Selecting participants when testing new drugs: the implications of age and gender discrimination

Risks versus benefits of gastrointestinal endoscopy during pregnancy

Although gastrointestinal endoscopy is generally safe, its safety must be separately analyzed during pregnancy with regard to fetal safety. Fetal risks from endoscopic medications are minimized by avoiding FDA category D drugs, minimizing endoscopic medications, and anesthesiologist attendance at endoscopy. Esophagogastroduodenoscopy seems to be relatively safe for the fetus and may be performed when strongly indicated during pregnancy. Despite limited clinical data, endoscopic banding of esophageal varices and endoscopic hemostasis of nonvariceal upper gastrointestinal bleeding seems justifiable during pregnancy. Flexible sigmoidoscopy during pregnancy also appears to be relatively safe for the fetus and may be performed when strongly indicated. Colonoscopy may be considered in pregnant patients during the second trimester if there is a strong indication. Data on colonoscopy during the other trimesters are limited. Therapeutic endoscopic retrograde cholangiopancreatography seems to be relatively safe during pregnancy and should be performed for strong indications (for example, complicated choledocholithiasis). Endoscopic safety precautions during pregnancy include the performance of endoscopy in hospital by an expert endoscopist and only when strongly indicated, deferral of endoscopy to the second trimester whenever possible, and obstetric consultation.

Hierarchical regulation of selenoprotein expression and sex-specific effects of selenium

The expression of selenoproteins is controlled on each one of the textbook steps of protein biosynthesis, i.e., during gene transcription, RNA processing, translation and posttranslational events as well as via control of the stability of the involved intermediates and final products. Selenoproteins are unique in their dependence on the trace element Se which they incorporate as the 21st proteinogenic amino acid, selenocysteine. Higher mammals have developed unique pathways to enable a fine-tuned expression of all their different selenoproteins according to developmental stage, actual needs, and current availability of the trace element. Tightly controlled and dynamic expression patterns of selenoproteins are present in different tissues. Interestingly, these patterns display some differences in male and female individuals, and can be grossly modified during disease, e.g. in cancer, inflammation or neurodegeneration. Likewise, important health issues related to the selenium status show unexpected sexual dimorphisms. Some detailed molecular insights have recently been gained on how the hierarchical Se distribution among the different tissues is achieved, how the selenoprotein biosynthesis machinery discriminates among the individual selenoprotein transcripts and how impaired selenoprotein biosynthesis machinery becomes phenotypically evident in humans. This review tries to summarize these fascinating findings and highlights some interesting and surprising sex-specific differences.

Exclusion of women from clinical research: myth or reality?

OBJECTIVE

To determine the proportion of male and female research participants and rates of sex-based analysis and sex-specific reporting in published Australian clinical research.

PARTICIPANTS AND METHODS

We assessed 400 clinical studies involving Australian-only participants, published in journals between January 1, 2003, and May 31, 2006 (100 per year). Numbers of male and female participants in each study and presence or absence of analysis by sex (covariate adjustment, subgroup analysis, or sex-specific reporting) were recorded. Sex-specific studies were evaluated to determine whether the exclusion of one sex was biologically necessary.

RESULTS

The total sample comprised 546,824 participants, of whom 73% were female; 36 studies were male-only, 78 were female-only. Of the participants in 286 studies that were not sex-specific, 56% were female. Of 114 sex-specific studies, the segregation by sex was deemed to be biologically necessary in 62%, ie, the research related directly to male or female biological function. More than one-quarter (28%) of studies with 30 participants or more published covariate adjustment or subgroup analysis by sex; 7% included sex-specific reporting of results.

CONCLUSION

We found no routine exclusion of women; however, few publications analyzed results by sex. Some studies excluded women or men for apparently arbitrary reasons. Research performed with male-only participants differed in nature and size from that performed with female-only participants. These data indicate the need to track the sex of research participants. In addition, they provide the basis for assessing appropriate inclusion of men and women in research and for comparing any relationship between different international regulatory models and the rates of female participation in research.

How to Get Older People Included in??Clinical Studies

Older people are systematically excluded from many clinical research studies. In this review, we examine the reasons for this state of affairs and summarise the current knowledge of strategies to increase the rate of participation of older people in clinical studies. Older people want to participate in clinical research and are driven by a mixture of altruism and self-interest. They are often excluded by overt age cut-offs or covert exclusions based on co-morbidity and frailty. Other barriers to participation include communication and cognitive difficulties, transport difficulties, low income and self-imposed agism. Possible strategies to improve recruitment of older people to clinical studies include abolishing age limits, reducing exclusion criteria, and allowing sufficient study time (to recruit and deal with older patients) and money (for reimbursement of their participation costs) in study protocols. Involving older people and their attending health professionals in the design of study protocols may also be helpful. Providing transportation, easy physical access to research institutions and use of personalised and face-to-face recruitment also pay dividends. A variety of recruitment methods have been found to be effective, but tailoring the strategy to the condition and population under study is necessary. Together, these strategies should improve the representation of older people in clinical research and ensure that the evidence base is relevant and useful to all those caring for older people.