TOPICS LIST AND LINKS




  1. The International Conference on Harmonisation and its Impact
  2. Case Report Form Design
  3. Coding of Data—MedDRA and other Medical Terminologies
  4. Database Design Issues for Central Laboratories
  5. Computer Systems
  6. Systems Software Validation Issues—Clinical Trials Database
  7. Re-engineering the Clinical Data Management Process
  8. Working with Contrac Data Capture
  9. Quality Assurance and Clinical Data Management
  10. Performance Measures
  11. Data Presentation
  12. Contract Research Organizations
  13. Data Management in Epidemiology and Pharmacoeconomics
  14. Planning and Implementation
  15. Data Validation

links


http://freeclinicaldatamanagementtraining.blogspot.com
http://cdmlifecycle.blogspot.com
http://datacapture-cdm.blogspot.com
http://cdmpharmacoeconomics.blogspot.com
http://croworking.blogspot.com
http://cdmprocess.blogspot.com
http://cdmsystemvalidation.blogspot.com
http://cdmcomputersystems.blogspot.com
http://cdmdatabasedesign.blogspot.com
http://cdmmedicalcoding.blogspot.com
http://cdmdatapresentation.blogspot.com
http://qa-cdm.blogspot.com






Case Report Form Design

























INTRODUCTION

Someone wisely said ‘if we take care in the beginning, the end will take care of itself’. This is true for the creation of both the protocol and the Case Report Form (CRF), which illustrates it, at the beginning of the clinical trial. If we take care in getting these two ‘right’ the remainder of the process, up to and including the Final Study Report, will take care of itself. Whatever medium is used for the CRF, paper, electronic or combina- tions of both, the CRF is only as good as the protocol. As a translation/ illustration of the protocol the CRF can never be better than the protocol or compensate for its inadequacies or oversights. Ultimately, the Final Study Report, which is the product of sophisticated computer programsand a statistical analysis, is only as good as the data collected in the CRF. The whole process from defining the data to be collected, collecting, checking, analysing and presenting it, is resource intensive, utilising soph- isticated technology and employing highly skilled professionals. Unex- pected delays can occur at any of these stages, which is costly. The process does not need the additional cost burdens and delays due to poor data quality or loss of data. Minimising these are within our control at the start with the protocol and CRF design.

FUNCTION OF THE CRF

The CRF is the tool we use to collect pre-defined data from a Subject in a clinical trial. The ICH Guidelines for Good Clinical Practice define the CRF as: A printed, optical or electronic document designed to record all of the pro-
tocol required information to be reported to the Sponsor on each trial Subject

Although considerable advances have been made in the study and produc- tion of electronic CRFs, the majority of trial data are collected on paper CRFs and the current review focuses on these, where the CRF refers to thetotal collection of pages for each Subject.

CLINICAL RESEARCH TRAINING  CLICK ON LINK---------->>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
THE LIFE HISTORY OF THE CRF                              
The CRF must be robust in content and material. The Life History Table,Table 3.1, illustrates the uses made of the CRF, and by whom, and the emphasis of use which impacts on the design. The Users can be categor- ised as individuals concerned with the data collected on the forms—Form Fillers and Readers, and those concerned with pages or whole CRFs— Handlers. Each User has created a process through which the CRF will pass. Ig- nore any User at your peril and delays will result. It takes less resource to incorporate their needs, within reason, in the design stage, than to amend the CRF during printing, or after distribution, or to expect Users to muddle through producing possible errors and/or delays

STAGE 1: PROTOCOL

As the precursor to the CRF, review of the protocol before it is final provides the designer with an overview of the clinical trial, and the oppor-tunity to assess its impact on the CRF design. Personal experience has shown that holding discussions focused on the CRF during the writing of the protocol produces a better final version and fewer protocol amendments.

Phases
The protocol defines the objectives of the study. Broadly speaking, these are concerned with safety and efficacy; the degree of emphasis for each is dependent on the phase of the clinical trial programme. Reviewing the protocol from this angle indicates the size of the task and where to focus energies for the design of the CRF. In general, early phase studies collect data over a short period of time,such as a large number of safety measurements and intense monitoring of the drug’s behaviour for a population selected by tightly defined exclu- sions, at a single site. By Phase III the sheer numbers of Subjects, studied for a longer period of time, using subjective questionnaires/opinions, more specific safety, efficacy and population details at many centres, add to the complexity of the CRF Time and Event Schedule The best review of the protocol is achieved by constructing a Schedule of Events against Time from the protocol text. The benefits of the exercise are:

(i) To highlight the Reviewer’s interpretation of the protocol which may differ from the Author’s.
(ii) To check for omissions/discrepancies of the proposed study events.
(iii) To highlight potential logistic problems for the CRF if numerous sources provide data for each Subject.
(iv) To generate a list of specific questions based on the following checklist:
● What data need to be collected if a Subject does not meet entry criteria?
● What standard data collection modules can be used? need modi-fying? are missing?
● What existing forms can be used?
● What new forms are needed?
● How is dosing/compliance being measured?
● What population-specific data are needed?
● Which data are needed for safety monitoring? efficacy?
● What happens if the Subject does not complete the study at any time point after enrolment?

STAGE 2: CRF DESIGN


Introduction

The CRF is a very specialised form. More forms are generated as our life becomes increasingly computer dependent. All forms collect data, but the use of the data varies, for example, applications, purchases and so on, which in turn influences the look of the form. Forms are composed of structured questions by someone else, demanding answers from us in a way that is foreign to our thinking and constraining to our freedom of expression of information. We are apathetic, possibly because we cannot interact with a form to, for example, clarify a meaning, request more space, provide an answer which has not been anticipated, or request a clean page if we make a mistake. Small wonder that for most, completing a form is a daunting task, and complex CRFs get a cool reception. Over the past 30 years or so, students of typography, ergonomics and occupational psychology have examined in depth the use of written lan-guage, presentation and various media in an attempt to measure the factors that facilitate reading, comprehension and action—known as Human Fac-tors. If these are understood, then we can incorporate those that motivate the Form Filler to provide better quality data into the structure of the CRF.The application of the findings to Clinical Trial forms was reviewed byWright and Haybittle when they proposed three aspects for
consideration1:
1. CONTENT—do you need to collect it?
2. PRESENTATION—are you asking the question correctly?
3. METHODOLOGY—what design alternatives are available to avoid/
minimise problems that Users have with the forms?

CONTENT—Do you need to collect it?


The protocol identifies the data to be collected during the trial to achieve the study objectives and meet regulatory requirements.
1. Date, phase and identification of the trial.
2. Identification of the Subject.
3. Age, sex, height, weight and ethnic group of the Subject.
4. Particular characteristics of the Subject (smoking, dietary, preg-nancy, previous treatment etc.).
5. Diagnosis, indication for which the product is administered in ac-cordance with the protocol.
6. Adherence to inclusion/exclusion criteria.
7. Duration of disease, time to last breakout, etc.
8. Dose, dosage schedule, administration of medical product, com-pliance record.
9. Duration of treatment.
10. Duration of observational period.
11. Concomitant use of other medicines and non-medicinalinterventions/therapy
12. Dietary regimens.
13. Recording of efficacy parameters met, date and time.
14. Recording Adverse Events, type, duration, intensity consequence and measures taken.
15. Reasons for withdrawal, breaking code.
Some study designs will legitimately omit a few of the above, for example,dietary regimens, breaking code, but the majority will be included.

The Mock-up CRF

General information that accompanies the mock-up will state:
● How the CRF will be finished?
1. Drilling? Crimping? Pads?
2. Folder? Ring binder? Covers?
● Numbers of CRFs required and when?
● Assembly instructions, order of pages
● Size, type, weight, colour, numbers, matt/shiny, thickness, etc. of all
materials
● Position and orientation of print on materials
● Materials?
1. Paper
2. Inks
3. Card
4. Tab dividers
5. Front sheets
6. Acetates or laminates
7. Attachment, insert stationery—wallets, folders, envelopes
8. Labels
9. Business reply cards?
Mark pages that require different materials, special printing, folding or binding on the mock-up.

ICH AND ITS IMPACT

HISTORY OF ICH

The ICH initiative started in November 1991 in Brussels. The purpose of this initiative was to bring together regulatory agencies and experts from the pharmaceutical industry of the three largest markets (Europe, Japan and the United States of America) in an effort to harmonise regulatory requirements for the registration of new human therapeutics. If harmo- nisation could be achieved without compromising the quality, efficacy and safety of medicinal products, then much of the repeat testing required to register a product in the three regions would be reduced or eliminated.

The aims of the ICH pro-cess are to:

● Unify the registration requirements for new medicinal products
● Accelerate medicinal product licensing times
● Reduce medicinal product development costs
● Increase patent protection times


Organisation of ICH

The ICH organisation involves representatives from three principal re-gions the European Union, Japan and the United States of America, with the assistance of observers from the World Health Organisation (WHO), the European Free Trade Association (EFTA) and the Canadian Health Protection Branch. There are six co-sponsors of the ICH process, two from each of the following geographical regions: Europe

  1. The Commission of the European Communities (CEC)
  2. The European Federation of Pharmaceutical Industries Association (EFPIA)
  3. The Ministry of Health and Welfare (MHW)
  4. Japan Pharmaceutical Manufacturers Association (JPMA)
  5. USA Food and Drug Administration (FDA)
  6. Pharmaceutical Research and Manufacturers Association (PhRMA)

Expert Working Groups

The Expert Working Groups (EWGs) consist of joint regulatory and indus-try representatives nominated by the six ICH co-sponsors. Several EWGs are appointed to advise the steering committee on topics for the harmo- nisation process. These topics are grouped under four areas:

1. Quality
2. Efficacy
3. Safety
4. Multidisciplinary (Cross-topics)

INTRODCUTION TO DRUG DESIGNING

Drug discovery and development is an expensive process due to the high costs of R&D and human clinical tests. The average total cost per drug development varies from US$ 897 million to US$ 1.9 billion. The typical development time is 10-15 years.

R&D of a new drug involves the identification of a target (e.g. protein) and the discovery of some suitable drug candidates that can block or activate the target. Clinical testing is the most extensive and expensive phase in drug development and is done in order to obtain the necessary governmental approvals. In the US drugs must be approved by the Food and Drug Administration (FDA).
R&D – Finding the Drug

One of the most successful ways to find promising drug candidates is to investigate how the target protein interacts with randomly chosen compounds, which are usually a part of compound libraries. This testing is often done in so called high-thoughput screening (HTS) facilities. Compound libraries are commercially available in sizes of up to several millions of compounds. The most promising compounds obtained from the screening are called hits – these are the compounds that show binding activity towards the target.

Some of these hits are then promoted to lead compounds – candidate structures which are further refined and modified in order to achieve more favorable interactions and less side-effects.
Drug Discovery Methods

The following are methods for finding a drug candidate, along with their pros and cons:
1. Virtual screening (VS) based on the computationally inferred or simulated real screening;
The main advantages of this method compared to laboratory experiments are:
-low costs, no compounds have to be purchased externally or synthesized by a chemist;
-it is possible to investigate compounds that have not been synthesized yet;
-conducting HTS experiments is expensive and VS can be used to reduce the initial number of compounds before using HTS methods;
-huge amount of chemicals to search from. The number of possible virtual molecules available for VS is exceedingly higher than the number of compounds presently available for HTS;
The disadvantage of virtual screening is that it can not substitute the real screening.
2. The real screening, such as high-throughput screening (HTS), can experimentally test the activity of hundreds of thousands of compounds against the target a day. This method provides real results that are used for drug discovery. However, it is highly expensive.
Virtual Screening in Drug Discovery

Computational methods can be used to predict or simulate how a particular compound interacts with a given protein target. They can be used to assist in building hypotheses about desirable chemical properties when designing the drug and, moreover, they can be used to refine and modify drug candidates. The following three virtual screening or computational methods are used in the modern drug discovery process: Molecular Docking, Quantitative Structure-Activity Relationships (QSAR) and Pharmacopoeia Mapping.
Molecular Docking

When the structure of the target is available, usually from X-ray crystallography, the most commonly used virtual screening method is molecular docking. Molecular docking can also be used to test possible hypotheses before conducting costly laboratory experiments. Molecular docking programs predict how a drug candidate binds to a protein target. This software consists of two core components:

1. A search algorithm, sometimes called an optimisation algorithm. The search algorithm is responsible for finding the best conformations of the ligand, a small drug-like molecule and protein system. A conformation is the position and orientation of the ligand relative to the protein. In flexible docking the conformation also contains information about the internal flexible structure of the ligand – and in some cases about the internal flexible structure of the protein. Since the number of possible conformations is extremely large, it is not possible to test all of them. Therefore, sophisticated search techniques have to be applied. Examples of some commonly used methods are Genetic Algorithms and Monte Carlo simulations.

2. An evaluation function, sometimes called a score function. This is a function providing a measure of how strongly a given ligand will interact with a particular protein. Energy force fields are often used as evaluation functions. These force fields calculate the energy contribution from different terms such as the known electrostatic forces between the atoms in the ligand and in the protein, forces arising from deformation of the ligand, pure electron-shell repulsion between atoms and effect from the solvent in which the interaction takes place.

It is not possible to guarantee that the search algorithm will find the same solution as the true natural process, but more efficient search algorithms will be more likely to find the true solution if the evaluation functions properly reflect the natural processes.

Metaphorically, the active site of the protein can be viewed as a lock, and the ligand can be thought of as a key. Molecular docking is the process of testing whether a given key fits a particular lock. This description is slightly oversimplified due to the fact that neither the ligand nor the proteins are completely rigid structures. Their shapes are somewhat flexible and may adapt to each other.
Quantitative Structure-Activity Relationships (QSAR)

As mentioned in the previous paragraph it is necessary to know the geometrical structure of both the ligand and the target protein in order to use molecular docking methods. QSAR (Quantitative Structure-Activity Relationships) is an example of a method which can be applied regardless of whether the structure is known or not.

QSAR formalizes what is experimentally known about how a given protein interacts with some tested compounds. As an example, it may be known from previous experiments that the protein under investigation shows signs of activity against one group of compounds, but not against another group.

In terms of the lock and key metaphor, we do not know what the lock looks like, but we do know which keys work, and which do not. In order to build a QSAR model for deciding why some compounds show sign of activity and others do not, a set of descriptors are chosen. These are assumed to influence whether a given compound will succeed or fail in binding to a given target. Typical descriptors are parameters such as molecular weight, molecular volume, and electrical and thermodynamical properties. QSAR models are used for virtual screening of compounds to investigate their appropriate drug candidates descriptors for the target.
Pharmacopoeia Mapping

Where QSAR focused on a set of descriptors like electrostatic and thermodynamic properties, Pharmacopoeia Mapping is a geometrical approach. A pharmacophore can be thought of as a 3D model of characteristic features of the binding site of the investigated protein (target). It may describe properties like: "In this region of the target a positive charge is needed, in this region there is a hydrogen donor, that region may not be occupied" and so on. On a pharmacophore model the spheres indicate regions where a certain feature (e.g. a cation or an anion) is required. The pharmacophores are also used to define the essential features of one or more molecules with the same biological activity.

Like QSAR models, pharmacophores can be built without knowing the structure of the target. This can be done by extracting features from compounds which are known experimentally to interact with the target in question. Afterwards, the derived pharmacophore model can be used to search compound databases (libraries) thus screening for potential drug candidates that may be of interest.

INTRODUCTION TO CLINICAL DATA MANAGEMENT

A clinical data management system or CDMS is used in clinical research to manage the data of a clinical trial. The clinical trial data gathered at the investigator site in the case report form are stored in the CDMS. To reduce the possibility of errors due to human entry, the systems employ different means to verify the entry. The most popular method being double data entry.

Once the data has been screened for typographical errors, the data can be validated to check for logical errors. An example is a check of the subject's age to ensure that they are within the inclusion criteria for the study. These errors are raised for review to determine if there is an error in the data or clarification from the investigator is required.

Another function that the CDMS can perform is the coding of data. Currently, the coding is generally centered around two areas; adverse event terms and medication names. With the variance on the number of references that can be made for adverse event Terms or medication names, standard dictionaries of these terms can be loaded into the CDMS. The data items containing the adverse event terms or medication names can be linked to one of these dictionaries. The system can check the data in the CDMS and compare it to the dictionaries. Items that do not match can be flagged for further checking. Some systems allow for the storage of synonyms to allow the system to match common abbreviations and map them to the correct term. As an example, ASA could be mapped to Aspirin, a common notation. Popular adverse event dictionaries are MedDRA and WHOART and popular Medication dictionaries are COSTART and WHO-DRUG.

At the end of the clinical trial the dataset in the CDMS is analyzed and sent to the regulatory authorities for approval.