Patient Advocates for Clinical Research (PACER): A Step Toward Ethical, Relevant, and Truly Participatory Clinical Research in India.

Background Clinical research presents a promising path for improving healthcare in contemporary India. Yet, researchers identify gaps in trust, awareness, as well as misconceptions about being a '"guinea pig." We proposed building the capacity of training patient advocacy groups (PAGs) in patient-centered clinical research and through them creating aware patients as research partners. Methodology Patient Advocates for Clinical Research (PACER) is a tiered program to share information and education about clinical research with PAGs. Tier one is a self-paced online learning course, followed by workshops on clinical research, Good Clinical Practice, research consent, case studies, and group discussions. Results A total of 20 PAGs represented by 48 participants, active in areas of pediatric cancer, breast cancer, multiple myeloma, type I diabetes, spinal muscular atrophy, sickle cell disease, and inflammatory bowel diseases, participated. Among 48 participants 30 successfully completed the online course (multiple-choice question evaluation score cut-off >70%), attaining an average score of 23.9 ± 2.1 out of 30. Overall, 48 participants attended workshop 1 and 45 workshop 2, with 140 participants joining the focus group discussion (FGD). An overall improvement of 9.4% (𝜒2 = 46.173; p < 0.001) for workshop 1 and 8.2% (𝜒2 = 25.412; p < 0.001) for workshop 2 was seen in knowledge gain about clinical research. The FGD raised issues such as misleading information from research teams, unethical recruitment, incomprehensible information sheets, and limited trial-related knowledge fostering fear of participation in clinical research. Conclusions Multimodal and tiered learning of clinical research such as that used by PACER has a good participatory and learning response from PAGs and may be further explored.

Mycobacterium tuberculosis ketol-acid reductoisomerase down-regulation affects its ability to persist, and its survival in macrophages and in mice.

Branched-chain amino acids (BCAAs) leucine, isoleucine and valine biosynthetic pathways have been reported from plants, fungi and bacteria including Mycobacterium tuberculosis (Mtb) but are absent in animals. This makes interventions with BCAAs biosynthesis an attractive proposition for antimycobacterial drug discovery. In the present study, Mycobacterium tuberculosis H37Ra (Mtb-Ra) ketol-acid reductoisomerase encoding ORF MRA_3031 was studied to establish its role in Mtb-Ra growth and survival. Recombinant knockdown (KD) and complemented (KDC) strains along with wild-type (WT) Mtb-Ra were studied under in-vitro and ex-vivo conditions. KD was defective for survival inside macrophages and showed time dependent decrease in its colony forming unit (CFU) counts, while, WT and KDC showed time dependent increase in CFUs, after macrophage infection. Also, KD showed reduced ability to form persister cells, had altered membrane permeability against ethidium bromide and nile red dyes, and had reduced biofilm maturation, compared to WT and KDC. The in-vivo studies showed that KD infected mice had lower CFU counts in lungs, compared to WT. In summary Mtb shows survival deficit in macrophages and in mice after ketol-acid reductoisomerase down-regulation.

Knockout of MRA_1916 in Mycobacterium tuberculosis H37Ra affects its growth, biofilm formation, survival in macrophages and in mice.

Mycobacterium tuberculosis H37Ra (Mtb-Ra) ORF MRA_1916 is annotated as a D-amino acid oxidase (DAO). These enzymes perform conversion of d-amino acids to corresponding imino acids followed by conversion into α-keto-acids. In the present study Mtb-Ra recombinants with DAO knockout (KO) and knockout complemented with DAO over-expressing plasmid (KOC) were constructed. The growth studies showed loss of growth of KO in medium containing glycerol as a primary carbon source. Substituting glycerol with acetate or with FBS addition, restored the growth. Growth was also restored in complemented strain (KOC). KO showed increased permeability to hydrophilic dye EtBr and reduced biofilm formation. Also, its survival in macrophages was low. Phagosome maturation studies suggested enhanced colocalization of KO, compared to WT, with lysosomal marker cathepsin D. Also, an increased intensity of Rab5 and iNOS was observed in macrophages infected with KO, compared to WT and KOC. The in vivo survival studies showed no increase in CFU of KO. This is the first study to show functional relevance of DAO encoded by MRA_1916 for Mtb-Ra growth on glycerol, its permeability and biofilm formation. Also, this study clearly demonstrates that DAO deletion leads to Mtb-Ra failing to grow in macrophages and in mice.

Down-regulation of malate synthase in Mycobacterium tuberculosis H37Ra leads to reduced stress tolerance, persistence and survival in macrophages.

Malate synthase is a condensing enzyme responsible for conversion of glyoxylate to malate in the presence of acetyl-CoA. This reaction helps in bypassing the TCA cycle reactions involving carbon loss and leads to diverting some of the carbon skeletons to gluconeogenic events while rest can continue to provide TCA cycle intermediates. Malate synthase (GlcB) is encoded by MRA_1848 of Mycobacterium tuberculosis H37Ra (Mtb-Ra). We developed a knockdown (KD) Mtb-Ra strain by down-regulating GlcB. The survival studies suggested increased susceptibility to oxidative and nitrosative stress as well as to rifampicin. The susceptibility profile was reversed in the presence of free radical scavengers. Also, KD showed reduced biofilm maturation, failed to enter persistent state, and showed reduced growth inside macrophages. The study of post-endocytosis events showed differences in late stage endosomal maturation behavior in macrophages infected with KD compared to WT. Increased iNOS, LAMP1 and cathepsin D expression was observed in macrophages infected with KD compared to WT.

Evaluation of antibody response to various developmental stage specific somatic antigens of Paramphistomum epiclitum in goats.

Electrophoretic analysis of various developmental stage specific somatic antigens of Paramphistomum epiclitum (Digenea: Paramphistomidae), namely, metacercariae (McAg), immature intestinal flukes (ImIAg), immature ruminal flukes (ImRAg), and adult flukes (AAg), was done by native polyacrylamide gel electrophoresis. Result revealed presence of 3 (range 15.2-40.3 kDa), 13 (9.3-121.2 kDa), 14 (9.3-169.3 kDa), and 15 (8.0-169.3 kDa) polypeptides in McAg, ImIAg, ImRAg, and AAg, respectively. With an aim to identify a suitable immunodiagnostic antigen for early diagnosis of amphistomosis, the IgG antibody response to various developmental stage antigens in goats experimentally infected with metacercariae of P. epiclitum was evaluated by ELISA. The highest OD values were recorded with ImIAg which ranged between 0.23 and 0.55 with a significant increase from the 2nd week till 8th week of infection with a peak at 6th week. The analysis of statistical significance using a one-way analysis of variance with multiple pair wise comparisons revealed that IgG response was significantly higher with all antigens (P < 0.01) except McAg (P > 0.05) with a maximum mean difference of 0.1838 in comparison to control with ImIAg, thus, indicating that ImIAg which could be further exploited for its potential is a candidate for immunodiagnostic antigen for early diagnosis of amphistomosis.

Post-coma persons emerged from a minimally conscious state and showing multiple disabilities learn to manage a radio-listening activity.

This study assessed microswitch-based technology to enable three post-coma adults, who had emerged from a minimally conscious state but presented motor and communication disabilities, to operate a radio device. The material involved a modified radio device, a microprocessor-based electronic control unit, a personal microswitch, and an amplified MP3 player. The study was carried out according to a non-concurrent multiple baseline design across participants. During the intervention, all three participants learned to operate the radio device, changing stations and tuning on some of them longer amounts of time than on others (i.e., suggesting preferences among the topics covered by those stations). They also ended a number of sessions before the maximum length of time allowed for them had elapsed. The practical (rehabilitation) implications of the findings were discussed.

Post-coma persons with extensive multiple disabilities use microswitch technology to access selected stimulus events or operate a radio device.

The present two studies extended research evidence on the use of microswitch technology by post-coma persons with multiple disabilities. Specifically, Study I examined whether three adults with a diagnosis of minimally conscious state and multiple disabilities could use microswitches as tools to access brief, selected stimulus events. Study II assessed whether an adult, who had emerged from a minimally conscious state but was affected by multiple disabilities, could manage the use of a radio device via a microswitch-aided program. Results showed that the participants of Study I had a significant increase of microswitch responding during the intervention phases. The participant of Study II learned to change radio stations and seemed to spend different amounts of session time on the different stations available (suggesting preferences among the programs characterizing them). The importance of microswitch technology for assisting post-coma persons with multiple disabilities to positively engage with their environment was discussed.

Effects of a mindfulness-based smoking cessation program for an adult with mild intellectual disability.

Smoking is a major risk factor for a number of health conditions and many smokers find it difficult to quit smoking without specific interventions. We developed and used a mindfulness-based smoking cessation program with a 31-year-old man with mild intellectual disabilities who had been a smoker for 17 years. The mindfulness-based smoking cessation program consisted of three components: intention, mindful observation of thoughts, and Meditation on the Soles of the Feet. A changing-criterion analysis showed that this man was able to fade his cigarette smoking from 12 at baseline to 0 within 3 months, and maintain this for a year. Follow-up data, collected every 3 months following the maintenance period, showed he was able to abstain from smoking for 3 years. Our study suggests that this mindfulness-based smoking cessation program merits further investigation.

Guidelines for the use of clozapine in individuals with developmental disabilities.

Clozapine is the most effective antipsychotic medication currently in use, but there has been a paucity of well-controlled research on its efficacy with people with developmental disabilities. We present a set of guidelines to ensure proper utilization of clozapine in individuals with developmental disabilities, because it can offer them therapeutic advantages similar to those observed in people with schizophrenia. We provide recommendations regarding the use of clozapine that are based on three main sources: literature and published professional practice guidelines regarding the use of clozapine in individuals who do not have developmental disabilities, the limited literature on the use of clozapine in individuals who have developmental disabilities, and our own clinical experience. The first part of the guidelines contains an overview of necessary practical knowledge regarding side effects, dose and blood level considerations, and interactions with other medications, diet and tobacco smoking. In the second part, we offer procedures for selecting individuals for clozapine therapy based on proper indications and contraindications for treatment. We also include requirements regarding informed consent, dosage and special laboratory and clinical monitoring.