Malaria patient spectrum representation in therapeutic clinical trials of uncomplicated malaria: a scoping review of the literature

BACKGROUND

For the results of clinical trials to have external validity, the patients included in the study must be representative of the population presenting in the general clinical settings. A scoping literature review was performed to evaluate how the eligibility criteria used in anti-malarial efficacy and safety trials translate into patient selection.

METHODS

A search of the WorldWide Antimalarial Resistance Network (WWARN) Clinical Trials Publication Library, MEDLINE, The Cochrane Library, and clinicaltrials.gov was conducted to identify trials investigating anti-malarial efficacy and safety, published between 14th April 2001 and 31st December 2017. An updated search using the WWARN Clinical Trial Publication Library was undertaken to identify eligible publications from 1st January 2018 to 31st July 2021. The review included studies in patients of any age with uncomplicated malaria and any pharmaceutical therapeutic intervention administered. The proportion of trials with malaria-positive patients excluded was calculated and linked to the reported reason for exclusion. A subgroup analysis on eligibility criteria and trial baseline demographics was conducted to assess whether criteria are complied with when recruiting patients.

RESULTS

Out of 847 studies, 176 (21%) trials were included in the final synthesis, screening a total of 157,516 malaria-positive patients, of whom 56,293 (36%) were enrolled and treated. Across the 176 studies included, 84 different inclusion and exclusion criteria were identified. The reason for exclusion of patients who tested positive for malaria was reported in 144 (82%) studies. Three criteria account for about 70% of malaria-positive patients excluded: mixed-species malaria infections or other specific Plasmodium species, parasite counts outside the set study ranges, and refusal of consent.

CONCLUSIONS

Nearly two-thirds of the malaria-positive subjects who present to health facilities are systematically excluded from anti-malarial treatment trials. Reasons for exclusions are largely under-reported. Anti-malarial treatment in the general population is informed by studies on a narrow selection of patients who do not fully represent the totality of those seeking antimalarial treatment in routine practice. While entry criteria ensure consistency across trials, pragmatic trials are also necessary to supplement the information currently available and improve the external validity of the findings of malaria clinical trials.

The fragmented COVID-19 therapeutics research landscape: a living systematic review of clinical trial registrations evaluating priority pharmacological interventions

Background: Many available medicines have been evaluated as potential repurposed treatments for coronavirus disease 2019 (COVID-19). We summarise the registered study landscape for 32 priority pharmacological treatments identified following consultation with external experts of the COVID-19 Clinical Research Coalition. Methods: All eligible trial registry records identified by systematic searches of the World Health Organisation International Clinical Trials Registry Platform as of 26th May 2021 were reviewed and extracted. A descriptive summary of study characteristics was performed. Results: We identified 1,314 registered studies that included at least one of the 32 priority pharmacological interventions. The majority (1,043, 79%) were randomised controlled trials (RCTs). The sample size of the RCTs identified was typically small (median (25th, 75th percentile) sample size = 140 patients (70, 383)), i.e. individually powered only to show very large effects. The most extensively evaluated medicine was hydroxychloroquine (418 registered studies). Other widely studied interventions were convalescent plasma (n=208), ritonavir (n=189) usually combined with lopinavir (n=181), and azithromycin (n=147). Very few RCTs planned to recruit participants in low-income countries (n=14; 1.3%). A minority of studies (348, 26%) indicated a willingness to share individual participant data. The living systematic review data are available at https://iddo.cognitive.city Conclusions: There are many registered studies planning to evaluate available medicines as potential repurposed treatments of COVID-19. Most of these planned studies are small, and therefore substantially underpowered for most relevant endpoints. Very few are large enough to have any chance of providing enough convincing evidence to change policies and practices. The sharing of individual participant data (IPD) from these studies would allow pooled IPD meta-analyses which could generate definitive conclusions, but most registered studies did not indicate that they were willing to share their data.

Baseline results of a living systematic review for COVID-19 clinical trial registrations

Background: Since the coronavirus disease 2019 (COVID-19) outbreak was first reported in December 2019, many independent trials have been planned that aim to answer similar questions. Tools allowing researchers to review studies already underway can facilitate collaboration, cooperation and harmonisation. The Infectious Diseases Data Observatory (IDDO) has undertaken a living systematic review (LSR) to provide an open, accessible and frequently updated resource summarising characteristics of COVID-19 study registrations. Methods: Review of all eligible trial records identified by systematic searches as of 3 April 2020 and initial synthesis of clinical study characteristics were conducted. In partnership with Exaptive, an open access, cloud-based knowledge graph has been created using the results.  Results: There were 728 study registrations which met eligibility criteria and were still active. Median (25 th, 75 th percentile) sample size was 130 (60, 400) for all studies and 134 (70, 300) for RCTs. Eight lower middle and low income countries were represented among the planned recruitment sites. Overall 109 pharmacological interventions or advanced therapy medicinal products covering 23 drug categories were studied. Majority (57%, 62/109) of them were planned only in one study arm, either alone or in combination with other interventions. There were 49 distinct combinations studied with 90% (44/49) of them administered in only one or two study arms. The data and interactive platform are available at https://iddo.cognitive.city/. Conclusions:  Baseline review highlighted that the majority of investigations in the first three months of the outbreak were small studies with unique treatment arms, likely to be unpowered to provide solid evidence.  The continued work of this LSR will allow a more dependable overview of interventions tested, predict the likely strength of evidence generated, allow fast and informative filtering of relevant trials for specific user groups and provide the rapid guidance needed by investigators and funders to avoid duplication of efforts.

Determining the sources of nutrient flux to water in headwater catchments: Examining the speciation balance to inform the targeting of mitigation measures

Diffuse water pollution from agriculture (DWPA) is a major environmental concern, with significant adverse impacts on both human and ecosystem health. However, without an appropriate understanding of the multiple factors impacting on water, mitigation measures cannot be targeted. Therefore, this paper addresses this gap in understanding, reporting the hydrochemical monitoring evidence collected from the UK Government's Demonstration Test Catchments (DTC) programme including contrasting chalk and clay/mudstone catchments. We use data collected at daily and sub-daily frequency over multiple sites to address: (1) How does the behaviour of the full range of nitrogen (N) species and phosphorus (P) fractions vary? (2) How do N species and P fractions vary inter- and intra-annually? (3) What do these data indicate about the primary pollution sources? And (4) which diffuse pollution mitigation measures are appropriate in our study landscapes? Key differences in the rates of flux of nutrients were identified, dependent on catchment characteristics. Full N speciation and P fractionation, together with dissolved organic carbon (DOC) enabled identification of the most likely contributing sources in each catchment. Nitrate (NO₃-N) was the dominant N fraction in the chalk whereas organic and particulate N comprised the majority of the load in the clay/mudstone catchments. Despite current legislation, orthophosphate (PO₄-P) was not found to be the dominant form of P in any of the catchments monitored. The chalk sub-catchments had the largest proportion of inorganic/dissolved organic P (DOP), accompanied by episodic delivery of particulate P (PP). Contrastingly, the clay/mudstone sub-catchments loads were dominated by PP and DOP. Thus, our results show that by monitoring both the inorganic and organic fractions a more complete picture of catchment nutrient fluxes can be determined, and sources of pollution pin-pointed. Ultimately, policy and management to bring nutrient impacts under control will only be successful if a multi-stressor approach is adopted.

A prospective observational study of the association between cabin and outside air temperature, and patient temperature gradient during helicopter transport in New South Wales

The prevalence of hypothermia in patients following helicopter transport varies widely. Low outside air temperature has been identified as a risk factor. Modern helicopters are insulated and have heating; therefore outside temperature may be unimportant if cabin heat is maintained. We sought to describe the association between outside air, cabin and patient temperature, and having the cabin temperature in the thermoneutral zone (18-36°C) in our helicopter-transported patients. We conducted a prospective observational study over one year. Patient temperature was measured on loading and engines off. Cabin and outside air temperature were recorded for the same time periods for each patient, as well as in-flight. Previously identified risk factors were recorded. Complete data was obtained for 133 patients. Patients' temperature increased by a median of 0.15°C (P=0.013). There was no association between outside air temperature or cabin temperature and patient temperature gradient. The best predictor of patient temperature on landing was patient temperature on loading (R2=0.86) and was not improved significantly when other risk factors were added (P=0.63). Thirty-five percent of patients were hypothermic on loading, including those transferred from district hospitals. No patient loaded normothermic became hypothermic when the cabin temperature was in the thermoneutral zone (P=0.04). A large proportion of patients in our sample were hypothermic at the referring hospital. The best predictor of patient temperature on landing is patient temperature on loading. This has implications for studies that fail to account for pre-flight temperature.

High-sensitivity ring-down evanescent-wave sensing in fiber resonators

We report on optical-fiber cavity ring-down spectroscopy (CRDS) in the liquid phase using a laser emitting at telecommunication wavelengths. A fiber-ring cavity, comprising a short evanescent-wave coupler for radiation-matter interaction, is used as a sensor while its resonance modes are frequency locked to the laser. Exploiting the intrinsic sensitivity and noise immunity of the CRDS technique, we show that liquid absorption can be detected down to a level that is nearly a factor of 20 above the shot noise limit. We provide a thorough comparison between the experimental results and various noise contributions and address different expressions that can be used to calculate the shot noise equivalent absorbance. As a proof of principle, polyamine detection in aqueous solutions is carried out demonstrating a minimum detectable absorbance of 1.8×10(-7)  Hz(-1/2), which, to our knowledge, is the best sensitivity limit reported to date for evanescent-wave sensors.

The political ecology of health: perceptions of environment, economy, health and well-being among ‘Namgis First Nation

Informed by Mayer's (Progr. Hum. Geogr 20 (1996) 441) political ecology of disease framework, this paper investigates First Nation's perceptions of the links between environment, economy and health and well-being. A case study of 'Namgis First Nation (Alert Bay, British Columbia, Canada) is used to explore the risks and benefits of salmon aquaculture for British Columbia's First Nations. Analysis of interview data (n = 23) indicates strong links between reduced access to environmental resources, marginal participation in the economy, and declining community health and well being. Results suggest that aquaculture development has further decreased the community's access to environmental resources, thereby restricting those economic, social, and cultural activities that determine good health and well-being for this community.

A REVISION OF PHOREIOBOTHRIUM (TETRAPHYLLIDEA: ONCHOBOTHRIIDAE) WITH DESCRIPTIONS OF FIVE NEW SPECIES

Five new species of Phoreiobothrium (Cestoda: Tetraphyllidea) are described from carcharhiniform sharks collected from a diversity of localities throughout the world. These are Phoreiobothrium perilocrocodilus n. sp. from Negaprion acutidens, Phoreiobothrium anticaporum n. sp. from Negaprion brevirostris, Phoreiobothrium lewinense n. sp. from Sphyrna lewini, Phoreiobothrium robertsoni n. sp. from Carcharhinus brachyurus, and Phoreiobothrium blissorum n. sp. from C. plumbeus, This brings the number of described species of Phoreiobothrium to 17. The new species from the lemon sharks, P. perilocrocodilus n. sp. and P. anticaporum n. sp., both possess more bothridial subloculi than do all species from hammerhead sharks, and fewer subloculi than do all species from sharks of Carcharhinus spp. Phoreiobothrium anticaporum n. sp. is unique among Phoreiobothrium species in that its genital pore is located in the extreme anterior portion of the proglottid. Phoreiobothrium lewinense n. sp. is unique in its possession of a combination of 8-11 subloculi and basal hook prongs that lack internal channels. Phoreiobothrium robertsoni n. sp. possesses 25-29 subloculi, triangular bothridia that flare posteriorly, and hooks that extend well beyond the middle of the bothridia. Phoreiobothrium blissorum n. sp. is most similar to Phoreiobothrium lasium in that it possesses rectangular bothridia with greater than 22 subloculi and long filitriches on its scolex. However, it differs from the latter species in that rather than articulating with one another, the bases of the medial and lateral hooks are widely separated; it also possesses 5-6 (vs.) 7-8 columns of testes. Phoreiobothrium lasium and Phoreiobothrium tiburonis are redescribed. The host associations of P. lasium are reevaluated and a neotype is designated for this species. The mature proglottid of P. tiburonis is described for the first time from voucher material collected from the type host and locality. These data suggest that the proglottid information provided in the original description, which was obtained from detached gravid proglottids, may have come from a tapeworm species other than P. tiburonis. All 7 species treated here in detail were examined with scanning electron microscopy; most were found to exhibit a microthrix pattern similar to that described previously for other members of the genus, e.g., Phoreiobothrium manirei. Bladelike spinitriches were present on the strobila, cephalic peduncle, and proximal bothridial surfaces, but were lacking from the distal bothridial surfaces. These spinitriches varied in length and density among species. Filitriches were present on all of these surfaces, but varied somewhat in length among species. Phoreiobothrium lewinense n. sp. is exceptional in that spinitriches were not seen on the proximal bothridial surfaces. A key to Phoreiobothrium species is provided. This work brings the number of carcharhinid shark species known to host this onchobothriid genus to 6, and the number of sphyrnid species to 5. Like many other onchobothriid tapeworms, species of Phoreiobothrium appear to exhibit oioxenous specificity for their hosts. Given this, and the fact that a total of 9 genera and 46 species of carcharhinid and sphyrnid sharks have yet to be examined for Phoreiobothrium, the diversity of the genus globally is likely to greatly exceed that described to date.

High-density microarray-mediated gene expression profiling of Escherichia coli

A nearly complete collection of 4,290 Escherichia coli open reading frames was amplified and arrayed in high density on glass slides. To exploit this reagent, conditions for RNA isolation from E. coli cells, cDNA production with attendant fluorescent dye incorporation, DNA-DNA hybridization, and hybrid quantitation have been established. A brief isopropyl-beta-D-thiogalactopyranoside (IPTG) treatment elevated lacZ, lacY, and lacA transcript content about 30-fold; in contrast, most other transcript titers remained unchanged. Distinct RNA expression patterns between E. coli cultures in the exponential and transitional phases of growth were catalogued, as were differences associated with culturing in minimal and rich media. The relative abundance of each transcript was estimated by using hybridization of a genomic DNA-derived, fluorescently labeled probe as a correction factor. This inventory provided a quantitative view of the steady-state level of each mRNA species. Genes the expression of which was detected by this method were enumerated, and results were compared with the current understanding of E. coli physiology.