Rising pharmaceutical innovation in the Global South: a landscape study

BACKGROUND

There is growing interest in pharmaceutical innovation in low- and middle-income countries (LMICs), but information on existing activities, capacities, and outcomes is scarce. We mapped available data at the global level, and studied the national pharmaceutical innovation systems of Bangladesh and Colombia to shed light on pharmaceutical research and development (R&D) in the Global South, including challenges and prospects, to help fill existing knowledge gaps.

METHODS

We gathered and analyzed data from three types of sources: literature, semi-structured interviews with key informants, and publicly available data on R&D funding, R&D scientific capacity measured by human resources, and clinical trial activities.

RESULTS

Pharmaceutical R&D activities are occurring in many LMICs, but 16 countries have emerged as frontrunners. Investment in R&D in LMICs has increased in the past decade, particularly from middle-income countries (MICs). Capacity is also growing, with an increase in the number of research organizations and the amount of funding available from external sources. The total number of clinical trials and the proportion of trials in LMICs increased markedly, and there is also growing activity in the earlier, more innovative and riskier Phase 1 and 2 trials. Non-commercial entities comprise the majority of clinical trial funders and sponsors in LMICs. Finally, investments have borne fruit, as indicated by a number of innovative medicines developed in LMICs. The Bangladesh and Colombia country studies showed that there is still a need for both targeted R&D policies to strengthen capacities in the pharmaceutical sector, and more government support to overcome the challenges of a lack of funding and coordination among different actors.

CONCLUSIONS

By triangulating between the data sources, it was possible to paint a broad picture of who was involved in pharmaceutical R&D in LMICs, in which particular countries, for which diseases, in which R&D phases, and with what results-as well as how these trends have changed over time. Prioritizing pharmaceutical R&D is an important strategy for better meeting health needs. The trendlines are promising, but focused attention is still needed to realize the potential for greater innovation in the Global South.

Point-of-care PSA testing: an evaluation of PSAwatch

We present a new quantitative prostate-specific antigen (PSA) assay using a portable, point-of-care test (PSAwatch) and reader system (BioScan) for measuring PSA concentrations in the range from 0.5 to < or =25 microg/l. Blood samples from patients (n=199) were submitted for laboratory PSA and also evaluated using PSAwatch and the BioScan system. PSA concentrations in 188 men were < or =25 microg/l and studied. Correlation between the two methods was good (R(2)=0.88) with a standard error of 1.588. The regression line had a bias of -0.02 at the concentration of 4.00 microg/l. This is the first report of a quantitative, portable, point-of-care PSA test and reader system. PSAwatch may reduce the number of hospital visits for patients with prostate disease.

Spectroscopic View of Life and Work of the Nobel Laureate Sir C.V. Raman

Raman spectroscopic and microscopic techniques have been used for nondestructive characterization of tissues and to differentiate benign and malignant tissues. The discovery of the principles of spectroscopy is credited to Sir C.V. Raman of India, who in 1930 brought the Nobel Prize in Physics to the East side of Suez. We present the life and work of Sir C.V. Raman with brief review of the uses of Raman spectroscopy in urology.

Robotic prostatectomy: the first UK experience

BACKGROUND

We describe a teamwork approach to setting up the UK's first clinical programme for robotically assisted laparoscopic radical prostatectomy.

METHODS

On 22 November 2004 the Imperial Robotic Urological Surgery Group performed their first robotically assisted prostatectomy. Robotically assisted prostatectomy lends itself to division into eight definable stages. A team of four consultant urological surgeons utilized a structured rotating system, using these stages, for time at the console and tableside assisting. Fluidity of surgery was maintained by a surgeon acting as the tableside assistant for the stage prior to moving to the console. Data was collected prospectively for the first 50 cases and parameters associated with the learning curve compared to other reported series.

RESULTS

Median operative time of 369.5 mins, median blood loss of 700 ml, with 12% of patients requiring a blood transfusion. Four patients required conversion to an open procedure; one resulting from equipment failure and three due to failure of progression. Four patients had an anastomotic leak with resulting ileus and two patients sustained rectal injuries, which were repaired intraoperatively using the robot. Median hospital stay was 4 days with a 22% positive surgical margin rate.

CONCLUSION

Parameters indicative of the learning curve are comparable to existing published initial series of other robotic centres. The use of teamwork has enabled us to provide safe and time-efficient training for four surgeons simultaneously. The structured approach used in this setting demonstrates that urological surgeons of varying laparoscopic experience can acquire the skills necessary to competently perform laparoscopic radical prostatectomy.

Randomised evaluation of alternative electrosurgical modalities to treat bladder outflow obstruction in men with benign prostatic hyperplasia

OBJECTIVES

To compare and evaluate the clinical and cost-effectiveness of transurethral vaporisation of the prostate (TUVP), a new electrosurgical modality, with the standard treatment, transurethral resection of the prostate (TURP).

DESIGN

A multicentre randomised controlled trial of pragmatic design with associated economic evaluation using cost minimisation.

SETTING

Patients were recruited from four centres in south-east England.

PARTICIPANTS

Men requiring surgery for lower urinary tract symptoms deemed to be due to benign prostatic hypertrophy.

INTERVENTIONS

TURP was performed and subsequent management conducted according to the usual practice of the clinical team. TUVP was performed with the most promising available equipment using a technique described in the literature. Postoperative management after TUVP was left to the ward team, who were not necessarily informed to which treatment arm the patient had been allocated. For the purpose of the study, patients were assessed clinically, by questionnaire and investigation at baseline, 2 months and 6 months after randomisation. A long-term follow-up postal questionnaire was sent to each patient at 2 years. For the economic evaluation, direct costs from the NHS viewpoint were collected.

MAIN OUTCOME MEASURES

A reduction of at least 5 from the International Prostate Symptom Score (IPSS) was taken as a satisfactory outcome. The IPSS quality of life (QoL) question provided disease-specific information about QoL. Secondary outcome measures included urinary flow rate, post-void urinary volume, prostate volume and pressure-flow urodynamics. Questionnaires used included SF-36, EuroQol and a sexual function section based on the International Continence Society 'Benign Prostatic Hyperplasia' (ICS-BPH) questionnaire. Measurement of full blood count and urea and electrolytes was made at baseline and at 24 hours. Adverse events were recorded during the hospital stay and at follow-up visits.

RESULTS

TURP and TUVP were both effective in producing a clinically important reduction in IPSS and positive change in the IPSS QoL question. The success rate for relief of symptoms was 85% for TURP and 74% for TUVP. Neither the success of the treatment nor the change in aggregated IPSS was significantly different between the groups. The improvement was sustained to 24 months after treatment with no significant difference between the groups. The effectiveness of both treatments was also equivalent when assessed through improvement in objective measures of urinary tract function, reduction in prostate size and the change in health questions of SF-36. The absolute incidence of adverse events was similar between the two groups. The incidence of severe or prolonged bleeding was less with TUVP, as evidenced by the need for blood transfusion and the drop in haemoglobin level 24 hours postoperatively. TURP and TUVP are broadly equivalent in direct NHS resource use. This study did not show any significant difference in inpatient stay or use of outpatient resources between the groups. The disposable electrodes used for TUVP are more expensive than reusable TURP electrodes.

CONCLUSIONS

TURP and TUVP are equivalently effective in improving the symptoms of benign prostatic enlargement over at least 2 years. TUVP is associated with less morbidity due to haemorrhage than TURP. Replacement of TURP by TUVP would not produce a significant cost benefit to the NHS unless a reduction hospital inpatient stay of at least 1 day could be secured. Further research is necessary to determine why patients stay in hospital after transurethral surgery to the prostate and how a reduction in the length of stay can be achieved. A much larger observational study/audit is required to assess the incidence of infrequently occurring adverse events after TUVP. Longer term follow-up is also needed.

Transurethral electrovaporization of the prostate: is it any better than conventional transurethral resection of the prostate?

OBJECTIVE

To evaluate transurethral electrovaporization of the prostate (TUVP), compared with transurethral resection of the prostate (TURP), as a treatment for men with symptomatic benign prostatic enlargement (BPE).

PATIENTS AND METHODS

In all, 235 men with symptomatic BPE in four hospitals in the South-East of England were randomized to TUVP (115) and TURP (120). Patients were assessed using the International Prostate Symptom Score (IPSS), the Short Form-36 (SF-36), EuroQol and sexual function questionnaire, uroflowmetry, ultrasonographic measurement of residual urine volume, pressure-flow urodynamics and transrectal ultrasonography.

RESULTS

There was no statistically significant difference in the objective and subjective outcome after TURP and TUVP. The latter was associated with a lower transfusion rate than TURP but this did not result in an overall reduction in complications. There was no difference in the length of hospital stay. Overall, the two operations produced equivalent results and equivalent complication rates.

CONCLUSION

TUVP is an effective treatment for symptomatic BPE, with results equivalent to TURP. TUVP has not led to the expected reduction in early postoperative morbidity or shorter hospital stays.