Inverting the patient involvement paradigm: defining patient led research

PLAIN ENGLISH SUMMARY

Patients usually understand their disease and lifestyle needs better than many medical professionals. They also have important ideas about what research would be most beneficial to their lives, especially on how to manage symptoms in a way that improves daily quality of life. In the UK, the National Institute for Health Research has recognised the value of patient insight, and now requires researchers with public funding to involve patients and the public throughout the research process. There are many opportunities for involvement, but these generally focus on improving study design to ensure the trial is acceptable to participants. Some programmes work towards setting research priorities as important to patients, public members, and medical experts, but due to the complexity and cost involved in running clinical trials, the majority of research originates with the pharmaceutical industry or academic institutions. There is a clear mismatch between research ideas that patients prioritise (quality of life), and those actually investigated (drug development).The Patient Led Research Hub (PLRH) is a new initiative hosted by the Cambridge Clinical Trials Unit. The PLRH supports research ideas as proposed by patient organisations, providing resources and expertise in research design and delivery. The PLRH aims to co-produce any technically feasible project, regardless of disease or symptom focus. The proposing patient group maintains ownership of the project with an active role in study management. This method of research has proven to produce credible research studies that are of direct relevance to patients.

ABSTRACT

Patient and Public Involvement has become an indispensable and expected component of healthcare research in the United Kingdom, largely driven by the National Institute of Health Research and other research funders. Opportunities for patients to become involved in research abound, and many organisations now have dedicated 'public involvement' teams. However, its value is often questioned amidst criticism of tokenism and the recognition that a mismatch persists between patient priorities and funded research. Although patients are frequently consulted, evidence that their involvement influences the research agenda remains limited. We propose a novel model that allows patients and the public not only to propose research questions, but to design, initiate and deliver their own research with all the necessary support from research professionals. We demonstrate the feasibility and utility of this approach in reporting the establishment, experiences and progress of the Patient Led Research Hub. Using this resource, patient organisations are now able to initiate and conduct rigorous clinical research unfettered by the constraints of academic or economic agendas.

Cross-reactive antigens in the pathogenesis of onchocerciasis

The ocular disease associated with infection with Onchocerca volvulus is unique in that there is a wealth of epidemiological evidence to support the casual nature of the association but there is little known about the pathogenic mechanisms involved. We have identified a 44,000 M(r) component of ocular tissues that shows immunological cross-reactivity with an O. volvulus antigen. This immunological cross-reactivity between parasite and a component of host tissues may underlie the development of ocular disease in onchocerciasis. Preliminary experiments indicate that it is possible to initiate ocular disease in susceptible rats using the recombinant parasite antigen. This should allow the development of a laboratory model of ocular onchocerciasis and further our understanding of the mechanisms by which an infective organism can produce an auto-immune-like disease in the host.

How long do the effects of ivermectin on adult Onchocerca volvulus persist?

The persistence of the effects of ivermectin on the viability, morphology and reproductivity of adult Onchocerca volvulus was examined eighteen months after treatment with a single or five six-monthly doses of ivermectin and compared with untreated controls. Treated nodules were removed from patients participating in a randomised controlled trial of ivermectin in Sierra Leone. Adult filariae, 545 females and 348 males, were isolated by collagenase digestion. The nodules were significantly smaller, contained fewer young worms and supported lower microfilarial production in those treated with five doses of ivermectin. The productivity index, a measure of the reproductive potential of a worm population, was still reduced by 83% eighteen months after five doses and by 63% after a single dose compared to controls. These results show that worms recover their fertility even after multiple doses of ivermectin, but do so slowly compared to standard dosage intervals. In addition ivermectin may have a partial chemoprophylactic effect which contributes to the maintenance of low microfilarial production in conditions of on-going transmission.

Immunologic cross-reactivity in the pathogenesis of ocular onchocerciasis

PURPOSE

Onchocerca volvulus, a filarial worm, is a major cause of infectious blindness and inflammatory eye disease. An autoimmune cause for ocular onchocerciasis has been suggested since the identification of a recombinant antigen of O. volvulus that shows immunologic cross-reactivity with a host ocular component of 44,000 M(r). The aim of this study was to establish the distribution of the cross-reactive antigens in both host tissues and the parasite, and to determine if significant autoantibody responses to the host antigen could be detected in infected persons.

METHODS

The tissue and organ distribution of the 44,000 M(r) antigen was determined by immunocytochemistry and Western blot analysis. Human autoantibody responses to the ocular antigen were demonstrated by Western blot analysis using sera collected from persons with onchocerciasis, with and without posterior segment pathology, Bancroftian filariasis, and Europeans with no filarial infection.

RESULTS

The tissue distribution of the 44,000 M(r) antigen correlates with the sites of pathology in onchocerciasis and antibody reactivity against this antigen could be detected in all persons with onchocerciasis and posterior segment pathology. The antigen is also recognized by sera from persons with Bancroftian filariasis, but not from normal persons.

CONCLUSIONS

A role is proposed for immunologic cross-reactivity in the pathogenesis of onchocerciasis and it is suggested that intraocular presentation of the cross-reactive parasite antigen by microfilariae is essential for the development of disease.

Age-related differences in parasitosis may indicate acquired immunity against microfilariae in cattle naturally infected with Onchocerca ochengi

Onchocerca ochengi is a common parasite of cattle in savanna areas of West Africa and its adult stages inhabit intradermal nodules. We have exploited the accessibility of the macrofilariae to examine quantitative and qualitative differences in both the macro- and microfilariae (mff) in relation to age in naturally infected cattle. Autochthonous cattle at a site on the Adamawa plateau, North Cameroon, situated near a perennial Simulium damnosum s.l. breeding site, were examined in three age groups (1.5-2.5, n = 34; 3-5, n = 39 and greater than or equal to 8 years old, n = 21). Skin mff densities were assessed from ventral skin biopsies, total body counts of nodules were done by palpation and 1-4 nodules were excised from positive animals, collagenase digested and the numbers and condition of macrofilariae determined. Embryogenesis profiles (embryograms) were done on a representative number of female worms in each age group. The overall prevalence of infection in the study population was 71% for mff and 85% for nodules. Nodule prevalence increased significantly from the 1.5-2.5 to 3-5 years old groups, but no other inter-age prevalences were significantly different. While the mean number of nodules per animal increased with age, geometric means (gm) 3.7, 15.5 and 23.1, the skin mff density maximized in the middle age group and decreased significantly in the old animals (gm 15.8, 44.7 and 11.4 mff/g, difference between latter two parameters significant, P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Chromosome numbers in Onchocerca dukei and O. tarsicola

Testicular examination of male Onchocerca dukei and German O. tarsicola revealed five pairs of chromosomes, which is typical of most filariae. In contrast to German O. tarsicola, specimens from Sweden had only three pairs of chromosomes.

Investigations of enzymatically isolated male Onchocerca volvulus: qualitative and quantitative aspects of spermatogenesis

A simple technique for the identification of the different spermatogenetic stages of Onchocerca volvulus is described. It is practicable for large-scale examinations in the field. The reproductivity of male worm populations can be assessed and directly correlated with the corresponding female worm populations. The activity of male filariae decreases with the increasing age of the worm population. Only few male worms transmit spermatozoa during mating, but spermatogenesis is continous also in very old male individuals. These old male filariae store high numbers of spermatozoa and cease their migration between the nodules.