[Ophthalmic agents during pregnancy]

The use of ophthalmic agents during pregnancy and breastfeeding always represents an off-label use. Therefore, the use of drugs must be particularly carefully assessed with respect to the risk-benefit assessment. In this overview the literature databank of the PubMed library, pharmaceutical lists (Red List, Swiss pharmaceutical compendium), guidelines of the specialist societies the German Society of Ophthalmology (DOG), the Swiss Society of Ophthalmology (SOG), the European Glaucoma Society (EGS), the American Academy of Ophthalmology (AAO) and internet portals (embryotox, reprotox) were inspected and recommendations for the use of ophthalmic agents during pregnancy and breastfeeding were derived. More attention should be dedicated to this topic in the specialist societies.

[Pregnancy and breastfeeding in women with multiple sclerosis]

The diagnosis of multiple sclerosis (MS) in women of reproductive age is associated with many uncertainties regarding childbearing and lactation. Pregnancies of MS patients are not usually considered high-risk pregnancies per se. The likelihood of pregnancy complications or adverse pregnancy outcomes is not increased by the disease; however, a careful planning of pregnancy is important in order to choose the treatment option with the greatest benefit for the mother and the least possible risk for the baby. For highly active courses of the disease, anti-CD20 antibodies, cladribine, or continued administration of natalizumab show the best data. Patients with MS can be supported in their desire to breastfeed. If women have had a very active disease course, it is recommended that treatment should be started as soon as possible postpartum. Interferon-beta preparations, glatiramer acetate and ofatumumab are also approved for use during breastfeeding but off-label breastfeeding is also possible with other monoclonal antibodies.

Please get me out of here: The difficult decision making in fit-to-fly assessments for international fixed-wing air ambulance operations

INTRODUCTION

With international travel for leisure and business almost back to pre-pandemic levels, demand for repatriation due to illness and injury abroad is increasing [1,2]. In any repatriation, there is considerable pressure on all involved to organize a rapid transport back home. Delay in such action may be perceived by the patient, relatives, and the public as an attempt by the underwriter to hold off on an expensive air ambulance mission [3-5].

METHODS

Review of the available literature and analysis of assistance and air ambulance Companies' infrastructure and processes to identify risk and benefit of executing or delaying aeromedical transport for international travellers.

KEY FINDINGS

While patients of almost any severity can be safely transported over great distances in modern air ambulance aircraft, immediate transport is not always in the patient's best interest. Each call for assistance requires a complex and dynamic risk-benefit analysis with multiple stakeholders involved to achieve an optimized outcome. Opportunities for risk mitigation within the assistance team include active case management with clearly assigned ownership, as well as medical and logistical experience with knowledge on local treatment opportunities and limitations. On the air ambulance side, modern equipment, experience, standards and procedures as well as accreditation can reduce risk.

CONCLUSIONS

Each patient evaluation remains a highly individual risk-benefit assessment. Optimal outcomes require a clear understanding of responsibilities, flawless communication and significant expertise among the key decision-makers. Negative outcomes are mostly associated with insufficient information, communication, inadequate experience or a lack of ownership/assigned responsibility.

[Secure app usage-Evaluation benchmarks for medical apps : Quality aspects for health apps based on 9 key criteria]

Smartphones and health apps are an integral part of everyday life. They are increasingly being used for medical purposes. However, there is no fundamental basis or consensus on the evidence on which decisions are made towards a unified digital strategy. Consequently, the understanding of the quality of health apps is only inconsistent and fuzzily defined. The 9 quality criteria presented by the Association of Medical Societies (AWMF)-transparency, appropriateness, risk appropriateness, ethical harmlessness, legal conformity, content validity, technical appropriateness, usability, resource efficiency-serve as a guide for individual and institutionalized quality assessment. The principles are based on a comprehensive compilation of existing (inter-) national standards and evaluation benchmarks. Analogously to usual medical practice, it is also obligatory to conduct one's own research for a suitable app and to weigh up the risks and benefits when using an app.

Risk-benefit assessment of methylmercury and n-3 polyunsaturated fatty acids through fish intake by pregnant women in Shanghai, China: Findings from the Shanghai Diet and Health Survey

BACKGROUND

Fish and shellfish contain nutrients essential for fetal health, especially docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). The concern of mercury (Hg) pollution limits fish consumption among women in pregnancy, which could adversely affect child development. This study aimed to conduct risk-benefit assessment and provide recommendations for fish intake by pregnant women in Shanghai, China.

METHODS

Secondary analysis was conducted using cross-sectional data from a representative sample of the Shanghai Diet and Health Survey (SDHS) (2016-2017), China. Dietary intakes of Hg and DHA + EPA were calculated from the food frequency questionnaire (FFQ) on fish items and 24hr recall record. Raw fish samples (59 common species of fish in Shanghai) were purchased in local markets and their concentrations of DHA, EPA and Hg were measured. Net IQ points gain was used to evaluate the health risk and benefit at a population level by FAO/WHO model. Recommended fish (i.e., high- DHA + EPA and low-level MeHg) were defined, and then the proportion of those hit 5.8 IQ points were simulated with their consumption frequency for 1, 2 and 3 times per week.

RESULTS

The average consumption of fish and shellfish was 66.24 g/d among pregnant women in Shanghai. The mean concentrations of Hg and EPA + DHA in fish species most commonly consumed in Shanghai were 0.179 mg/kg and 0.374 g/100 g, respectively. Only 1.4% of the population exceeded the MeHg reference dose of 0.1 μg/kg·bw/d, whereas 81.3% of those who did not meet the recommended daily intakes of 250 mg EPA + DHA. In FAO/WHO model, the proportion of 28.4% reached the maximum IQ points gain. Along with the increase of "recommended fish" consumed, the simulated values of the proportion raised to 74.5, 87.3 and 91.9%, respectively.

CONCLUSION

The pregnant women in Shanghai, China had an adequate fish consumption with low-level Hg exposure, but balancing the benefits of fish intake and risk of potential Hg exposure was still a challenge. It is necessary to define a local level of "recommended fish" consumption for developing dietary recommendations for pregnant women.

Probabilistic risk and benefit assessment of nitrates and nitrites by integrating total diet study-based exogenous dietary exposure with endogenous nitrite formation using toxicokinetic modeling

The impacts of dietary nitrates and nitrites on human health have been a controversial topic for many years. However, the risk and benefit assessment of nitrates and nitrites is complicated by the large variation in nitrate and nitrite intake among people and the endogenous nitrite formation in the body. This study conducted a probabilistic risk-benefit assessment of dietary nitrates and nitrites based on internal dose by integrating exogenous and endogenous exposures with human trial data on cardiovascular benefits. A total diet study was carried out to quantify the age-specific dietary intakes of nitrates and nitrites. A previously well-validated human toxicokinetic model was used to predict internal doses for different age groups. In addition, the integrated approach was applied to different populations from different countries/regions based on reported exposure estimates to conduct a comprehensive risk-benefit assessment of dietary nitrates and nitrites. The results demonstrated that vegetable consumption was the main contributor to the internal nitrate and nitrite levels in all age groups. Exposure to nitrates and nitrites exceeding acceptable daily intakes in a variety of foods showed cardiovascular benefits. The probabilistic risk assessment showed that the exposure to nitrates and nitrites did not pose an appreciable health and safety risk. Therefore, the present results suggest that dietary nitrates and nitrites have clear cardiovascular benefits that may outweigh potential risks. Our analysis contributes significantly to addressing the controversy regarding risks and benefits from dietary nitrates and nitrites, and our approach could be applied to other dietary constituents with the potential for both risks and benefits.

FishChoice 2.0: Information on health benefits / risks and sustainability for seafood consumers

Since seafood is a significant source of nutrients with known health benefits, its consumption is promoted as a healthy food choice. However, seafood can also contain potentially hazardous environmental pollutants. In the context of the ECsafeSEAFOOD FP7 project, FishChoice (www.fishchoice.eu) was developed as a communication tool to help to the consumers to take the most appropriate decisions on their seafood consumption habits. FishChoice relies on scientific information that allows calculating, on an individual basis, intakes of nutrients and pollutants derived from seafood consumption. In the framework of the EU-H2020 funded SEAFOOD^TOMORROW project, an optimized version of the online tool has been released. FishChoice is available in 25 EU languages with a customized list of seafood species per EU country, considering specific (national) consumption habits. The list of nutrients has been extended according to the latest EFSA recommendations, while pollutants data incorporate results from recent studies. The sustainability of seafood consumption has been also implemented, providing recommendations to help preserve the marine environment. Finally, FishChoice is suitable not only for consumers, but also health professionals, schools and academia, as well as the industrial sector and public health providers.

Research Ethics for Clinical Researchers

This chapter deals with the fundamental principles of ethical research. Although there is particular emphasis on the process of initial ethical review of research, it is important to note that the ethical obligations of researchers continue throughout the entire continuum of the research process. The paramount importance of protecting the privacy and confidentiality of research participants is discussed. Particular emphasis is placed on the process of informed consent, and step-by-step practical guidelines are described. The issue of inclusivity in research is touched upon, and suggestions are provided. Practical advice is provided for researchers to guide their interactions with research ethics boards.

Risk-Benefit Assessment for Total Mercury, Arsenic, Selenium, and Omega-3 Fatty Acids Exposure from Fish Consumption in Jamaica

Fish is important in the traditional diet of Jamaicans, and the fishing industry contributes to social and economic development, as well as food security in Jamaica. However, there are associated health risks from contaminant exposure. The aim of this paper was to use risk-benefit analysis methods to determine the best fish species for consumption. Composite samples consisting of 14 fish species were collected from major fishing villages in 2016 and measured for total mercury, arsenic, selenium, and omega-3 fatty acids (EPA and DHA). Food frequency questionnaires were randomly distributed to 400 participants from different locations on the island. Participants were asked to identify the types of fish, portion size, and the frequency of consumption. An estimate of their weight was also recorded. Total mercury concentrations in fish samples ranged from 0.003 to 0.215 μg/g. The range of arsenic concentrations was 0.11 to 7.8 μg/g. The range of selenium concentrations was 0.302 μg/g to 1.08 μg/g. The mean omega-3 fatty acid concentration was 123.1 ± 93.6 mg/100 g. The fish consumption rates range from 3.2 to 1132.8 g/day. Cod fish was the most consumed species at 23.2 g/day. Four risk-benefit analysis methods were able to recommend four fish species that were best for consumption based on the levels of mercury, arsenic, selenium, and omega-3 fatty acids. They were doctorfish, parrotfish, snappers, and cod fish. The results of this study concluded that there was a low risk of mercury exposure from fish consumed in Jamaica.

Mercury concentration and fatty acid composition in muscle tissue of marine fish species harvested from Liaodong Gulf: An intelligence quotient and coronary heart disease risk assessment

Marine fish species are an important source of biologically valuable proteins, fats, fat-soluble vitamins, and n-3 polyunsaturated fatty acids, but they are also susceptible to pollutants. Mercury is liable to bioamplify in the aquatic food chain, and the health risks posed by methylmercury (MeHg) could undermine the benefits of eating fish, so risk-benefit assessments are needed for those fish species regularly consumed. The purpose of this study was to analyze the concentrations of mercury and characteristics of fatty acids in marine fish harvested from Liaodong Gulf, China, so as to better understand the risk-benefit effects of marine fish consumption. We found that the ratio of MeHg to total Hg (THg) was normally distributed. The concentrations of THg and MeHg in marine fish muscles (14 species, a total of 239) ranged from 0.920 to 0.288 μg/g and 0.050 to 0.192 μg/g, respectively. There were no significant interannual differences in the muscles' concentrations of MeHg and THg, or of their fatty acids (p > 0.05). The proportion of total saturated fatty acids (SFAs) and monounsaturated fatty acids (MUFAs) varied significantly among different marine fish-feeding habits (predacious, omnivorous, benthivorous and planktivorous), but the differences between polyunsaturated fatty acids (PUFAs) were not significant, which may be due to the undistinguished fatty acids (p < 0.05). The risk-benefit assessment using the intelligence quotient (IQ) scoring model revealed that all the studied marine fish had positive effects on child IQ under different consumption scenarios. Additionally, the integrated risk-benefit analysis for adult cardiovascular health showed that all the studied marine fish, but especially Ditrema temmincki Bleeker, are capable of reducing the relative cardiovascular risk posed by the MeHg in the fish. We conclude the positive effects of eating common marine fish from the Liaodong Gulf far outweigh their negative ones.

Simultaneous exploration of nutrients and pollutants in human milk and their impact on preterm infant growth: An integrative cross-platform approach

Early nutritional management including fortified human breastmilk is currently recommended to fulfil the energy demands and counterbalance risks associated to preterm birth. However, little is known about the potential adverse effects of exposure to persistent organic pollutants (POPs) carried in human milk on preterm infant growth. We conducted a pilot study proving the application of an integrative analytical approach based on mass spectrometry (MS) coupled to advanced statistical models, favouring the comprehensive molecular profiling to support the identification of multiple biomarkers. We applied this workflow in the frame of a preterm infants' cohort to explore environmental determinants of growth. The combination of high resolution gas and liquid chromatography MS platforms generated a large molecular profile, including 102 pollutants and nutrients (targeted analysis) and 784 metabolites (non-targeted analysis). Data analysis consisted in a preliminary examination of associations between the signatures of POPs and the normalised growth of preterm infants, using multivariate linear regression adjusting for known confounding variables. A second analysis aimed to identify multidimensional biomarkers using a multiblock algorithm allowing the integration of multiple datasets in the growth model of preterm infants. The preliminary results did not suggest an impairment of preterm growth associated to the milk concentrations of POPs. The multiblock approach however revealed complex interrelated molecular networks of POPs, lipids, metabolites and amino acids in breastmilk associated to preterm infant growth, supporting the high potential of biomarkers exploration of this proposed workflow. Whereas the present study intended to identify simultaneously pollutant and nutrient exposure profiles associated to early preterm infant growth, this workflow may be easily adapted and applied to other matrices (e.g. serum) and research settings, favouring the functional exploration of environmental determinants of complex and multifactorial diseases.

Mercury and omega-3 fatty acid profiles in freshwater fish of the Dehcho Region, Northwest Territories: Informing risk benefit assessments

Traditional foods have significant nutritional, sociocultural and economic value in subarctic First Nations communities of the Northwest Territories, and play a crucial role in promoting cultural continuity and sovereignty. Omega-3 polyunsaturated fatty acids (N-3 PUFAs), including eicosapentaenoic (EPA) and docosahexaenoic acid (DHA), carry significant benefits for neurocognitive development and cardiovascular health. However, the health risks posed by methylmercury may serve to undermine the benefits of fish consumption in Northern Indigenous communities. The objective of this study was to characterize profiles for mercury (Hg) and fatty acids in fish species harvested across lakes of the Dehcho Region, in the Mackenzie Valley of the Northwest Territories, to better understand the risks and benefits associated with traditional foods. Hg levels increased with trophic position, with the highest levels found in Burbot, Lake Trout, Walleye, and Northern Pike. Lake Trout, along with planktivorous species including Lake Whitefish, Cisco, and Sucker, demonstrated higher N-3 PUFAs than other species. Negative associations were observed between Hg and N-3 PUFAs in Lake Trout, Northern Pike, Walleye and Burbot. Further stratifying these relationships revealed significant interactions by lake. Significant differences observed in fatty acid and Hg profiles across lakes underscore the importance of considering both species- and lake-specific findings. This growing dataset of freshwater fish of the Dehcho will inform future efforts to characterize human Hg exposure profiles using probabilistic dose reconstruction models.

Risk Benefit Assessment of foods: Key findings from an international workshop

Whilst risk management measures, including food policy, are developed for the protection of public health and the environment, they may also lead to a reduction in health benefits. Policy decisions require then consideration of these necessary trade-offs, which leads to an increasing need to apply formal risk-benefit assessment (RBA) of foods. In this context, the European Food Safety Authority sponsored a Risk-Benefit Assessment Workshop on "past, current and future developments within the risk-benefit assessment of foods (RBA)" held in May 2017. The overall aims of the RBA Workshop were to discuss existing methods, challenges and needs within RBA, and to draft a roadmap for future development of RBA. The specific objectives were to i) identify RBA activities in Europe and globally; ii) discuss how to further develop and optimize RBA methodology; iii) identify challenges and opportunities within RBA; and iv) increase collaboration internationally. The two-day workshop gathered 28 participants from 16 institutions in 11 countries. It included technical presentations of RBA methods and case studies, and two break-out sessions for group discussions. All participants agreed that RBA has substantial potential to inform risk-management decisions in the areas of food safety, nutrition and public health. Several activities to optimize further developments within RBA were suggested. This paper provides a summary of workshop presentations, a discussion of challenges that limit progress in this area, and suggestions of next steps for this promising approach supporting a science-based decision process in the area of risk-benefit management of foods.

The benefits and risks of asking research participants about suicide: A meta-analysis of the impact of exposure to suicide-related content

One obstacle potentially hindering research on suicide is the assumption that assessing suicide may make individuals more likely to engage in suicidal thoughts or behaviours; a concern expressed by ethics committees, researchers, and clinicians. However, decisions which are overly cautious and restrictive when approving research proposals will hinder important research in this area. The present aim was to conduct a meta-analysis to examine whether asking about suicide or exposure to suicide-related content in research studies led to changes in participants' levels of distress, suicidal ideation, or suicide attempts. A systematic search of peer-reviewed and unpublished literature from 2000 to 2017 identified 18 studies. Exposure to suicide-related content led to significant, albeit small, reductions in suicidal ideation (g = -0.13, p < .001) and a lower likelihood of engaging in suicidal behaviour (OR = 0.714, p < .05). The reduction in suicidal ideation was moderated by age such that adolescents showed nearly twice as large a reduction in suicidal ideation from pre- to post-exposure as adults did. Thus, evidence to date suggests that asking research participants about suicide does not increase risk, and may be associated with small benefits. Ethics review boards should calibrate their consideration of the risks associated with participation based on the available evidence and relative to the cost of depriving potential participants of any benefits that participation may offer.

Opening the debate on deep brain stimulation for Alzheimer disease - a critical evaluation of rationale, shortcomings, and ethical justification

BACKGROUND

Deep brain stimulation (DBS) as investigational intervention for symptomatic relief from Alzheimer disease (AD) has generated big expectations. Our aim is to discuss the ethical justification of this research agenda by examining the underlying research rationale as well as potential methodological pitfalls. The shortcomings we address are of high ethical importance because only scientifically valid research has the potential to be ethical.

METHOD

We performed a systematic search on MEDLINE and EMBASE. We included 166 publications about DBS for AD into the analysis of research rationale, risks and ethical aspects. Fifty-eight patients were reported in peer-reviewed journals with very mixed results. A grey literature search revealed hints for 75 yet to be published, potentially enrolled patients.

RESULTS

The results of our systematic review indicate methodological shortcomings in the literature that are both scientific and ethical in nature. According to our analysis, research with human subjects was performed before decisive preclinical research was published examining the specific research question at stake. We also raise the concern that conclusions on the potential safety and efficacy have been reported in the literature that seem premature given the design of the feasibility studies from which they were drawn. In addition, some publications report that DBS for AD was performed without written informed consent from some patients, but from surrogates only. Furthermore, registered ongoing trials plan to enroll severely demented patients. We provide reasons that this would violate Art. 28 of the Declaration of Helsinki, because DBS for AD involves more than minimal risks and burdens, and because its efficacy and safety are not yet empirically established to be likely.

CONCLUSION

Based on our empirical analysis, we argue that clinical research on interventions of risk class III (Food and Drug Administration and European Medicines Agency) should not be exploratory but grounded on sound, preclinically tested, and disease-specific a posteriori hypotheses. This also applies to DBS for dementia as long as therapeutic benefits are uncertain, and especially when research subjects with cognitive deficits are involved, who may foreseeably progress to full incapacity to provide informed consent during the required follow-up period.

Randomized clinical trials and observational studies in the assessment of drug safety

Randomized clinical trials are considered as the preferred design to assess the potential causal relationships between drugs or other medical interventions and intended effects. For this reason, randomized clinical trials are generally the basis of development programs in the life cycle of drugs and the cornerstone of evidence-based medicine. Instead, randomized clinical trials are not the design of choice for the detection and assessment of rare, delayed and/or unexpected effects related to drug safety. Moreover, the highly homogeneous populations resulting from restrictive eligibility criteria make randomized clinical trials inappropriate to describe comprehensively the safety profile of drugs. In that context, observational studies have a key added value when evaluating the benefit-risk balance of the drugs. However, observational studies are more prone to bias than randomized clinical trials and they have to be designed, conducted and reported judiciously. In this article, we discuss the strengths and limitations of randomized clinical trials and of observational studies, more particularly regarding their contribution to the knowledge of medicines' safety profile. In addition, we present general recommendations for the sensible use of observational data.

Critical risk-benefit assessment of the novel anti-cancer aurora a kinase inhibitor alisertib (MLN8237): A comprehensive review of the clinical data

BACKGROUND

Many current anticancer chemotherapeutics suffer from significant side effects, which have led to the exploration of more targeted therapies. This resulted in the exploration of inhibitors of Aurora A kinase as a potential anti-cancer treatment. Alisertib (MLN8237) has proven to be a potent Aurora A kinase inhibitor that had the highest safety profile among its therapeutic family. Phase I/II/III clinical trials with Alisertib have been carried out and reported promising efficacy, yet serious side effects. This article attempts to assess the clinical effect of Alisertib administration in various cancer phenotypes while describing the reported side effects.

METHODS

Alisertib clinical data were systematically retrieved from Medline, CINAHL, PubMed, and Cochrane Central Register of Controlled Trials and analyzed for quality, relevance, and originality in three stages prior to inclusion.

RESULTS

Overall, seven studies met inclusion criteria and enrolled a total of 630 patients. The reported "potential" clinical effect of Alisertib in various tumours is promising as it improved time to disease progression, progression-free survival, and the duration of disease stability. The achieved improvement therefore rationalizes its further investigation as a novel anticancer therapy. However, the administration of the drug was associated with serious haematological disturbances in a relatively high percentage of patients.

CONCLUSION

The evidence of the anti-tumour effect of Alisertib administration is compelling in various types of malignancies. The reported side effects were serious but manageable in many cases. Topical or more targeted routes of administration are suggested when possible to overcome off-target events with systematic administration of the drug.

[Affective disorders during pregnancy : Therapy with antidepressants and mood stabilizers]

BACKGROUND

It is not rare that the first manifestation or relapse of an affective disorder occurs during pregnancy. Should a pharmacological treatment be indicated, the selection of a suitable substance should be made on a basis which is as safe as possible. Even when treating women of childbearing age it should be assured that the psychotropic drug selected is safe to use during pregnancy as a high percentage of pregnancies are unplanned.

OBJECTIVE

When assessing the risks and benefits of psychopharmacotherapy in women who are or wish to get pregnant, not only the exposure of the child to potentially teratogenic drug effects but also potential complications during or after pregnancy and long-term neuropsychological issues need to be addressed.

METHODS

This article provides an overview of the currently available literature on the use of antidepressants and mood stabilizers during pregnancy.

RESULTS

A growing body of increasingly reliable data for many antidepressants and mood stabilizers are available, which allow a good prediction of their suitability for use during pregnancy and lactation.

CONCLUSION

When treating affective disorders during pregnancy an individual assessment of the benefits and risks for mother and child is required. The benefit of an appropriate treatment for the mother by including medication which may be potentially harmful to the child versus the risk of an insufficient treatment for the mother by excluding medication which may be potentially harmful to both the mother and the child need to be weighed up. When a suitable psychopharmacotherapy during pregnancy has been selected, the risk for mother and child can be minimized by incorporation of therapeutic drug monitoring.

[Psychopharmacotherapy during pregnancy : Which antipsychotics, tranquilizers and hypnotics are suitable?]

BACKGROUND

When administering psychotropic drugs during pregnancy not only the potential teratogenic effects on the child must be addressed but also the fetotoxic implications for pregnancy and/or the peripartum phase as well as possible neurocognitive developmental disorders must be considered.

OBJECTIVE

Evaluation of the risks and benefits of administering psychotropic drugs during pregnancy or for women who wish to become pregnant.

METHODS

The literature has been reviewed with the purpose of providing information on psychotropic drugs which can safely be administered during pregnancy. The review considers antipsychotics as well as tranquilizers and hypnotics.

RESULTS

Data are available for a multitude of psychotropic drugs that allow a safe estimation on their suitability for use during pregnancy.

CONCLUSION

When treating mental illnesses during pregnancy the option of administering drugs must not principally be ruled out. What is required is an individual assessment of benefits and risks. The risk of an untreated mental illness versus the benefit of a suitable treatment, which may include the use of medication and the potential harm to the infant must be evaluated. If certain rules are observed and a suitable drug is selected the risk to the newborn child and/or mother during pregnancy can be minimized. During pregnancy, therapeutic drug monitoring is indicated and increases the safety for use of drugs and preventing harm to both mother and infant.

Gain-of-Function Research: Ethical Analysis

Gain-of-function (GOF) research involves experimentation that aims or is expected to (and/or, perhaps, actually does) increase the transmissibility and/or virulence of pathogens. Such research, when conducted by responsible scientists, usually aims to improve understanding of disease causing agents, their interaction with human hosts, and/or their potential to cause pandemics. The ultimate objective of such research is to better inform public health and preparedness efforts and/or development of medical countermeasures. Despite these important potential benefits, GOF research (GOFR) can pose risks regarding biosecurity and biosafety. In 2014 the administration of US President Barack Obama called for a "pause" on funding (and relevant research with existing US Government funding) of GOF experiments involving influenza, SARS, and MERS viruses in particular. With announcement of this pause, the US Government launched a "deliberative process" regarding risks and benefits of GOFR to inform future funding decisions-and the US National Science Advisory Board for Biosecurity (NSABB) was tasked with making recommendations to the US Government on this matter. As part of this deliberative process the National Institutes of Health commissioned this Ethical Analysis White Paper, requesting that it provide (1) review and summary of ethical literature on GOFR, (2) identification and analysis of existing ethical and decision-making frameworks relevant to (i) the evaluation of risks and benefits of GOFR, (ii) decision-making about the conduct of GOF studies, and (iii) the development of US policy regarding GOFR (especially with respect to funding of GOFR), and (3) development of an ethical and decision-making framework that may be considered by NSABB when analyzing information provided by GOFR risk-benefit assessment, and when crafting its final recommendations (especially regarding policy decisions about funding of GOFR in particular). The ethical and decision-making framework ultimately developed is based on the idea that there are numerous ethically relevant dimensions upon which any given case of GOFR can fare better or worse (as opposed to there being necessary conditions that are either satisfied or not satisfied, where all must be satisfied in order for a given case of GOFR to be considered ethically acceptable): research imperative, proportionality, minimization of risks, manageability of risks, justice, good governance (i.e., democracy), evidence, and international outlook and engagement. Rather than drawing a sharp bright line between GOFR studies that are ethically acceptable and those that are ethically unacceptable, this framework is designed to indicate where any given study would fall on an ethical spectrum-where imaginable cases of GOFR might range from those that are most ethically acceptable (perhaps even ethically praiseworthy or ethically obligatory), at one end of the spectrum, to those that are most ethically problematic or unacceptable (and thus should not be funded, or conducted), at the other. The aim should be that any GOFR pursued (and/or funded) should be as far as possible towards the former end of the spectrum.

Influence of bioaccessibility of total mercury, methyl-mercury and selenium on the risk/benefit associated to the consumption of raw and cooked blue shark (Prionace glauca)

This study aimed to identify the benefit and risk associated with raw and cooked blue shark consumption taking into account the bioaccessibility of Se, Hg and MeHg, by using in vitro digestion method. Selenium, Hg and MeHg levels were higher in cooked samples, particularly in grilled blue shark. Whereas Se bioaccessibility was above 83% in grilled samples, Hg and MeHg bioaccessibility was lower in grilled samples with values near 50%. In addition, all Se-Health Beneficial Values were negative and the molar MeHg:Se ratios were higher than one. The risk-benefit assessment yielded a maximum consumption of one yearly meal for raw or cooked blue shark, thus emphasizing the need to recommend the consumption of a wider variety of seafood species in a balanced and healthy diet.