease in HIV-infected individuals in Viet Nam. However, when routine sputum culture is not available, an algorithm combining CD4+ cell count, AFB sputum smear and CXR is recommended for diagnosing PTB.

Low-temperature crystal structures of tetrakis-mu-3,5-diisopropylsalicylatobis-dimethylformamidodico pper(II) and tetrakis-mu-3,5-diisopropylsalicylatobis-diethyletheratodicopp er(II) and their role in modulating polymorphonuclear leukocyte activity in overcoming seizures.

Two binuclear copper(II) complexes of 3,5-diisopropylsalicylic acid were characterized by single crystal X-ray diffraction methods and examined for anti-inflammatory activity using activated polymorphonuclear leukocytes and for anticonvulsant activities using electroshock and metrazol models of seizures. These complexes were crystallized from dimethylformamide (DMF) or diethylether. Tetrakis-mu-3,5-diisopropylsalicylatobis-dimethylformamidodicop per(II) [Cu(II)2(3,5-DIPS)4(DMF)2] I is in space group P 1; a = 10.393 (2), b = 11.258 (2), c = 12.734 (2) A, alpha = 96.64 (2), beta = 92.95 (2), gamma = 94.90 (2) degrees; V = 1471.7 (4) A3; Z = 1. Tetrakis-mu-3,5-diisopropylsalicylatobis-etheratodicopper(II ) [Cu(II)2(3,5-DIPS)4(ether)2] II is in space group P 1; a = 10.409 (3), b = 11.901 (4), c = 12.687 (6) A, alpha = 91.12 (5), beta = 90.84 (5), gamma = 100.90 (4) degrees; V = 1542 (1) A3; Z = 1. The structure of I was determined at 140 K from 4361 unique reflections (I > 2sigma(1)) and refined on F2 to R1 = 0.04 and wR2 = 0.09. The structure of II was determined at 180 K from 4605 unique reflections (I > 2sigma(I)) and refined on F2 to R1 = 0.05 and wR2 = 0.13. Each compound is a crystallographically centrosymmetric binuclear complex with Cu atoms bridged by four 3,5-diisopropylsalicylate ligands related by a symmetry center [Cu-Cu(i): 2.6139 (9) A in I and 2.613 (1) in II]. The four nearest O atoms around each Cu atom form a nearly rectangular planar arrangement with the square pyramidal coordination completed by the dimethylformamide (or diethylether) oxygen atom occupying an apical position, at a distance of 2.129 (2) A in I and 2.230 (3) A in II. Each Cu atom is displaced towards the DMF (or diethylether) ligand, by 0.189 A in I and 0.184 A in II, from the plane of the four O atoms. The crystal structures of I and II are essentially similar to each other, except for the DMF or diethylether accommodation. Many disorder phenomena were found in the crystal structure of I. Copper(II)2(3,5-DIPS)4(DMF)2 inhibited polymorphonuclear leukocyte (PMNL) oxidative metabolism in vitro. This effect was concentration related and significant for concentrations higher than 10 microg or 0.68 nmol/ml. Copper(II)2(3,5-DIPS)4(DMF)2 was more active than the parent ligand, 3,5-DIPS, as has been demonstrated with copper complexes of other non-steroidal anti-inflammatory drugs. The DMF and diethylether ternary complexes of Cu(II)2(3,5-DIPS)4 were found to have anticonvulsant activity in the maximal electroshock model of grand mal epilepsy in doses ranging from 26 to 258 micromol/kg of body mass following intraperitoneal, subcutaneous, or oral treatment. The DMF ternary complex was also found to be effective in the subcutaneous injection of metrazol model of petit mal epilepsy. We conclude that both ternary copper complexes are lipophilic and bioavailable, capable of facilitating the inflammatory response to brain injury and causing the subsidence of this response in bringing about remission of these disease states.

Copper(II) complexes of a nonsteroidal anti-inflammatory drug niflumic acid. Synthesis, crystal structure of tetrakis-mu-(2-[3-(trifluoromethyl) phenyl]aminonicotinato)bis(dimethylsulfoxide)-dicopper(II) complex at 190 K. Anti-inflammatory properties.

The synthesis and characterization of three complexes with a potent nonsteroidal anti-inflammatory drug niflumic acid {2-[3-(trifluoromethyl)phenyl]aminonicotinic acid} with formula [Cu(niflumato)2L] (L = H2O, DMSO = dimethylsulfoxide, DMF = N,N-dimethylformamide) were investigated. The crystal and molecular structure of the {Cu(niflumato)2(DMSO)}2 was reported. Crystallographic data are as follows: monoclinic system, space group P2(1)/n, Z = 2, a = 11.1318(8), b = 17.513(2), c = 15.336(1) A, beta = 103.316(8) degrees, V = 2909.4(4) A3. The structure was refined to R = 0.030 and wR = 0.037 for 3702 reflections with I > sigma (I). It consists of centrosymmetric binuclear units with the Cu-Cui (symmetry code i: 1-x, -y, 1-z) distance between two centrosymmetrically related ions of 2.6272(5) A. Each Cu(II) ion in [Cu2(DMSO)2(mu-niflumato)4] is coordinated to an apical dimethylsulfoxide O atom on the one hand and to the equatorial carbonyl and carboxylic O atoms of two crystallographically independent niflumate moieties and their centrosymmetric counterparts on the other hand. In spite of the low-temperature (190 K) crystal measurements, one L-CF3 grouping exhibits some disorder. The biological activities of these complexes were compared to that of niflumic acid. Niflumic acid and its various copper complexes significantly inhibited polymorphonuclear leukocyte (PMNL) oxidative metabolism, as assessed by chemiluminescence and O2- generation measurement. This effect was dose-dependent. All copper complexes exerted a similar inhibiting effect which was always significantly higher than that exerted by the parent drug.

Synthesis, Crystal Structure and Interaction With DNA of N,N'-(Butane-1,4-Diyl)Bis(Guanidinium) Tetrachloroplatinate (II).

The design, synthesis, crystal structure and interaction with DNA of the N,N'-(butane-1,4-diyl)bis(guanidinium) tetrachloroplatinate(ll) are described. Crystal data: a = 8.152(1), b = 8.889(4), c = 10.700(3) A , alpha = 81.59(3), beta = 87.99(5), gamma = 78.48(6) degrees , V = 752(1) A(3), Z = 2 , space group P-1. The structure was refined to R = 0.039 and Rw = 0.046 from 1853 reflections (I > 3sigma(I)). This compound, named PtC(4)Gua, does not exhibit a center of symmetry and the center linker chain C(2) - C(3) - C(4) - C(5) is in gauche conformation. The cation is bisprotonated with the H(+) attached to the imine group of each terminal guanidinium function. The presence of the platinum moiety reinforces the binding of the butane(bis)guanidinium structure with double stranded DNA as judged from thermal denaturation studies and DNA unwinding experiments.

Ternary Copper(II) Complexes With Indomethacin, a Potent Non-Steroidal Antiinflammatory Drug. Crystal Structure of Bis (Dimethylformamide)-Tetrakis[1-(4-Chlorobenzoyl)-5-Methoxy-2-Methyl-1-H-Indole-3-Acetato]Dicopper(II). Antiinflammatory Properties and Prevention of Gastrointestinal Side Effects by Nanocapsules.

Two ternary copper(ll) complexes of indomethacin [1-(4-chlorobenzoyl)-5-methoxy-2- methyl-1-H-indole-3-acetic acid] called hereafter lndo, were prepared and characterized by single crystal X-ray diffraction. The first complex Cu(2)(Indo)(4)(DMF)(2) I crystallizes in space group P-1 (a = 10.829(2), b = 13.379(2), c = 16.491(3) A; alpha = 105.58(2), beta = 101.06(2), gamma = 106.96(2) degrees ; V= 2104.6(6) A(3), Z= 1). The title molecule is a centrosymmetric binuclear complex, with Cu atoms bridged by the carboxylate moieties of four indomethacinate ligands. The four nearest O atoms around each Cu atom form a square planar arrangement with the square pyramidal coordination completed by the O atom of N,N'-dimethylformamide. Daily administration for seven days of 1 mg/kg of indomethacin, I and I encapsulated into liposomes induces a weak inflammation of rat gastrointestinal tract. I was less inflammatory than indomethacin but the better protection was brought by encapsulation of the compound. This might be of interest in sustained therapies of chronic inflammatory diseases.

cis-dichloro-palladium(II) complexes with diaminosuccinic acid and its diethyl ester: synthesis, molecular structure, and preliminary DNA-binding and antitumor studies.

The reactions of K2PdCl4 with meso-diaminosuccinic acid (H2dasa) in 0.1 M HCl or its diethyl ester dihydrochloride Et2dasa.2HCl in neutralized aqueous solution yield cis-[Pd(H2dasa)Cl2](I) and cis-[Pd(Et2dasa)Cl2](II), respectively. These products were characterized by elemental analysis, IR spectroscopy, and TG-DTA thermal analysis. The crystal of II is monoclinic, space group C2/c (a = 14.292(5), b = 14.636(5), c = 13.435(5) A, beta = 98.08(2) degrees, Z = 8, R = 0.041 and wR = 0.06). The Pd(II) atom exhibits a roughly square planar coordination with two Pd-N bonds (Et2dasa) (2.014(2) and 2.049(7) A) and two cis-imposed Pd-Cl bonds (2.294(2) and 2.303(2) A). Compound I reacts with 2,2'-bipyridine in neutral aqueous solution to give [Pd(2,2'-bipy)(dasa)].3H2O(III) in a process of cis-chloride substitution by 2,2'-bipy as a model N-heterocyclic chelating entity. The molecular and crystal structure of III is also reported. It was observed that both cis-dichloro-Pd(II) complexes having Pd(H2dasa) (acidic) and Pd-(Et2dasa)(esterified) chelate entities induce conformational changes in the covalent closed circular (ccc) form of pUC8 plasmid. Both compounds were assayed for antitumor activity in vitro against MDA-MB 468 and HL-60 human cancer cell lines. The results show that compounds I and II have values of ID50 lower than those of K2PdCl4, and also lower than those of diaminoacid ligands (meso-diaminosuccinic acid and meso-diaminosuccinate diethyl ester). Thus it is likely that the imposed cis-coordination of the chelating H2dasa or Et2dasa to the Pd(II) center increases the biological activity of these palladium(II) complexes.