The Lived Experience of Pediatric Gene Therapy: A Scoping Review

Genome Editing in Medicine: A Scoping Review of Ethical, Bioethical, and Medico-Legal Implications

Genome editing, prominently led by the revolutionary CRISPR-Cas9 technology, is a powerful tool with significant applications in diverse fields, particularly in medicine and agriculture. It empowers scientists with the ability to effect precise genetic modifications, thereby potentially paving the way for advanced treatments for genetic disorders such as Huntington's disease, hemophilia, and cystic fibrosis. Yet, the significant capabilities of this technology also brings to the fore a myriad of intricate bioethical, legal, and regulatory dilemmas. In light of these complexities, this article endeavors to conduct a comprehensive scoping review of the existing literature on the most significant ethical implications emanating from genome editing. In conducting this review, we utilized the power of software tools like EndNote and Rayyan to aid in the systematic and thorough review of the literature. EndNote, a reference management software, was instrumental in organizing and managing the references and bibliographies, while Rayyan, a web application designed for managing and screening records for systematic and scoping reviews, proved crucial in the import and management of text records for the review.The review identified as main aspects of ethical, bioethical and medico-legal interest the exacerbation of social inequalities, safety concerns such as off-target mutations and immunological risks, ecological and evolutionary implications, and challenges to human dignity. It highlights the necessity for equitable access, rigorous regulation, and public engagement to address these issues responsibly.The ultimate objective of this article is to underscore the importance of an informed and inclusive dialogue regarding genome editing. Such dialogue is pivotal for fostering responsible innovation in this rapidly advancing field, ensuring that scientific progress aligns with ethical considerations. By presenting a comprehensive examination of the ethical implications of genome editing, we aim to contribute to this ongoing dialogue and promote a balanced and nuanced understanding of this impactful technology.

The participants' perspective on facioscapulohumeral muscular dystrophy trials in The Netherlands - A qualitative study

BACKGROUND

Facioscapulohumeral muscular dystrophy (FSHD) is a hereditary muscle disease without an available cure. The first trials with potentially disease-modifying therapies have started, including a phase ll open-label study and a phase lll double-blind randomized placebo-controlled trial assessing the safety and efficacy of losmapimod. Having a more in-depth understanding of the patient's experience of these trials will further enhance the design and recruitment of future trials.

OBJECTIVE

To explore the motivation, expectations, concerns, and experiences of FSHD patients in the first clinical trials in the Netherlands resulting in recommendations for future trials.

METHODS

Semi-structured interviews with participants of phase II and III losmapimod trials were conducted. The interview guide was based on previous conducted literature reviews and consultation of a patient representative. Participants were selected through convenience sampling. Four main themes were discussed: motivation for participation, expectations regarding study drug and trial visits, trial participation experience, and recommendations for future trials. The interviews were transcribed, anonymized, and analyzed using Atlas.ti version 23.1.1 using a deductive approach.

RESULTS

Thirteen participants were interviewed; six phase II participants and seven phase III participants. The primary motivations to participate concerned altruistic motives, contribute to science or improve their own health status. The participants had realistic expectations of the effect of the study drug before trial participation. Overall, participants were positive about their trial participation. Specifically, the personal and transparent communication within a trusting and dedicated trial team was appreciated. The phase III participants reported a higher than expected psychological burden on participating in a placebo-controlled trial. Recommendations consisted of more frequent updates on the overall progress and results of the trials.

CONCLUSIONS

This study presents the participants' perspective on FSHD trials, providing important key findings for future clinical trial design, study site practices and patient education.

A conceptual model and practical guidance for the development, administration, and evaluation of individualized therapies

Bespoke therapies represent a promising tool to address a diverse range of genetic and acquired conditions, offering new hope where conventional treatments have fallen short. With the rapid rise of bespoke therapies, profound ethical and regulatory challenges emerge, making it crucial to establish a comprehensive framework that ensures these treatments reach clinical settings and meet patients' needs as quickly as possible while protecting all parties involved. Although current guidelines are continually evolving to address the range of ethical tensions raised by these therapies, several gaps remain. A significant unresolved question is determining where personalized interventions fall on the research-care continuum and understanding the institutional, regulatory, and ethical implications when custom therapies are classified as research, care, or a mix of both. To address these questions, we introduce a conceptual model alongside practical guidance for the development, administration, and evaluation of individualized therapies, using CRISPR/Cas9-based interventions for Duchenne Muscular Dystrophy as a case study. We argue that the goals of an intervention should be as individualized as the bespoke product itself, tailored to the specifics of each case. Rather than attempting to pinpoint the exact location of an intervention on the continuum, which may be hard to operationalize and have limited utility, our approach focuses on the practical details of how such interventions are administered and the individual component parts of an intervention. It advocates for transparent discussions among all partners to anticipate and adjust various components/parameters along the process of administering individualized interventions. Our paper highlights the most critical of these parameters in (1) the planning and development of individualized therapies in laboratory settings, (2) their regulatory oversight, and (3) evaluation. By discussing these stages and parameters in detail, we aim to provide guidance on how to navigate the ethical complexities inherent to individualized interventions and offer a preliminary framework for balancing the interplay between research objectives and patient care needs. Acknowledging that the scientific rigor and adequacy of any new model must be evaluated, we also identify the types of evidence that are required to validate that our model effectively meets individual and societal needs.