Chemogenomic Profiling of Antileishmanial Efficacy and Resistance in the Related Kinetoplastid Parasite <i>Trypanosoma brucei</i>

The arsenal of drugs used to treat leishmaniasis, caused by Leishmania spp., is limited and beset by emergent resistance and toxicity. Our understanding of drug mode-of-action and potential routes to resistance is also limited. Forward genetic approaches have revolutionised our understanding of drug mode-of-action in the related kinetoplastid parasite, Trypanosoma brucei. Therefore, we screened our genome-scale T. brucei RNAi library for knockdowns that render cells resistant to the current anti-leishmanial drugs, sodium stibogluconate (antimonial), paromomycin, miltefosine and amphotericin-B. Identification of T. brucei orthologues of the known Leishmania antimonial and miltefosine plasma membrane transporters effectively validated our approach, while a cohort of 42 novel drug efficacy determinants provides new insights and serves as a resource

Development and formative evaluation of the e-Health implementation toolkit

&lt;b&gt;Background&lt;/b&gt; The use of Information and Communication Technology (ICT) or e-Health is seen as essential for a modern, cost-effective health service. However, there are well documented problems with implementation of e-Health initiatives, despite the existence of a great deal of research into how best to implement e-Health (an example of the gap between research and practice). This paper reports on the development and formative evaluation of an e-Health Implementation Toolkit (e-HIT) which aims to summarise and synthesise new and existing research on implementation of e-Health initiatives, and present it to senior managers in a user-friendly format.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Results&lt;/b&gt; The content of the e-HIT was derived by combining data from a systematic review of reviews of barriers and facilitators to implementation of e-Health initiatives with qualitative data derived from interviews of "implementers", that is people who had been charged with implementing an e-Health initiative. These data were summarised, synthesised and combined with the constructs from the Normalisation Process Model. The software for the toolkit was developed by a commercial company (RocketScience). Formative evaluation was undertaken by obtaining user feedback. There are three components to the toolkit - a section on background and instructions for use aimed at novice users; the toolkit itself; and the report generated by completing the toolkit. It is available to download from http://www.ucl.ac.uk/pcph/research/ehealth/documents/e-HIT.xls&lt;p&gt;&lt;/p&gt; &lt;b&gt;Conclusions&lt;/b&gt; The e-HIT shows potential as a tool for enhancing future e-Health implementations. Further work is needed to make it fully web-enabled, and to determine its predictive potential for future implementations

In the dedicated pursuit of dedicated capital: restoring an indigenous investment ethic to British capitalism

Tony Blair’s landslide electoral victory on May 1 (New Labour Day?) presents the party in power with a rare, perhaps even unprecedented, opportunity to revitalise and modernise Britain’s ailing and antiquated manufacturing economy.* If it is to do so, it must remain true to its long-standing (indeed, historic) commitment to restore an indigenous investment ethic to British capitalism. In this paper we argue that this in turn requires that the party reject the very neo-liberal orthodoxies which it offered to the electorate as evidence of its competence, moderation and ‘modernisation’, which is has internalised, and which it apparently now views as circumscribing the parameters of the politically and economically possible

Implementing health research through academic and clinical partnerships : a realistic evaluation of the Collaborations for Leadership in Applied Health Research and Care (CLAHRC)

Background: The English National Health Service has made a major investment in nine partnerships between higher education institutions and local health services called Collaborations for Leadership in Applied Health Research and Care (CLAHRC). They have been funded to increase capacity and capability to produce and implement research through sustained interactions between academics and health services. CLAHRCs provide a natural ‘test bed’ for exploring questions about research implementation within a partnership model of delivery. This protocol describes an externally funded evaluation that focuses on implementation mechanisms and processes within three CLAHRCs. It seeks to uncover what works, for whom, how, and in what circumstances. Design and methods: This study is a longitudinal three-phase, multi-method realistic evaluation, which deliberately aims to explore the boundaries around knowledge use in context. The evaluation funder wishes to see it conducted for the process of learning, not for judging performance. The study is underpinned by a conceptual framework that combines the Promoting Action on Research Implementation in Health Services and Knowledge to Action frameworks to reflect the complexities of implementation. Three participating CLARHCS will provide indepth comparative case studies of research implementation using multiple data collection methods including interviews, observation, documents, and publicly available data to test and refine hypotheses over four rounds of data collection. We will test the wider applicability of emerging findings with a wider community using an interpretative forum. Discussion: The idea that collaboration between academics and services might lead to more applicable health research that is actually used in practice is theoretically and intuitively appealing; however the evidence for it is limited. Our evaluation is designed to capture the processes and impacts of collaborative approaches for implementing research, and therefore should contribute to the evidence base about an increasingly popular (e.g., Mode two, integrated knowledge transfer, interactive research), but poorly understood approach to knowledge translation. Additionally we hope to develop approaches for evaluating implementation processes and impacts particularly with respect to integrated stakeholder involvement

Uncovering treatment burden as a key concept for stroke care: a systematic review of qualitative research

&lt;b&gt;Background&lt;/b&gt; Patients with chronic disease may experience complicated management plans requiring significant personal investment. This has been termed ‘treatment burden’ and has been associated with unfavourable outcomes. The aim of this systematic review is to examine the qualitative literature on treatment burden in stroke from the patient perspective.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Methods and findings&lt;/b&gt; The search strategy centred on: stroke, treatment burden, patient experience, and qualitative methods. We searched: Scopus, CINAHL, Embase, Medline, and PsycINFO. We tracked references, footnotes, and citations. Restrictions included: English language, date of publication January 2000 until February 2013. Two reviewers independently carried out the following: paper screening, data extraction, and data analysis. Data were analysed using framework synthesis, as informed by Normalization Process Theory. Sixty-nine papers were included. Treatment burden includes: (1) making sense of stroke management and planning care, (2) interacting with others, (3) enacting management strategies, and (4) reflecting on management. Health care is fragmented, with poor communication between patient and health care providers. Patients report inadequate information provision. Inpatient care is unsatisfactory, with a perceived lack of empathy from professionals and a shortage of stimulating activities on the ward. Discharge services are poorly coordinated, and accessing health and social care in the community is difficult. The study has potential limitations because it was restricted to studies published in English only and data from low-income countries were scarce.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Conclusions&lt;/b&gt; Stroke management is extremely demanding for patients, and treatment burden is influenced by micro and macro organisation of health services. Knowledge deficits mean patients are ill equipped to organise their care and develop coping strategies, making adherence less likely. There is a need to transform the approach to care provision so that services are configured to prioritise patient needs rather than those of health care systems

Stark choices: exploring health sector costs of policy responses to COVID-19 in low-income and middle-income countries.

OBJECTIVES: COVID-19 has altered health sector capacity in low-income and middle-income countries (LMICs). Cost data to inform evidence-based priority setting are urgently needed. Consequently, in this paper, we calculate the full economic health sector costs of COVID-19 clinical management in 79 LMICs under different epidemiological scenarios. METHODS: We used country-specific epidemiological projections from a dynamic transmission model to determine number of cases, hospitalisations and deaths over 1 year under four mitigation scenarios. We defined the health sector response for three base LMICs through guidelines and expert opinion. We calculated costs through local resource use and price data and extrapolated costs across 79 LMICs. Lastly, we compared cost estimates against gross domestic product (GDP) and total annual health expenditure in 76 LMICs. RESULTS: COVID-19 clinical management costs vary greatly by country, ranging between <0.1%-12% of GDP and 0.4%-223% of total annual health expenditure (excluding out-of-pocket payments). Without mitigation policies, COVID-19 clinical management costs per capita range from US$43.39 to US$75.57; in 22 of 76 LMICs, these costs would surpass total annual health expenditure. In a scenario of stringent social distancing, costs per capita fall to US$1.10-US$1.32. CONCLUSIONS: We present the first dataset of COVID-19 clinical management costs across LMICs. These costs can be used to inform decision-making on priority setting. Our results show that COVID-19 clinical management costs in LMICs are substantial, even in scenarios of moderate social distancing. Low-income countries are particularly vulnerable and some will struggle to cope with almost any epidemiological scenario. The choices facing LMICs are likely to remain stark and emergency financial support will be needed

3011 Fc Receptor Targeting Reduces Bone Disease in a Pre-Clinical Model of Multiple Myeloma

Background: Multiple Myeloma (MM) is currently incurable, with a median survival of 5-7 years post diagnosis. MM-associated bone disease (MM-OBD), represents a major cause of morbidity and mortality in MM patients. Despite current therapies for MM-OBD exhibiting significant potential (e.g. Zoledronate), their clinical use has been restricted due to severe treatment associated toxicities. Safe novel therapies for MM-OBD are therefore crucially required. Molecular crosstalk between receptor activator of nuclear factor Kappa B ligand (RANKL), present on and secreted by MM plasma cells, and its corresponding receptor (RANK) on osteoclast precursors (OCPs), represents a key mechanism driving osteoclastogenesis and subsequent bone pathology in MM. Our previous studies have demonstrated that Fc receptor (FcR)-mediated signals can inhibit RANKL induced osteoclastogenesis in vitro1. In addition, findings from preliminary studies show that FcR-mediated signalling in pre-osteoclasts can reduce MM plasma cell driven osteoclastogenesis in vitro. Further interrogation of the underlying molecular mechanisms show that FcR-mediated signals profoundly reduce RANK transcript, and subsequent protein expression, in pre-osteoclasts. However, the effects of FcR engagement on MM-OBD in vivo, and the FcR elicited signalling pathways responsible for inhibition of RANK expression have still to be elucidated.  Aims: This study aimed to determine the in vivo potential of FcR engagement to treat bone disease in a pre-clinical model of MM. Additionally, the mechanisms underlying FcR-mediated down-regulation of RANK expression in OCPs were interrogated. Methods: The well-characterised 5TGM1 murine model of MM, together with micro-computed topography (micro-CT), were used to evaluate the effect of FcR engagement on MM-OBD. FcR stimulation was achieved by I.P. injecting mice (every other day, following 5TGM1 I.V. cell injection), with 100 μg/ml of Protein A derived from Staphylococcus aureus (SpA). SpA has been shown to form small immune complexes (SICs) through its affinity for endogenous IgG, which in turn binds to FcγR1 receptors on monocytes and pre-OCs1. Additionally, the potential involvement of FcR signalling pathways in the down-regulation of RANK in healthy and MM-derived human OCPs was determined via immunoblotting and the use of signalling pathway inhibitors. Results: Twenty six days post-myeloma cell injection, micro-CT analysis of femurs revealed that mice receiving PBS (vehicle control, n=5) exhibited a significant decrease in bone morphmetric parameters consistent with bone erosion compared to non-myeloma bearing  mice (n=3); trabecullar bone volume [BV/TV] = 2.673 vs. 3.449, p=0.034; trabecullar number [Tb.N] = 0.0035 vs. 0.0042, p=0.0041; trabecullar pattern factor [Tb.Pf] = 0.2329 vs. 0.2033, p=0.0393. Importantly, myeloma bearing mice (n=5) receiving SpA, were protected from MM-OBD. In human OCPs (sourced from healthy individuals and MM patients), FcR engagement substantially activated SyK, MEK-ERK1/2, and PI3K signaling cascades. However, inhibition of these pathways failed to restore RANK transcript levels. Discussion: These findings demonstrate novel mechanisms of RANK gene expression regulation in healthy and MM OCPs, with Fc receptors representing a potential therapeutic strategy for MM-OBD. Further studies will aim to elucidate the molecular mechanisms responsible for FcR-mediated regulation of RANK gene expression

3011 Fc Receptor Targeting Reduces Bone Disease in a Pre-Clinical Model of Multiple Myeloma

Background: Multiple Myeloma (MM) is currently incurable, with a median survival of 5-7 years post diagnosis. MM-associated bone disease (MM-OBD), represents a major cause of morbidity and mortality in MM patients. Despite current therapies for MM-OBD exhibiting significant potential (e.g. Zoledronate), their clinical use has been restricted due to severe treatment associated toxicities. Safe novel therapies for MM-OBD are therefore crucially required. Molecular crosstalk between receptor activator of nuclear factor Kappa B ligand (RANKL), present on and secreted by MM plasma cells, and its corresponding receptor (RANK) on osteoclast precursors (OCPs), represents a key mechanism driving osteoclastogenesis and subsequent bone pathology in MM. Our previous studies have demonstrated that Fc receptor (FcR)-mediated signals can inhibit RANKL induced osteoclastogenesis in vitro1. In addition, findings from preliminary studies show that FcR-mediated signalling in pre-osteoclasts can reduce MM plasma cell driven osteoclastogenesis in vitro. Further interrogation of the underlying molecular mechanisms show that FcR-mediated signals profoundly reduce RANK transcript, and subsequent protein expression, in pre-osteoclasts. However, the effects of FcR engagement on MM-OBD in vivo, and the FcR elicited signalling pathways responsible for inhibition of RANK expression have still to be elucidated.  Aims: This study aimed to determine the in vivo potential of FcR engagement to treat bone disease in a pre-clinical model of MM. Additionally, the mechanisms underlying FcR-mediated down-regulation of RANK expression in OCPs were interrogated. Methods: The well-characterised 5TGM1 murine model of MM, together with micro-computed topography (micro-CT), were used to evaluate the effect of FcR engagement on MM-OBD. FcR stimulation was achieved by I.P. injecting mice (every other day, following 5TGM1 I.V. cell injection), with 100 μg/ml of Protein A derived from Staphylococcus aureus (SpA). SpA has been shown to form small immune complexes (SICs) through its affinity for endogenous IgG, which in turn binds to FcγR1 receptors on monocytes and pre-OCs1. Additionally, the potential involvement of FcR signalling pathways in the down-regulation of RANK in healthy and MM-derived human OCPs was determined via immunoblotting and the use of signalling pathway inhibitors. Results: Twenty six days post-myeloma cell injection, micro-CT analysis of femurs revealed that mice receiving PBS (vehicle control, n=5) exhibited a significant decrease in bone morphmetric parameters consistent with bone erosion compared to non-myeloma bearing  mice (n=3); trabecullar bone volume [BV/TV] = 2.673 vs. 3.449, p=0.034; trabecullar number [Tb.N] = 0.0035 vs. 0.0042, p=0.0041; trabecullar pattern factor [Tb.Pf] = 0.2329 vs. 0.2033, p=0.0393. Importantly, myeloma bearing mice (n=5) receiving SpA, were protected from MM-OBD. In human OCPs (sourced from healthy individuals and MM patients), FcR engagement substantially activated SyK, MEK-ERK1/2, and PI3K signaling cascades. However, inhibition of these pathways failed to restore RANK transcript levels. Discussion: These findings demonstrate novel mechanisms of RANK gene expression regulation in healthy and MM OCPs, with Fc receptors representing a potential therapeutic strategy for MM-OBD. Further studies will aim to elucidate the molecular mechanisms responsible for FcR-mediated regulation of RANK gene expression