New lessons favoring physicians' support of clinical trials

Stem cell tourism and the power of hope

This paper explores the notions of hope and how individual patient autonomy can trump carefully reasoned ethical concerns and policies intended to regulate stem cell transplants. We argue that the same limits of knowledge that inform arguments to restrain and regulate unproven treatments might also undermine our ability to comprehensively dismiss or condemn them. Incautiously or indiscriminately reasoned policies and attitudes may drive critical information and data underground, impel patients away from working with clinical researchers, and tread needlessly on hope, the essential motivator of patients, advocates and researchers alike. We offer recommendations to clinicians and health care providers to help balance the discourse with individuals seeking treatment while guarding against fraud, misconception, and patient harm.

Understanding investigative clinical trials

This article reviews the background, rationale, and principles of clinical trials and their role and influence on medical practice. The relationship of clinical trials to other forms of clinical studies is explored. The fundamentals of sound design, analysis, interpretation, and reporting of clinical trials are detailed. Ethical issues, costs, and limitations of trials are explored. The article reviews the trends in program content of 749 abstracts presented at the joint vascular surgical meetings during the past 17 years, demonstrating a significant increase in reported clinical trials during the last half of this period. Finally, future trends in the use of clinical trials to "validate" medical practice are suggested in response to efforts to control rising health care costs. Physicians, including vascular surgeons, must become knowledgeable in the principles of clinical trials to interpret more effectively, apply, or even participate in such clinical research.

Review: clinical trials in peptic ulcer disease--problems of methodology and interpretation

This review focuses on the methodology and interpretation of drug trials in peptic ulcer disease. The problems of planning and conduct that are discussed include the ethics of using placebo, eligibility criteria, estimations of sample size, stopping rules, randomization, blinding, and efficacy criteria, that is, ulcer healing and pain relief in the short term and prevention of relapse and complications in the long term. Statistical topics covered include confidence intervals, evaluation of survival type data, post-stratification, and sub-group analysis. The difference between clinical and statistical significance is discussed, major problems being overemphasis on P-value, type II errors, and post hoc power determinations. Explanatory and pragmatic questions are based on compliance-to-protocol and intention-to-treat cohorts, respectively, and involve problems of compliance testing, evaluation of withdrawals, and the use of fixed-dose regimens. The rather slow process for clinical trials to gain acceptance is described, and it is proposed to rely on disease-related and behavioural barriers, lack of knowledge of the inherent limitations of methodology, and overemphasis on the subject of peptic ulcer healing, in addition to some concern at the relevance of assessing long-term drug intervention by repeated endoscopies rather than by studying symptoms and the incidence of complications. We foresee an increased impact of clinical trials on ulcer research and therapeutic decision making, provided physicians are able to develop the proper methodology to answer the relevant questions.