A Strategic Analysis of Vaccine Access for Developing Countries

Vaccination has been one of the major successes in global health, providing a costeffective method of reducing morbidity and mortality. However, middle- and low-income countries are often unable to access newer vaccines in a timely manner. This analysis outlines market-influenced solutions that address the inequity. First, the current state of the vaccine industry and the roles of manufacturers are examined, and then the impact of innovation on the industry is assessed. High-, middle- and low-income country markets are compared. Finally, an assessment is made of the models that increase vaccine access. The industry, innovation impact, market and access model analyses lead to a proposal of a complementary strategic plan for improved vaccine access for developing countries. This analysis defines the key success factors for future vaccine development and manufacturing that will equilibrate vaccine use across the globe

An Integrated Strategy to Study Muscle Development and Myofilament Structure in Caenorhabditis elegans

A crucial step in the development of muscle cells in all metazoan animals is the assembly and anchorage of the sarcomere, the essential repeat unit responsible for muscle contraction. In Caenorhabditis elegans, many of the critical proteins involved in this process have been uncovered through mutational screens focusing on uncoordinated movement and embryonic arrest phenotypes. We propose that additional sarcomeric proteins exist for which there is a less severe, or entirely different, mutant phenotype produced in their absence. We have used Serial Analysis of Gene Expression (SAGE) to generate a comprehensive profile of late embryonic muscle gene expression. We generated two replicate long SAGE libraries for sorted embryonic muscle cells, identifying 7,974 protein-coding genes. A refined list of 3,577 genes expressed in muscle cells was compiled from the overlap between our SAGE data and available microarray data. Using the genes in our refined list, we have performed two separate RNA interference (RNAi) screens to identify novel genes that play a role in sarcomere assembly and/or maintenance in either embryonic or adult muscle. To identify muscle defects in embryos, we screened specifically for the Pat embryonic arrest phenotype. To visualize muscle defects in adult animals, we fed dsRNA to worms producing a GFP-tagged myosin protein, thus allowing us to analyze their myofilament organization under gene knockdown conditions using fluorescence microscopy. By eliminating or severely reducing the expression of 3,300 genes using RNAi, we identified 122 genes necessary for proper myofilament organization, 108 of which are genes without a previously characterized role in muscle. Many of the genes affecting sarcomere integrity have human homologs for which little or nothing is known

Adding 6 months of androgen deprivation therapy to postoperative radiotherapy for prostate cancer: a comparison of short-course versus no androgen deprivation therapy in the RADICALS-HD randomised controlled trial

Background Previous evidence indicates that adjuvant, short-course androgen deprivation therapy (ADT) improves metastasis-free survival when given with primary radiotherapy for intermediate-risk and high-risk localised prostate cancer. However, the value of ADT with postoperative radiotherapy after radical prostatectomy is unclear. Methods RADICALS-HD was an international randomised controlled trial to test the efficacy of ADT used in combination with postoperative radiotherapy for prostate cancer. Key eligibility criteria were indication for radiotherapy after radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to radiotherapy alone (no ADT) or radiotherapy with 6 months of ADT (short-course ADT), using monthly subcutaneous gonadotropin-releasing hormone analogue injections, daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as distant metastasis arising from prostate cancer or death from any cause. Standard survival analysis methods were used, accounting for randomisation stratification factors. The trial had 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 80% to 86% (hazard ratio [HR] 0·67). Analyses followed the intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov, NCT00541047. Findings Between Nov 22, 2007, and June 29, 2015, 1480 patients (median age 66 years [IQR 61–69]) were randomly assigned to receive no ADT (n=737) or short-course ADT (n=743) in addition to postoperative radiotherapy at 121 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 9·0 years (IQR 7·1–10·1), metastasis-free survival events were reported for 268 participants (142 in the no ADT group and 126 in the short-course ADT group; HR 0·886 [95% CI 0·688–1·140], p=0·35). 10-year metastasis-free survival was 79·2% (95% CI 75·4–82·5) in the no ADT group and 80·4% (76·6–83·6) in the short-course ADT group. Toxicity of grade 3 or higher was reported for 121 (17%) of 737 participants in the no ADT group and 100 (14%) of 743 in the short-course ADT group (p=0·15), with no treatment-related deaths. Interpretation Metastatic disease is uncommon following postoperative bed radiotherapy after radical prostatectomy. Adding 6 months of ADT to this radiotherapy did not improve metastasis-free survival compared with no ADT. These findings do not support the use of short-course ADT with postoperative radiotherapy in this patient population

Duration of androgen deprivation therapy with postoperative radiotherapy for prostate cancer: a comparison of long-course versus short-course androgen deprivation therapy in the RADICALS-HD randomised trial

Background Previous evidence supports androgen deprivation therapy (ADT) with primary radiotherapy as initial treatment for intermediate-risk and high-risk localised prostate cancer. However, the use and optimal duration of ADT with postoperative radiotherapy after radical prostatectomy remains uncertain. Methods RADICALS-HD was a randomised controlled trial of ADT duration within the RADICALS protocol. Here, we report on the comparison of short-course versus long-course ADT. Key eligibility criteria were indication for radiotherapy after previous radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to add 6 months of ADT (short-course ADT) or 24 months of ADT (long-course ADT) to radiotherapy, using subcutaneous gonadotrophin-releasing hormone analogue (monthly in the short-course ADT group and 3-monthly in the long-course ADT group), daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as metastasis arising from prostate cancer or death from any cause. The comparison had more than 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 75% to 81% (hazard ratio [HR] 0·72). Standard time-to-event analyses were used. Analyses followed intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov , NCT00541047 . Findings Between Jan 30, 2008, and July 7, 2015, 1523 patients (median age 65 years, IQR 60–69) were randomly assigned to receive short-course ADT (n=761) or long-course ADT (n=762) in addition to postoperative radiotherapy at 138 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 8·9 years (7·0–10·0), 313 metastasis-free survival events were reported overall (174 in the short-course ADT group and 139 in the long-course ADT group; HR 0·773 [95% CI 0·612–0·975]; p=0·029). 10-year metastasis-free survival was 71·9% (95% CI 67·6–75·7) in the short-course ADT group and 78·1% (74·2–81·5) in the long-course ADT group. Toxicity of grade 3 or higher was reported for 105 (14%) of 753 participants in the short-course ADT group and 142 (19%) of 757 participants in the long-course ADT group (p=0·025), with no treatment-related deaths. Interpretation Compared with adding 6 months of ADT, adding 24 months of ADT improved metastasis-free survival in people receiving postoperative radiotherapy. For individuals who can accept the additional duration of adverse effects, long-course ADT should be offered with postoperative radiotherapy. Funding Cancer Research UK, UK Research and Innovation (formerly Medical Research Council), and Canadian Cancer Society

Molecular regulators of apical/basal polarity during mammary epithelial morphogenesis and invasive tumor progression

During breast cancer progression, the mammary gland undergoes architectural changes marked by a disruption of epithelial apical/basal polarity. In infiltrating lobular carcinomas (ILC) this disruption is marked by a loss of adherens (AJ) and tight (TJ) junctions. However, in the more prevalent infiltrating ductal carcinomas (IDC), AJ often remain while TJ are lost or disorganized. Thus, the loss of TJ polarity may be an important component of invasive, cancer progression. Because TJs and the basement membrane (BM) are critical components of apical and basal polarity, I chose to study the importance of polarity changes during breast cancer progression. To identify the molecular regulators of TJ dynamics in the normal breast I used a 3D hierarchical model of mammary epithelial cell morphogenesis in vitro. In this hierarchy, functional AJ were initially formed and then the TJs were formed. These TJs were not polarized and the TJ scaffolding protein ZO-1 co-localized with the AJ protein β-catenin at AJs. Upon addition of a soluble BM, ZO-1 was released from the AJ complex and the TJ complex migrated apically. This apical polarization of the TJ was mediated, at least in part, by interactions of the α6β4 integrin with laminin in the BM. The ETV6-NTRK3 (EN) fusion protein is expressed in secretory breast carcinomas (SBC) and two proteins, Podocalyxin and the Integrin-linked kinase (ILK), are involved in modulating cell-cell junctions. Thus, I examined the effects of these three genes on cell polarity. Forced expression of EN in normal epithelial cells induced cell proliferation without affecting TJ polarity, further explaining the non-metastatic phenotype of SBC. Podocalyxin was highly expressed in a subset of ductal tumors that become metastatic. When podocalyxin was expressed in a well-differentiated breast cancer cell line, TJs and polarity were perturbed, resulting a phenotype similar to IDC. When ILK was expressed in normal epithelial cells, they completely lost both TJs and AJs initiating an epithelial to mesenchymal transformation, hence an ILC phenotype. These data suggest that the establishment of polarized TJs is critical for normal mammary epithelial architecture, while changes to this architecture, at least in part, contribute to invasive breast tumor progression.Medicine, Faculty ofGraduat

Role of the cytoskeleton in basement membrane-induced mammary epithelial morphogenesis and differentiation

Basement membrane-mediated mammary epithelial morphogenesis is characterized by both morphological changes to the cells and the induction of milk protein gene expression. When mammary epithelial cells are placed on a reconstituted basement membrane gel, they aggregate, pull the gel around them and cavitation takes place. During this morphogenic process, the cells undergo changes in shape, polarity and cell-cell junctions. In this thesis I have sought to identify the role of the three major cytoskeletal elements in theses changes and to determine their involvement in the associated induction of milk protein gene induction. When scp2 cells were placed on Matrigel, they formed polarized structures with a central lumen that resemble functional mammary alveolar in vivo. Within these "mammospheres" E-cadherin was localized to adherens junctions, occluding was localized to tight junctions and actin filaments formed an apical junction-associated network. These mammospheres differentiated and expressed two milk proteins: lactoferrin, which is transcriptionally regulated by cell rounding only and β-casein, which is transcriptionally regulated by α6β4 integrin-mediated morphogenic changes initiated by the ligation to laminin within the Matrigel. The cells cultured on Matrigel were treated with increasing concentrations of nocodazole (ND), acrylamide (Ac) and cytochalasin D (CD) for 4 hours and allowed to under go morphogenesis for 72 hours. All three disrupting agents prevented the cells from undergoing morphogenesis and inhibited differentiation. ND treatment inhibited the synthesis of both lactoferrin and fi-casein while Ac and CD treatments inhibited the β casein induction only. These observations suggested that ND was not specifically inhibiting differentiation by preventing morphogenesis. In contrast, Ac and CD appeared to inhibit differentiation in a morphogenesis-dependent manner. The α6β4 integrin becomes physically linked to keratin intermediate filaments after its ligation to laminin. Because α6β4 ligation also initiates apical/basal polarity, cells on Matrigel were treated with a short term high-dose of CD to completely disrupt factin and were then observed for a six day recovery period. The apical actin network and tight junctions were re-established first followed by the induction of β-casein. Therefore, keratin and actin appear to influence functional mammosphere formation by helping to initiate and maintain cell polarity.Medicine, Faculty ofGraduat

Child occupants and side-impact crashes : Commentary

Commentary piece. Side-impact crashes are more dangerous for children and represent a challenge to injury prevention efforts. A recent study found that significant injury occurred in 41% of side-impact crashes, 15% of frontal impacts, and 3% of rear impacts involving child occupants. In addition, other studies have reported child mortality rates of 30% for side-impact crashes and 17% for frontal-impact crashes. Because of the large size of the head in relation to the rest of the body, a child's head and neck are more vulnerable than those of an adult. Children have more head surface area and a lower-seated height, both of which increase the risk of contact with the interior door panel or pillars during side-impact crashes.Pediatrics, Department ofMedicine, Faculty ofOther UBCNon UBCReviewedFacult