Objectives: Indigenous medicines are widely used throughout Africa, despite a lack of scientific evidence for their safety or efficacy. The aims of this study were: (a) to conduct a pilot study of the safety of a common indigenous South African phytotherapy, Lessertia frutescens (Sutherlandia), in healthy adults; and (b) to contribute to establishing procedures for ethical and scientifically rigorous clinical trials of African indigenous medicines. Design: A randomized, double-blind, placebo-controlled trial of Sutherlandia leaf powder in healthy adults. Setting: Tiervlei Trial Centre, Karl Bremer Hospital, Bellville, South Africa. Participants: 25 adults who provided informed consent and had no known significant diseases or allergic conditions nor clinically abnormal laboratory blood profiles during screening. Intervention: 12 participants randomized to a treatment arm consumed 400 mg capsules of Sutherlandia leaf powder twice daily (800 mg/d). 13 individuals randomized to the control arm consumed a placebo capsule. Each participant received 180 capsules for the trial duration of 3 mo. Outcome Measures: The primary endpoint was frequency of adverse events; secondary endpoints were changes in physical, vital, blood, and biomarker indices. Results: There were no significant differences in general adverse events or physical, vital, blood, and biomarker indices between the treatment and placebo groups (p > 0.05). However, participants consuming Sutherlandia reported improved appetite compared to those in the placebo group (p = 0.01). Although the treatment group exhibited a lower respiration rate (p < 0.04) and higher platelet count (p = 0.03), MCH (p = 0.01), MCHC (p = 0.02), total protein (p = 0.03), and albumin (p = 0.03), than the placebo group, these differences remained within the normal physiological range, and were not clinically relevant. The Sutherlandia biomarker canavanine was undetectable in participant plasma. Conclusion: Consumption of 800 mg/d Sutherlandia leaf powder capsules for 3 mo was tolerated by healthy adults.
Endpoints are outcome measures used to address the objectives of a clinical trial. The primary endpoint is the most important outcome and is used to assess the primary objective of a trial (e.g., the variable used to compare the effect difference of two treatment groups). A fundamental principle in the design of randomized trials involves setting out in advance the endpoints that will be assessed in the trial [1], as failure to prespecify endpoints can introduce bias into a trial and creates opportunities for manipulation. However, sometimes new information may come to light that could merit changes to endpoints during the course of a trial. This new information might include, for example, results from other trials or identification of better biomarkers or surrogate outcome measures. Such changes can allow incorporation of up-to-date knowledge into the trial design. However, changes to endpoints can also compromise the scientific integrity of a trial. Here I discuss some of the issues and decision-making processes that should be considered when evaluating whether to make changes to endpoints, and discuss the documentation and reporting of clinical trials that have revised endpoints.
OBJECTIVES:To respond to the primary safety objective of the Perinatal HIV Prevention Trial 1 (PHPT-1) by studying the evolution of haematological parameters according to zidovudine exposure duration in HIV-1-infected pregnant women.DESIGN:Multicenter, randomized, double-blind, controlled trial of different durations of zidovudine prophylaxis.SETTING:27 hospitals in Thailand.PARTICIPANTS:1,436 HIV-infected pregnant women in PHPT-1.INTERVENTION:Zidovudine prophylaxis initiation at 28 or 35 wk gestation.OUTCOME MEASURES:Haemoglobin level, leucocytes, total lymphocyte counts, and absolute neutrophil counts were measured at 26, 32, and 35 wk and at delivery. The evolution of haematological parameters was estimated between 26 and 35 wk (zidovudine/placebo) and between 35 wk and delivery to compare a long versus short zidovudine exposure. For each parameter, linear mixed models were adjusted on baseline sociodemographic variables, HIV clinical stage, CD4 count, and viral load.RESULTS:Between 26 and 35 wk, haemoglobin, leucocytes, and absolute neutrophil counts decreased in zidovudine-exposed compared to unexposed women (mean difference [95% CI] -0.4 [-0.5 to -0.3], -423 [-703 to -142], -485 [-757 to -213], respectively). However, between 35 wk and delivery, the haematological parameters increased faster in women exposed to long rather than short durations of zidovudine (0.1 [0.0 to 0.1]; 105 [18 to 191]; 147 [59 to 234], respectively). At delivery, the differences were not statistically significant, except for mean haemoglobin level, which remained slightly lower in the long zidovudine treatment group (difference: 0.2 g/dl). Zidovudine had no negative impact on the absolute lymphocyte counts.CONCLUSION:Zidovudine initiated at 28 wk gestation rather than 35 wk had a transient negative impact on the evolution of haematological parameters, which was largely reversed by delivery despite continuation of zidovudine. This result provides reassurance about the safety of early initiation of zidovudine prophylaxis during pregnancy to maximize prevention of perinatal HIV.
OBJECTIVE:Recombinant human growth hormone (GH) and pioglitazone (PIO) in abdominally obese adults with impaired glucose tolerance were evaluated under the hypothesis that the combination attenuates GH-induced increases in glucose concentrations, reduces visceral adipose tissue (VAT), and improves insulin sensitivity over time.DESIGN:Randomized, double-blind, placebo-controlled, 2 x 2 factorial design.SETTING:Veterans Affairs Palo Alto Health Care System, Palo Alto, California, United States.PARTICIPANTS:62 abdominally obese adults aged 40-75 with impaired glucose tolerance.INTERVENTIONS:GH (8 microg/kg/d, or placebo) and pioglitazone (30 mg/d, or placebo) for 40 wk.OUTCOME MEASURES:Baseline and after 40 wk of treatment, VAT content was quantified by CT scan, glucose tolerance was assessed using a 75-g oral glucose tolerance test, and insulin sensitivity was measured using steady-state plasma glucose levels obtained during insulin suppression test.RESULTS:BASELINE: body mass index (BMI), plasma glucose, and visceral fat content were similar. 40 wk: visceral fat area declined 23.9 +/- 7.4 cm(2) in GH group, mean difference from placebo: -28.1 cm(2) (95% CI -49.9 to -6.3 cm(2); p = 0.02). Insulin resistance declined 52 +/- 11.8 mg/dl with PIO, mean difference from placebo of -58.8 mg/dl (95% CI -99.7 to -18.0 mg/dl; p = 0.01). VAT and SSPG declined with GH and PIO combined, mean differences from placebo of -31.4 cm(2) (95% CI -56.5 cm(2) to -6.3 cm(2); p = 0.02) and -55.3 mg/dl (95% CI -103.9 to -6.7 mg/dl; p = 0.02), respectively. Fasting plasma glucose increased transiently in GH group. No significant changes in BMI were observed.CONCLUSIONS:Addition of PIO to GH attenuated the short-term diabetogenic effect of GH; the drug combination reduced VAT and insulin resistance over time. GH plus PIO may have added benefit on body composition and insulin sensitivity in the metabolic syndrome.
Currently more than 20 antiretrovirals are commercially available for treatment of HIV infection [1]. Using them in combination therapy, we are able to treat HIV-infected patients with highly potent regimens and suppress the virus below detectable levels. Correct adherence to these regimens is important to ensure that the viral load will remain undetectable and that the disease does not progress. Moreover, even if adherence is not perfect and the virus becomes resistant to a first-line regimen, there are other treatment options to suppress the virus again to undetectable levels. Given the choice of several different potent antiretroviral regimens, doctors and patients will tend to prefer those regimens that are easy to take and that have limited short-term and long-term side effects. One potential side effect of antiretroviral treatment that has received very little scientific attention so far is sexual dysfunction. Sexual dysfunction is defined as difficulty during any stage of the sexual act, including desire, arousal, orgasm, and resolution, that prevents the individual or couple from enjoying sexual activity [2], and, according to DSM-IV (the Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria, causing ‘‘marked level of distress or interpersonal difficulty’’ [3]. Sexual dysfunction disorders are generally classified into four categories: sexual desire disorders, sexual arousal disorders, orgasm disorders, and sexual pain disorders [2,3]. Most data relating to the association between antiretroviral therapy and sexual dysfunction are based on cross-sectional studies or case series, and have emerged from industrialised countries [4–12]. Some studies have suggested that antiretrovirals, in particular certain protease inhibitors, may cause sexual problems or dysfunction [4–10]; however, other studies have not confirmed this observation [11,12]. Furthermore, sexual dysfunctions in people infected with HIV may be caused by many different factors. Both organic and psychological factors have been identified, including coping with HIV, pre-existing sexual dysfunctions, sex hormone abnormalities, neuropathy from HIV itself (or related treatment for HIVcaused illnesses), and other iatrogenic causes [13]. Sexual dysfunctions are conceptualised as one component of sexual health, which is an essential element of overall healthrelated quality of life (HRQOL). While it may include a variety of diverse issues, comprehensive definitions such as the World Health Organization’s (WHO) working definition define sexual health as a state of physical, emotional, mental, and social well-being, and not merely the absence of disease, dysfunction, or infirmity. Sexual health encompasses the possibility of having pleasurable and safe sexual experiences [14]. The essence of such lengthy definitions has been summarised in one single statement as ‘‘the enjoyment of sexual activity of one’s choice, without causing or suffering physTable 1. Overview of the Most Commonly Used Questionnaires in Clinical HIV Trials
