Methodological variation in economic evaluations conducted in low- and middle-income countries: information for reference case development

Information generated from economic evaluation is increasingly being used to inform health resource allocation decisions globally, including in low- and middle- income countries. However, a crucial consideration for users of the information at a policy level, e.g. funding agencies, is whether the studies are comparable, provide sufficient detail to inform policy decision making, and incorporate inputs from data sources that are reliable and relevant to the context. This review was conducted to inform a methodological standardisation workstream at the Bill and Melinda Gates Foundation (BMGF) and assesses BMGF-funded cost-per-DALY economic evaluations in four programme areas (malaria, tuberculosis, HIV/AIDS and vaccines) in terms of variation in methodology, use of evidence, and quality of reporting. The findings suggest that there is room for improvement in the three areas of assessment, and support the case for the introduction of a standardised methodology or reference case by the BMGF. The findings are also instructive for all institutions that fund economic evaluations in LMICs and who have a desire to improve the ability of economic evaluations to inform resource allocation decisions.

Protein engineering and preclinical development of a GM-CSF receptor antibody for the treatment of rheumatoid arthritis

BACKGROUND AND PURPOSE

For antibody therapies against receptor targets, in vivo outcomes can be difficult to predict because of target-mediated clearance or antigen 'sink' effects. The purpose of this work was to engineer an antibody to the GM-CSF receptor α (GM-CSFRα) with pharmacological properties optimized for chronic, s.c. treatment of rheumatoid arthritis (RA) patients.

EXPERIMENTAL APPROACH

We used an in silico model of receptor occupancy to guide the target affinity and a combinatorial phage display approach for affinity maturation. Mechanism of action and internalization assays were performed on the optimized antibody in vitro before refining the modelling predictions of the eventual dosing in man. Finally, in vivo pharmacology studies in cynomolgus monkeys were carried out to inform the predictions and support future clinical development.

KEY RESULTS

Antibody potency was improved 8600-fold, and the target affinity was reached. The refined model predicted pharmacodynamic effects at doses as low as 1 mg kg(-1) and a study in cynomolgus monkeys confirmed in vivo efficacy at 1 mg kg(-1) dosing.

CONCLUSIONS AND IMPLICATIONS

This rational approach to antibody drug discovery enabled the isolation of a potent molecule compatible with chronic, s.c. self-administration by RA patients. We believe this general approach enables the development of optimal biopharmaceuticals.

Reproduction and development of laboratory and wild house dust mites (Acari: Pyroglyphidae) and their relationship to the natural dust ecosystem

Life histories of "wild" house dust mites, Dermatophagoides pteronyssinus (Trouessart) (Acari: Pyroglyphidae), were compared with laboratory cultures by using a diet consisting of skin and dust or a laboratory diet consisting of dried liver and yeast. Under constant conditions of 25 degrees C and 75% RH, fecundity and rate of reproduction were higher in laboratory cultures on both diets compared with wild mites. There were also trends for a shorter prereproductive period and more rapid egg development of laboratory mites compared with wild mites. Overall, there was little effect of diet on either strain of mites at 75% RH. At low RH (64%), fecundity was significantly lower (for both strains on both diets), and there were also trends for longer prereproductive period, reduced rate of reproduction, reduced adult survival, prolonged egg and juvenile development, or a combination compared with 75% RH. Additionally egg and juvenile mortality were significantly higher on the liver and yeast diet. Overall, the skin and dust diet favored both strains of mites at 64% RH. On the liver and yeast diet at 64% RH, wild mite adults performed significantly better than laboratory mites, and egg mortality was lower. These results suggest that laboratory mites have stronger reproduction and development than wild mites, except when under environmental stress and that diet is a significant factor, particularly in suboptimal conditions. This could have important implications for predictive models of house dust mite populations in their natural habitat. Ideally, such models should be developed using data from wild dust mite populations reared on a natural diet.