Patient Experiences of Self-Management for Chronic Low Back Pain: A Qualitative Study.

OBJECTIVE: Chronic low back pain (CLBP) is a lifelong condition causing disability and distress. One aim of treatment is to enhance self-management. To date, self-management interventions have had limited effectiveness. A greater understanding of self-management for CLBP has the potential to improve future interventional trials. The purpose of this study was to identify the experience of CLBP self-management for patients attending outpatient physical therapy and assess how the experience of CLBP self-management changes over time. METHODS: This qualitative study used constructivist grounded theory. Patients with CLBP who were attending an outpatient physical therapy department were recruited using convenience sampling. Each participant attended a semistructured interview. These were audio recorded and transcribed verbatim. The data were coded and thematically analyzed by the lead researcher. Recruitment continued until data saturation. Participants reviewed preliminary themes for validation. RESULTS: Six subthemes emerged from 9 interviews: (1) self-doubt, (2) coping day to day, (3) independent discovery, (4) developing resilience, (5) health care: opportunity and threat, and (6) living with pain differently. Two themes took on greatest significance. Self-doubt appeared most strongly and was prevalent in all experiences. However, living with pain differently appeared in those who had developed a level of pain acceptance. These themes formed a conceptual model, "Fluctuating Uncertainty." CONCLUSION: The experience of CLBP self-management is one of fluctuating self-doubt. Self-doubt is the predominant experience and is characterized by the perception of pain as a threat and low pain self-efficacy. During times of greater clarity, individuals develop strategies that increase pain self-efficacy and reinforce the perception of pain without threat. These are features of learning to live well with pain. IMPACT: CLBP is a lifelong condition requiring self-management. The current study characterizes the self-management strategies used by patients attending physical therapy. The fluctuating nature of these strategies is dependent upon perception of pain and pain self-efficacy. LAY SUMMARY: People with CLBP who self-manage their pain fluctuate between attempting to control pain and learning to live with pain. People who understand their condition develop wider-ranging self-management strategies.

The concept of HRQoL for patients on hemodialysis in Saudi Arabia: an exploratory study.

BACKGROUND: The concept of health-related quality of life (HRQoL), a patient-reported outcome measure, is poorly defined within the Saudi literature. There is a lack of culturally adapted measures to assess the HRQoL of patients on hemodialysis in Saudi Arabia. Hence, this study aims to explore and define the concept of HRQoL, identify its key domains and develop a conceptual model as perceived by patients with renal failure who are undergoing hemodialysis in Saudi Arabia. METHODS: Qualitative research methods was used; data were collected in one dialysis center in the Eastern Region of Saudi Arabia. Twenty-two semi structured qualitative interviews were conducted using a topic guide. The data were analyzed using thematic analysis methods as the transcripts were coded, the categories identified, and the themes generated. RESULTS: Seven definitions of the HRQoL concept emerged from data analysis in terms of health status and psychological wellbeing including the satisfaction with life, socialization and the ability to play the expected social role and having social relationships that are supportive, religiosity and the belief in God and being able to perform religious worships and finally needs satisfaction was used to define HRQoL which included financial needs and the quality of healthcare services. All these themes were utilized to develop one common definition that emphasized the personal satisfaction with health, social, psychological and financial needs in addition to religious performance and the quality of healthcare services provided. The conceptual model was developed using five key domains of HRQoL: physiological, social, psychological, religious and vocational domains that were defined by certain indicators and the relationships between the domains were clarified in the model. CONCLUSION: The findings of this study could guide the selection of the appropriate HRQoL instrument to assess the HRQoL of patients on hemodialysis in Saudi Arabia, which would ensure the validity of the findings that could be used in healthcare decisions and planning of care.

The legal, governance and ethical implications of involving service users and carers in research.

PURPOSE: Service user and carer involvement in all aspects of the health and care research process, from co-applicant on funding applications to active engagement in a research study, is now a requirement for most research funders. However, as co-production increases and service users and carers take on more responsibilities, this involvement has legal, governance and ethical implications. The purpose of this paper is to raise awareness of the issues and consider potential solutions. DESIGN/METHODOLOGY/APPROACH: Experiences of engagement as co-applicants in research funding applications, of involvement as research study team members, and as co-researchers were gathered from a range of service user and carer experts. Consultation and a workshop gathered further evidence from a range of stakeholders across the research management community. FINDINGS: Service users and carers, who contribute to the research protocol and process, feel a strong sense of responsibility to ensure the high quality of a research study. However, they may be new to their roles, status and key responsibilities when acting as project team members, co-researchers or co-applicants engaging in funding applications. The responsibility of sponsors, grant holding organisations, funders and other members of the research community is to communicate with and support service users and carers in those roles. More needs to be done to understand the contractual, a legal and governance issues and responsibilities that are specific to service user and carer co-applicants, project team members and co-researchers, from both an organisational and individual service user and carer perspective. PRACTICAL IMPLICATIONS: The implications of the findings are to raise awareness of the practical, legal and ethical issues arising from this type of involvement and the potential risks arising from lack of cohesion or understanding. The review also highlights the concerns and barriers service users and carers may find in becoming involved. ORIGINALITY/VALUE: The findings highlight a range of issues for research regulators, sponsors and investigators to consider to ensure service users and carers can fulfil their responsibilities and be supported in doing so.

Patient and public involvement in reducing health and care research waste.

PLAIN ENGLISH SUMMARY: As much as 85 % of health research is believed to be wasted because it is not published or reported, the design is poor or does not consider what is already known in the topic area. Although a great deal of work has been done in the UK to reduce research waste, the role of patients and the public has not been discussed.This paper describes a survey, on the role of patients in reducing research waste, which was carried out as part of a larger piece of work on reducing waste in healthcare. The study found that patients were interested in reducing research waste. The key roles they play in research, for example being co-applicants for funding, members of project teams, co-researchers, means they have some shared responsibility for making sure the quality of research is high. This includes finding out what is already known about a topic and getting the study design right before seeking funding, publishing and reporting the results when the study is finished. Recognising where waste happens is part of good management of a research study. ABSTRACT: Background Eighty five per cent of health research expenditure is potentially wasted due to failure to publish research, unclear reporting of research that is published, and the failure of new research studies to systematically review previous research in the same topic area, poor study design and conduct. A great deal of progress has been made to address this issue but the role of patients and the public has not been considered.Main A small survey was undertaken, as part of a larger programme of work on reducing health and care waste, to understand the role of patients in reducing research waste. The study showed that patients are interested in this issue particularly in relation to the prioritisation of research and patient and public involvement.Conclusions Patients undertake key roles in the research process including co-applicancy, project management, or as co-researchers. This brings responsibility for ensuring high quality research and value for money. Responsibility for recognition of the potential for wasteful practices is part of the conduct and operation of research studies.

The PETRA (Perinatal Emergency Team Response Assessment) Scale: A High-Fidelity Simulation Validation Study.

OBJECTIVE: The objective of this study was to establish the validity and reliability of a new interdisciplinary teamwork assessment scale, the Perinatal Emergency Team Response Assessment (PETRA), to assess team dynamics during a simulated obstetric crisis. METHODS: This observational cohort study was conducted using high-fidelity simulation and multidisciplinary obstetric teams in order to evaluate the validity and reliability of the previously developed PETRA scale for the assessment of teamwork in the management of obstetric crises. Two high-fidelity simulations of preeclampsia and postpartum hemorrhage (PPH) were conducted 50 times; 42 were performed by multidisciplinary teams and eight (four "good," four "poor") were performed by actors. Five raters used the PETRA tool to assess the simulation video recordings. Three additional raters assessed each performance without the use of PETRA as "good" or "poor" in order to provide an overall rating (referred to as the standardized score). The primary outcome measure was the PETRA score. Cronbach's alpha and intra-class correlation coefficients (2,1) with 95% CIs were calculated to examine internal consistency of the scale and level of agreement among raters, respectively. Construct validity was established by comparing the assessments of the raters with the standardized scores. Generalizability theory analysis was performed to demonstrate PETRA's reliability and to investigate the sources of variation in scores. RESULTS: The simulated emergencies were performed by 119 participants. There was overall high consistency (Cronbach's alpha [95% CI] 0.984 [0.981 to 0.987]) and moderate agreement (intra-class correlation coefficients [95% CI] 0.49 [0.35 to 0.63]) among raters. Significantly higher PETRA scores (mean [standard deviation]) were recorded with "good" versus "poor" performing teams (real scenarios 3.8 [0.7] vs. 2.9 [0.7]; P < 0.001; acted scenarios 4.7 [0.5] vs. 2.2 [0.7]; P < 0.001), suggesting strong construct validity. The overall PETRA scores were not different between the PPH (3.7 [0.7]) and preeclampsia (3.7 [0.8]) scenarios (P = 0.49). Generalizability coefficients were 0.83 for PPH and 0.76 for preeclampsia. CONCLUSION: PETRA is a valid and reliable scale that may be a valuable tool in the assessment and training of multidisciplinary teams in their management of obstetric crises.

Multidisciplinary Delphi Development of a Scale to Evaluate Team Function in Obstetric Emergencies: The PETRA Scale.

OBJECTIVE: The objective of this study was to develop a new interdisciplinary teamwork scale, the Perinatal Emergency: Team Response Assessment (PETRA), for the management of obstetric crises, through consensus agreement of obstetric caregivers. METHODS: This prospective study was performed using expert consensus, based on a Delphi method. The study investigators developed a new PETRA tool, specifically related to obstetric crisis management, based on the existing literature and discussions among themselves. The scale was distributed to a selected panel of experts in the field for the Delphi process. After each round of Delphi, every component of the scale was analyzed quantitatively by the percentage of agreement ratings and each comment reviewed by the blinded investigators. The assessment scale was then modified, with components of less than 80% agreement removed from the scale. The process was repeated on three occasions to reach a consensus and final PETRA scale. RESULTS: Fourteen of 24 invited experts participated in the Delphi process. The original PETRA scale included six categories and 48 items, one global scale item, and a 3-point rubric for rating. The overall percentage agreement by experts in the first, second, and third rounds was 95.0%, 93.2%, and 98.5%, respectively. The final scale after the third round of Delphi consisted of the following seven categories: shared mental model, communication, situational awareness, leadership, followership, workload management, and positive/effective behaviours and attitudes. There were 34 individual items within these categories, each with a 5-point rating rubric (1 = unacceptable to 5 = perfect). CONCLUSION: Using a structured Delphi method, we established the face and content validity of this assessment scale that focuses on important aspects of interdisciplinary teamwork in the management of obstetric crises.

Molecular Characterization Reveals Diverse and Unknown Malaria Vectors in the Western Kenyan Highlands.

The success of mosquito-based malaria control is dependent upon susceptible bionomic traits in local malaria vectors. It is crucial to have accurate and reliable methods to determine mosquito species composition in areas subject to malaria. An unexpectedly diverse set of Anopheles species was collected in the western Kenyan highlands, including unidentified and potentially new species carrying the malaria parasite Plasmodium falciparum. This study identified 2,340 anopheline specimens using both ribosomal DNA internal transcribed spacer region 2 and mitochondrial DNA cytochrome oxidase subunit 1 loci. Seventeen distinct sequence groups were identified. Of these, only eight could be molecularly identified through comparison to published and voucher sequences. Of the unidentified species, four were found to carry P. falciparum by circumsporozoite enzyme-linked immunosorbent assay and polymerase chain reaction, the most abundant of which had infection rates comparable to a primary vector in the area, Anopheles funestus. High-quality adult specimens of these unidentified species could not be matched to museum voucher specimens or conclusively identified using multiple keys, suggesting that they may have not been previously described. These unidentified vectors were captured outdoors. Diverse and unknown species have been incriminated in malaria transmission in the western Kenya highlands using molecular identification of unusual morphological variants of field specimens. This study demonstrates the value of using molecular methods to compliment vector identifications and highlights the need for accurate characterization of mosquito species and their associated behaviors for effective malaria control.

'A bite before bed': exposure to malaria vectors outside the times of net use in the highlands of western Kenya.

BACKGROUND: The human population in the highlands of Nyanza Province, western Kenya, is subject to sporadic epidemics of Plasmodium falciparum. Indoor residual spraying (IRS) and long-lasting insecticide treated nets (LLINs) are used widely in this area. These interventions are most effective when Anopheles rest and feed indoors and when biting occurs at times when individuals use LLINs. It is therefore important to test the current assumption of vector feeding preferences, and late night feeding times, in order to estimate the extent to which LLINs protect the inhabitants from vector bites. METHODS: Mosquito collections were made for six consecutive nights each month between June 2011 and May 2012. CDC light-traps were set next to occupied LLINs inside and outside randomly selected houses and emptied hourly. The net usage of residents, their hours of house entry and exit and times of sleeping were recorded and the individual hourly exposure to vectors indoors and outdoors was calculated. Using these data, the true protective efficacy of nets (P*), for this population was estimated, and compared between genders, age groups and from month to month. RESULTS: Primary vector species (Anopheles funestus s.l. and Anopheles arabiensis) were more likely to feed indoors but the secondary vector Anopheles coustani demonstrated exophagic behaviour (p < 0.05). A rise in vector biting activity was recorded at 19:30 outdoors and 18:30 indoors. Individuals using LLINs experienced a moderate reduction in their overall exposure to malaria vectors from 1.3 to 0.47 bites per night. The P* for the population over the study period was calculated as 51% and varied significantly with age and season (p < 0.01). CONCLUSIONS: In the present study, LLINs offered the local population partial protection against malaria vector bites. It is likely that P* would be estimated to be greater if the overall suppression of the local vector population due to widespread community net use could be taken into account. However, the overlap of early biting habit of vectors and human activity in this region indicates that additional methods of vector control are required to limit transmission. Regular surveillance of both vector behaviour and domestic human-behaviour patterns would assist the planning of future control interventions in this region.

Systematic review, meta-analysis and economic modelling of molecular diagnostic tests for antibiotic resistance in tuberculosis.

BACKGROUND: Drug-resistant tuberculosis (TB), especially multidrug-resistant (MDR, resistance to rifampicin and isoniazid) disease, is associated with a worse patient outcome. Drug resistance diagnosed using microbiological culture takes days to weeks, as TB bacteria grow slowly. Rapid molecular tests for drug resistance detection (1 day) are commercially available and may promote faster initiation of appropriate treatment. OBJECTIVES: To (1) conduct a systematic review of evidence regarding diagnostic accuracy of molecular genetic tests for drug resistance, (2) conduct a health-economic evaluation of screening and diagnostic strategies, including comparison of alternative models of service provision and assessment of the value of targeting rapid testing at high-risk subgroups, and (3) construct a transmission-dynamic mathematical model that translates the estimates of diagnostic accuracy into estimates of clinical impact. REVIEW METHODS AND DATA SOURCES: A standardised search strategy identified relevant studies from EMBASE, PubMed, MEDLINE, Bioscience Information Service (BIOSIS), System for Information on Grey Literature in Europe Social Policy & Practice (SIGLE) and Web of Science, published between 1 January 2000 and 15 August 2013. Additional 'grey' sources were included. Quality was assessed using quality assessment of diagnostic accuracy studies version 2 (QUADAS-2). For each diagnostic strategy and population subgroup, a care pathway was constructed to specify which medical treatments and health services that individuals would receive from presentation to the point where they either did or did not complete TB treatment successfully. A total cost was estimated from a health service perspective for each care pathway, and the health impact was estimated in terms of the mean discounted quality-adjusted life-years (QALYs) lost as a result of disease and treatment. Costs and QALYs were both discounted at 3.5% per year. An integrated transmission-dynamic and economic model was used to evaluate the cost-effectiveness of introducing rapid molecular testing (in addition to culture and drug sensitivity testing). Probabilistic sensitivity analysis was performed to evaluate the impact on cost-effectiveness of diagnostic and treatment time delays, diagnosis and treatment costs, and associated QALYs. RESULTS: A total of 8922 titles and abstracts were identified, with 557 papers being potentially eligible. Of these, 56 studies contained sufficient test information for analysis. All three commercial tests performed well when detecting drug resistance in clinical samples, although with evidence of heterogeneity between studies. Pooled sensitivity for GenoType® MTBDRplus (Hain Lifescience, Nehren, Germany) (isoniazid and rifampicin resistance), INNO-LiPA Rif.TB® (Fujirebio Europe, Ghent, Belgium) (rifampicin resistance) and Xpert® MTB/RIF (Cepheid Inc., Sunnyvale, CA, USA) (rifampicin resistance) was 83.4%, 94.6%, 95.4% and 96.8%, respectively; equivalent pooled specificity was 99.6%, 98.2%, 99.7% and 98.4%, respectively. Results of the transmission model suggest that all of the rapid assays considered here, if added to the current diagnostic pathway, would be cost-saving and achieve a reduction in expected QALY loss compared with current practice. GenoType MTBDRplus appeared to be the most cost-effective of the rapid tests in the South Asian population, although results were similar for GeneXpert. In all other scenarios GeneXpert appeared to be the most cost-effective strategy. CONCLUSIONS: Rapid molecular tests for rifampicin and isoniazid resistance were sensitive and specific. They may also be cost-effective when added to culture drug susceptibility testing in the UK. There is global interest in point-of-care testing and further work is needed to review the performance of emerging tests and the wider health-economic impact of decentralised testing in clinics and primary care, as well as non-health-care settings, such as shelters and prisons. STUDY REGISTRATION: This study is registered as PROSPERO CRD42011001537. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Electroconvulsive therapy during pregnancy: a systematic review of case studies.

This study aims to explore practice, use, and risk of electroconvulsive therapy (ECT) in pregnancy. A systematic search was undertaken in the databases Medline, Embase, PsycINFO, SveMed and CINAHL (EBSCO). Only primary data-based studies reporting ECT undertaken during pregnancy were included. Two reviewers independently checked study titles and abstracts according to inclusion criteria and extracted detailed use, practice, and adverse effects data from full text retrieved articles. Studies and extracted data were sorted according to before and after year 1970, due to changes in ECT administration over time. A total of 67 case reports were included and studies from all continents represented. Altogether, 169 pregnant women were identified, treated during pregnancy with a mean number of 9.4 ECTs, at mean age of 29 years. Most women received ECT during the 2nd trimester and many were Para I. Main diagnostic indication in years 1970 to 2013 was Depression/Bipolar disorder (including psychotic depression). Missing data on fetus/child was 12 %. ECT parameter report was often sparse. Both bilateral and unilateral electrode placement was used and thiopental was the main anesthetic agent. Adverse events such as fetal heart rate reduction, uterine contractions, and premature labor (born between 29 and 37 gestation weeks) were reported for nearly one third (29 %). The overall child mortality rate was 7.1 %. Lethal outcomes for the fetus and/or baby had diverse associations. ECT during pregnancy is advised considered only as last resort treatment under very stringent diagnostic and clinical indications. Updated international guidelines are urgently needed.

Funding infectious disease research: a systematic analysis of UK research investments by funders 1997-2010.

BACKGROUND: Research investments are essential to address the burden of disease, however allocation of limited resources is poorly documented. We systematically reviewed the investments awarded by funding organisations to UK institutions and their global partners for infectious disease research. METHODOLOGY/PRINCIPAL FINDINGS: Public and philanthropic investments for the period 1997 to 2010 were included. We categorised studies by infectious disease, cross-cutting theme, and by research and development value chain, reflecting the type of science. We identified 6165 funded studies, with a total research investment of UK £2.6 billion. Public organisations provided £1.4 billion (54.0%) of investments compared with £1.1 billion (42.4%) by philanthropic organisations. Global health studies represented an investment of £928 million (35.7%). The Wellcome Trust was the leading investor with £688 million (26.5%), closely followed by the UK Medical Research Council (MRC) with £673 million (25.9%). Funding over time was volatile, ranging from ∼£40 million to ∼£160 million per year for philanthropic organisations and ∼£30 million to ∼£230 million for public funders. CONCLUSIONS/SIGNIFICANCE: Infectious disease research funding requires global coordination and strategic long-term vision. Our analysis demonstrates the diversity and inconsistent patterns in investment, with volatility in annual funding amounts and limited investment for product development and clinical trials.

Investments in respiratory infectious disease research 1997-2010: a systematic analysis of UK funding.

OBJECTIVES: Respiratory infections are responsible for a large global burden of disease. We assessed the public and philanthropic investments awarded to UK institutions for respiratory infectious disease research to identify areas of underinvestment. We aimed to identify projects and categorise them by pathogen, disease and position along the research and development value chain. SETTING: The UK. PARTICIPANTS: Institutions that host and carry out infectious disease research. PRIMARY AND SECONDARY OUTCOME MEASURES: The total amount spent and number of studies with a focus on several different respiratory pathogens or diseases, and to correlate these against the global burden of disease; also the total amount spent and number of studies relating to the type of science, the predominant funder in each category and the mean and median award size. RESULTS: We identified 6165 infectious disease studies with a total investment of £2·6 billion. Respiratory research received £419 million (16.1%) across 1192 (19.3%) studies. The Wellcome Trust provided greatest investment (£135.2 million; 32.3%). Tuberculosis received £155 million (37.1%), influenza £80 million (19.1%) and pneumonia £27.8 million (6.6%). Despite high burden, there was relatively little investment in vaccine-preventable diseases including diphtheria (£0.1 million, 0.03%), measles (£5.0 million, 1.2%) and drug-resistant tuberculosis. There were 802 preclinical studies (67.3%) receiving £273 million (65.2%), while implementation research received £81 million (19.3%) across 274 studies (23%). There were comparatively few phase I-IV trials or product development studies. Global health research received £68.3 million (16.3%). Relative investment was strongly correlated with 2010 disease burden. CONCLUSIONS: The UK predominantly funds preclinical science. Tuberculosis is the most studied respiratory disease. The high global burden of pneumonia-related disease warrants greater investment than it has historically received. Other priority areas include antimicrobial resistance (particularly within tuberculosis), economics and proactive investments for emerging infectious threats.

Comparing patient and professional views of expected treatment outcomes for chronic obstructive pulmonary disease: a Delphi study identifies possibilities for change in service delivery in England, UK.

AIMS AND OBJECTIVES: To clarify by consensus the professional and patient views of expected treatment outcomes for chronic obstructive pulmonary disease and to compare the similarities and differences and identify the potential for adjusting service delivery. BACKGROUND: Chronic obstructive pulmonary disease is an under-researched topic necessary to illuminate health planning, and patient partnership needs in the UK clinical screening is low priority for this condition. Government policy expects that service users are involved in planning services for their condition, but few opportunities exist for this process. DESIGN: A feasibility study in two phases conducted three service user focus groups and one specialist professional group to provide statements of expected treatment outcomes from chronic obstructive pulmonary disease interventions. The statements then formed a further two-round Delphi structured survey to compare service users' and carers' views with those of specialist professionals to ascertain what differences could be developed in service delivery for people with chronic obstructive pulmonary disease. METHODS: Three rounds of Delphi survey were administered. Round 1: Specialist professionals and patients with chronic obstructive pulmonary disease ranked statements using nominal group technique. A nine-point scale Delphi consensus study used the statements in two further rounds. RESULTS: Twenty-four of 54 professionals contacted, and 52 of 152 patients and carers completed Delphi rounds 2 and 3. Consensus was found within and between both groups. The greatest difference was where professionals sought government targets and did not realise patient expectations, which were constrained by policy disincentives. The greatest agreement was for accurate record keeping and the need for revised chronic obstructive pulmonary disease services. CONCLUSIONS: Patients consider that services should support them to retain their independence and enable their adaptation to the condition. RELEVANCE TO CLINICAL PRACTICE: Health professionals aim to provide patient focused care based on need. This helps improve outcomes of interventions. Patients are willing and able if supported to increase independence and maintain self-help.

Systematic analysis of funding awarded for antimicrobial resistance research to institutions in the UK, 1997-2010.

OBJECTIVES: To assess the level of research funding awarded to UK institutions specifically for antimicrobial resistance-related research and how closely the topics funded relate to the clinical and public health burden of resistance. METHODS: Databases and web sites were systematically searched for information on how infectious disease research studies were funded for the period 1997-2010. Studies specifically related to antimicrobial resistance, including bacteriology, virology, mycology and parasitology research, were identified and categorized in terms of funding by pathogen and disease and by a research and development value chain describing the type of science. RESULTS: The overall dataset included 6165 studies receiving a total investment of £2.6 billion, of which £102 million was directed towards antimicrobial resistance research (5.5% of total studies, 3.9% of total spend). Of 337 resistance-related projects, 175 studies focused on bacteriology (40.2% of total resistance-related spending), 42 focused on antiviral resistance (17.2% of funding) and 51 focused on parasitology (27.4% of funding). Mean annual funding ranged from £1.9 million in 1997 to £22.1 million in 2009. CONCLUSIONS: Despite the fact that the emergence of antimicrobial resistance threatens our future ability to treat many infections, the proportion of the UK infection-research spend targeting this important area is small. There are encouraging signs of increased investment in this area, but it is important that this is sustained and targeted at areas of projected greatest burden. Two areas of particular concern requiring more investment are tuberculosis and multidrug-resistant Gram-negative bacteria.

Differences in research funding for women scientists: a systematic comparison of UK investments in global infectious disease research during 1997-2010.

OBJECTIVES: There has not previously been a systematic comparison of awards for research funding in infectious diseases by sex. We investigated funding awards to UK institutions for all infectious disease research from 1997 to 2010, across disease categories and along the research and development continuum. DESIGN: Systematic comparison. METHODS: Data were obtained from several sources for awards from the period 1997 to 2010 and each study assigned to-disease categories; type of science (preclinical, phases I-III trials, product development, implementation research); categories of funding organisation. Fold differences and statistical analysis were used to compare total investment, study numbers, mean grant and median grant between men and women. RESULTS: 6052 studies were included in the final analysis, comprising 4357 grants (72%) awarded to men and 1695 grants (28%) awarded to women, totalling £2.274 billion. Of this, men received £1.786 billion (78.5%) and women £488 million (21.5%). The median value of award was greater for men (£179 389; IQR £59 146-£371 977) than women (£125 556; IQR £30 982-£261 834). Awards were greater for male principal investigators (PIs) across all infectious disease systems, excepting neurological infections and sexually transmitted infections. The proportion of total funding awarded to women ranged from 14.3% in 1998 to 26.8% in 2009 (mean 21.4%), and was lowest for preclinical research at 18.2% (£285.5 million of £1.573 billion) and highest for operational research at 30.9% (£151.4 million of £489.7 million). CONCLUSIONS: There are consistent differences in funding received by men and women PIs: women have fewer funded studies and receive less funding in absolute and in relative terms; the median funding awarded to women is lower across most infectious disease areas, by funder, and type of science. These differences remain broadly unchanged over the 14-year study period.

UK investments in global infectious disease research 1997-2010: a case study.

BACKGROUND: Infectious diseases account for 15 million deaths per year worldwide, and disproportionately affect young people, elderly people, and the poorest sections of society. We aimed to describe the investments awarded to UK institutions for infectious disease research. METHODS: We systematically searched databases and websites for information on research studies from funding institutions and created a comprehensive database of infectious disease research projects for the period 1997-2010. We categorised studies and funding by disease, cross-cutting theme, and by a research and development value chain describing the type of science. Regression analyses were reported with Spearman's rank correlation coefficient to establish the relation between research investment, mortality, and disease burden as measured by disability-adjusted life years (DALYs). FINDINGS: We identified 6170 funded studies, with a total research investment of UK£2·6 billion. Studies with a clear global health component represented 35·6% of all funding (£927 million). By disease, HIV received £461 million (17·7%), malaria £346 million (13·3%), tuberculosis £149 million (5·7%), influenza £80 million (3·1%), and hepatitis C £60 million (2·3%). We compared funding with disease burden (DALYs and mortality) to show low levels of investment relative to burden for gastrointestinal infections (£254 million, 9·7%), some neglected tropical diseases (£184 million, 7·1%), and antimicrobial resistance (£96 million, 3·7%). Virology was the highest funded category (£1 billion, 38·4%). Leading funding sources were the Wellcome Trust (£688 million, 26·4%) and the Medical Research Council (£673 million, 25·8%). INTERPRETATION: Research funding has to be aligned with prevailing and projected global infectious disease burden. Funding agencies and industry need to openly document their research investments to redress any inequities in resource allocation. FUNDING: None.

Simulation of malaria epidemiology and control in the highlands of Western Kenya.

BACKGROUND: Models of Plasmodium falciparum malaria epidemiology that provide realistic quantitative predictions of likely epidemiological outcomes of existing vector control strategies have the potential to assist in planning for the control and elimination of malaria. This work investigates the applicability of mathematical modelling of malaria transmission dynamics in Rachuonyo South, a district with low, unstable transmission in the highlands of western Kenya. METHODS: Individual-based stochastic simulation models of malaria in humans and a deterministic model of malaria in mosquitoes as part of the OpenMalaria platform were parameterized to create a scenario for the study area based on data from ongoing field studies and available literature. The scenario was simulated for a period of two years with a population of 10,000 individuals and validated against malaria survey data from Rachuonyo South. Simulations were repeated with multiple random seeds and an ensemble of 14 model variants to address stochasticity and model uncertainty. A one-dimensional sensitivity analysis was conducted to address parameter uncertainty. RESULTS: The scenario was able to reproduce the seasonal pattern of the entomological inoculation rate (EIR) and patent infections observed in an all-age cohort of individuals sampled monthly for one year. Using an EIR estimated from serology to parameterize the scenario resulted in a closer fit to parasite prevalence than an EIR estimated using entomological methods. The scenario parameterization was most sensitive to changes in the timing and effectiveness of indoor residual spraying (IRS) and the method used to detect P. falciparum in humans. It was less sensitive than expected to changes in vector biting behaviour and climatic patterns. CONCLUSIONS: The OpenMalaria model of P. falciparum transmission can be used to simulate the impact of different combinations of current and potential control interventions to help plan malaria control in this low transmission setting. In this setting and for these scenarios, results were highly sensitive to transmission, vector exophagy, exophily and susceptibility to IRS, and the detection method used for surveillance. The level of accuracy of the results will thus depend upon the precision of estimates for each. New methods for analysing and evaluating uncertainty in simulation results will enhance the usefulness of simulations for malaria control decision-making. Improved measurement tools and increased primary data collection will enhance model parameterization and epidemiological monitoring. Further research is needed on the relationship between malaria indices to identify the best way to quantify transmission in low transmission settings. Measuring EIR through mosquito collection may not be the optimal way to estimate transmission intensity in areas with low, unstable transmission.