Safety and feasibility of apheresis to harvest and concentrate parasites from subjects with induced blood stage Plasmodium vivax infection.

BACKGROUND: In the absence of a method to culture Plasmodium vivax, the only way to source parasites is ex vivo. This hampers many aspects of P. vivax research. This study aimed to assess the safety of apheresis, a method for selective removal of specific components of blood as a means of extracting and concentrating P. vivax parasites. METHODS: An iterative approach was employed across four non-immune healthy human subjects in single subject cohorts. All four subjects were inoculated with ~ 564 blood stage P. vivax (HMP013-Pv) and subjected to apheresis 10 to 11 days later. Blood samples collected during apheresis (haematocrit layers 0.5% to 11%) were tested for the presence and concentration of P. vivax by microscopy, flow cytometry, 18S rDNA qPCR for total parasites, and pvs25 qRT-PCR for female gametocyte transcripts. Safety was determined by monitoring adverse events. Malaria transmission to mosquitoes was assessed by membrane feeding assays. RESULTS: There were no serious adverse events and no significant safety concerns. Apheresis concentrated asexual parasites by up to 4.9-fold (range: 0.9-4.9-fold) and gametocytes by up to 1.45-fold (range: 0.38-1.45-fold) compared to pre-apheresis densities. No single haematocrit layer contained > 40% of all the recovered P. vivax asexual parasites. Ex vivo concentration of parasites by Percoll gradient centrifugation of whole blood achieved greater concentration of gametocytes than apheresis. Mosquito transmission was enhanced by up to fivefold in a single apheresis sample compared to pre-apheresis. CONCLUSION: The modest level of parasite concentration suggests that the use of apheresis may not be an ideal method for harvesting P. vivax. Trial Registration Australia New Zealand Clinical Trials Registry (ANZCTR) Trial ID: ACTRN12617001502325 registered on 19th October 2017. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373812.

Characterizing the disability experience among adults living with HIV: a structural equation model using the HIV disability questionnaire (HDQ) within the HIV, health and rehabilitation survey.

BACKGROUND: People aging with HIV can experience a variety of health challenges associated with HIV and multimorbidity, referred to as 'disability'. Our aim was to characterize the disability experience and examine relationships between dimensions of disability among adults living with HIV. METHODS: We performed a structural equation modeling analysis with data from the Canadian web-based HIV, Health and Rehabilitation Survey. We measured disability using the HIV Disability Questionnaire (HDQ), a patient-reported outcome (69 items) that measures presence, severity and episodic features of disability across six domains: 1) physical symptoms, 2) cognitive symptoms, 3) mental-emotional health symptoms, 4) difficulties carrying out day-to-day activities, 5) uncertainty and worrying about the future, and 6) challenges to social inclusion. We used HDQ severity domain scores to represent disability dimensions and developed a structural model to assess relationships between disability dimensions using path analysis. We determined overall model fit with a Root Mean Square Error of Approximation (RMSEA) of < 0.05. We classified path coefficients of ≥ 0.2-0.5 as a medium (moderate) effect and > 0.5 a large (strong) effect. We used Mplus software for the analysis. RESULTS: Of the 941 respondents, most (79%) were men, taking combination antiretroviral medications (90%) and living with two or more simultaneous health conditions (72%). Highest HDQ presence and severity scores were in the uncertainty domain. The measurement model had good overall fit (RMSEA= 0.04). Results from the structural model identified physical symptoms as a strong direct predictor of having difficulties carrying out day-to-day activities (standardized path coefficient: 0.54; p < 0.001) and moderate predictor of having mental-emotional health symptoms (0.24; p < 0.001) and uncertainty (0.36; p < 0.001). Uncertainty was a strong direct predictor of having mental-emotional health symptoms (0.53; p < 0.001) and moderate direct predictor of having challenges to social inclusion (0.38; p < 0.001). The relationship from physical and cognitive symptoms to challenges to social inclusion was mediated by uncertainty, mental-emotional health symptoms, and difficulties carrying out day-to-day activities (total indirect effect from physical: 0.22; from cognitive: 0.18; p < 0.001). CONCLUSIONS: Uncertainty is a principal dimension of disability experienced by adults with HIV. Findings provide a foundation for clinicians and researchers to conceptualize disability and identifying areas to target interventions.

Considerations for conducting Web-based survey research with people living with human immunodeficiency virus using a community-based participatory approach.

BACKGROUND: Web or Internet-based surveys are increasingly popular in health survey research. However, the strengths and challenges of Web-based surveys with people living with human immunodeficiency virus (HIV) are unclear. OBJECTIVE: The aim of this article is to describe our experience piloting a cross-sectional, Web-based, self-administered survey with adults living with HIV using a community-based participatory research approach. METHODS: We piloted a Web-based survey that investigated disability and rehabilitation services use with a sample of adults living with HIV in Canada. Community organizations in five provinces emailed invitations to clients, followed by a thank you/reminder one week later. We obtained survey feedback in a structured phone interview with respondents. Participant responses were transcribed verbatim and analyzed using directed content analysis. RESULTS: Of 30 people living with HIV who accessed the survey link, 24/30 (80%) initiated and 16/30 (53%) completed the survey instrument. A total of 17 respondents participated in post-survey interviews. Participants described the survey instrument as comprehensive, suggesting content validity. The majority (13/17, 76%) felt instruction and item wording were clear and easy to understand, and found the software easy to navigate. Participants felt having a pop-up reminder directing them to missed items would be useful. CONCLUSIONS: Strengths of implementing the Web-based survey included: our community-based participatory approach, ease of software use, ability for respondents to complete the questionnaire on one's own time at one's own pace, opportunity to obtain geographic variation, and potential for respondent anonymity. Considerations for future survey implementation included: respondent burden and fatigue, the potentially sensitive nature of HIV Web-based research, data management and storage, challenges verifying informed consent, varying computer skills among respondents, and the burden on community organizations. Overall, results provide considerations for researchers conducting community-based participatory Web-based survey research with people living with HIV.

Improving Functional Communication Outcomes in Post-Stroke Aphasia via Telepractice: An Alternative Service Delivery Model for Underserved Populations.

Many persons with aphasia (PWA) have limited access to speech-language treatment (SLT) due to limited funding, speech-language pathologist shortages, geographical barriers, physical disabilities, transportation barriers, and the COVID-19 pandemic. The purpose of this study was to determine if telepractice is an effective and feasible service delivery model for PWA. Ten PWA completed 8 hours of remote treatment over 4 weeks. Synchronous telepractice sessions employed Oral Reading for Language in Aphasia (ORLA) and Conversational Script Training (CST). Pre- and post-assessment outcome measures included the Communication Activities of Daily Living-3 (CADL-3) and the Communication Confidence Rating Scale for Aphasia (CCRSA). Participants completed a telepractice satisfaction survey following post-assessment. All participants demonstrated improvements in CCRSA scores, total words produced correctly on trained CST stimuli, and total words produced correctly on trained ORLA stimuli. No differences were noted in CADL-3 scores. All participants were highly satisfied with telepractice as a service delivery model.

On the Annotation of Health Care Pathways to Allow the Application of Care-Plans That Generate Data for Multiple Purposes.

Objectives: Procedural interoperability in health care requires information support and monitoring of a common work practice. Our aim was to devise an information model for a complete annotation of actions in clinical pathways that allow use of multiple plans concomitantly as several partial processes underlie any composite clinical process. Materials and Methods: The development of the information model was based on the integration of a defined protocol for clinical interoperability in the care of patients with chronic obstructive pulmonary disease and an observational study protocol for cohort characterization at the group level. In the clinical process patient reported outcome measures were included. Results: The clinical protocol and the observation study protocol were developed on the clinical level and a single plan definition was developed by merging of the protocols. The information model and a common data model that had been developed for care pathways was successfully implemented and data for the medical records and the observational study could be extracted independently. The interprofessional process support improved the communication between the stakeholders (health care professionals, clinical scientists and providers). Discussion: We successfully merged the processes and had a functionally successful pilot demonstrating a seamless appearance for the health care professionals, while at the same time it was possible to generate data that could serve quality registries and clinical research. The adopted data model was initially tested and hereby published to the public domain. Conclusion: The use of a patient centered information model and data annotation focused on the care pathway simplifies the annotation of data for different purposes and supports sharing of knowledge along the patient care path.

Molecular diagnosis of scabies using a novel probe-based polymerase chain reaction assay targeting high-copy number repetitive sequences in the Sarcoptes scabiei genome.

BACKGROUND: The suboptimal sensitivity and specificity of available diagnostic methods for scabies hampers clinical management, trials of new therapies and epidemiologic studies. Additionally, parasitologic diagnosis by microscopic examination of skin scrapings requires sample collection with a sharp scalpel blade, causing discomfort to patients and difficulty in children. Polymerase chain reaction (PCR)-based diagnostic assays, combined with non-invasive sampling methods, represent an attractive approach. In this study, we aimed to develop a real-time probe-based PCR test for scabies, test a non-invasive sampling method and evaluate its diagnostic performance in two clinical settings. METHODOLOGY/PRINCIPAL FINDINGS: High copy-number repetitive DNA elements were identified in draft Sarcoptes scabiei genome sequences and used as assay targets for diagnostic PCR. Two suitable repetitive DNA sequences, a 375 base pair microsatellite (SSR5) and a 606 base pair long tandem repeat (SSR6), were identified. Diagnostic sensitivity and specificity were tested using relevant positive and negative control materials and compared to a published assay targeting the mitochondrial cox1 gene. Both assays were positive at a 1:100 dilution of DNA from a single mite; no amplification was observed in DNA from samples from 19 patients with other skin conditions nor from house dust, sheep or dog mites, head and body lice or from six common skin bacterial and fungal species. Moderate sensitivity of the assays was achieved in a pilot study, detecting 5/7 (71.4% [95% CI: 29.0% - 96.3%]) of clinically diagnosed untreated scabies patients). Greater sensitivity was observed in samples collected by FLOQ swabs compared to skin scrapings. CONCLUSIONS/SIGNIFICANCE: This newly developed qPCR assay, combined with the use of an alternative non-invasive swab sampling technique offers the possibility of enhanced diagnosis of scabies. Further studies will be required to better define the diagnostic performance of these tests.

A Plasmodium vivax experimental human infection model for evaluating efficacy of interventions.

BACKGROUNDInterventions that interrupt Plasmodium vivax transmission or eliminate dormant P. vivax liver-stage parasites will be essential for malaria elimination. Development of these interventions has been hindered by the lack of P. vivax in vitro culture and could be accelerated by a safe and reproducible clinical model in malaria-naive individuals.METHODSHealthy, malaria-naive adults were enrolled in 2 studies to assess the safety, infectivity, and transmissibility of a new P. vivax isolate. Participants (Study 1, n = 2; Study 2, n = 24) were inoculated with P. vivax-infected red blood cells to initiate infection, and were treated with artemether-lumefantrine (Study 1) or chloroquine (Study 2). Primary endpoints were safety and infectivity of the new isolate. In Study 2, transmission to mosquitoes was also evaluated using mosquito feeding assays, and sporozoite viability was assessed using in vitro cultured hepatocytes.RESULTSParasitemia and gametocytemia developed in all participants and was cleared by antimalarial treatment. Adverse events were mostly mild or moderate and none were serious. Sixty-nine percent of participants (11/16) were infectious to Anopheles mosquitoes at peak gametocytemia. Mosquito infection rates reached 97% following membrane feeding with gametocyte-enriched blood, and sporozoites developed into liver-stage schizonts in culture.CONCLUSIONWe have demonstrated the safe, reproducible, and efficient transmission of P. vivax gametocytes from humans to mosquitoes, and have established an experimental model that will accelerate the development of interventions targeting multiple stages of the P. vivax life cycle.TRIAL REGISTRATIONACTRN12614000930684 and ACTRN12616000174482.FUNDING(Australian) National Health and Medical Research Council Program Grant 1132975 (Study 1). Bill and Melinda Gates Foundation (OPP1111147) (Study 2).

Automated post-collection concentration for purified preparative fractions via solid phase extraction.

Recent advancements in preparative HPLC have improved and streamlined compound purification. However, fraction evaporation remains a bottleneck within the process. An alternative to fraction evaporation is to remove the water and reduce the overall volume of the collection by trapping the fraction onto a solid phase extraction (SPE) cartridge. This method (as opposed to analytical applications involving SPE) works by collecting and then diluting the fraction(s), passing the fraction(s) through a SPE, drying the SPE with nitrogen and ultimately eluting the concentrated fraction(s) in a small amount of 100% organic solvent. An appreciable breakthrough is not observed using this method. In addition, recovery from the SPE for the tested compounds rosmarinic acid and carvacrol, two naturally occurring antioxidants in oregano, was found to be 95-98% for a 100mg injection via preparative HPLC purification at 50mg/compound.

Community Involvement in Development of Evidence-Informed Recommendations for Rehabilitation for Older Adults Living With HIV.

BACKGROUND: Involving community in development of clinical practice guidelines (CPGs) can decrease the gap between patient preferences and research evidence. OBJECTIVE: To incorporate meaningful participation of people living with human immunodeficiency virus (HIV; people living with HIV [PHAs]) in the development of evidence informed recommendations for rehabilitation practice. METHODS: PHAs were involved in a process to develop practice recommendations internally as members of a project team and externally through formal endorsement of the recommendations. LESSONS LEARNED: Lessons learned include 1) providing time to develop as a team and understand the roles, biases, and expertise of each member, 2) engaging community in initial discussions to determine the most meaningful involvement, 3) realizing that participation in research may trigger anxiety and stress in community members, 4) developing terms of reference to clarify roles and expectations, 5) providing opportunities for skill development, and 6) conducting formal evaluation of the process and satisfaction of community. CONCLUSION: Meaningful inclusion of community can improve the quality of practice guidelines.

Community-based HIV education and prevention workers respond to a changing environment.

The purpose of this study was to understand the culture, values, skills and activities of staff involved in education and prevention activities in community-based AIDS Service Organizations (ASOs) in Ontario, Canada, and to understand the role of evaluation research in their prevention programming. In this qualitative study, 33 staff members from 11 ASOs participated in semi-structured interviews that were analyzed using the grounded theory approach. ASO staff experience tension between a historical grassroots organizational culture characterized by responsiveness and relevance and a more recent culture of professionalization. Target populations have changed from being primarily gay men to an almost unlimited variety of communities. Program emphasis has shifted from education and knowledge dissemination to a broadly based mandate of health promotion, community development, and harm reduction. Integration of evidence of effectiveness, social-behavioral theory, or systematic evaluation is uncommon. Understanding these points of tension is important for the nursing profession when it is engaged with ASOs in programming or evaluation research.

Evidence-informed recommendations for rehabilitation with older adults living with HIV: a knowledge synthesis.

OBJECTIVE: Our aim was to develop evidence-informed recommendations for rehabilitation with older adults living with HIV. DESIGN: We conducted a knowledge synthesis, combining research evidence specific to HIV, rehabilitation and ageing, with evidence on rehabilitation interventions for common comorbidities experienced by older adults with HIV. METHODS: We included highly relevant HIV-specific research addressing rehabilitation and ageing (stream A) and high-quality evidence on the effectiveness of rehabilitation interventions for common comorbidities experienced by older adults ageing with HIV (stream B). We extracted and synthesised relevant data from the evidence to draft evidence-informed recommendations for rehabilitation. Draft recommendations were refined based on people living with HIV (PLHIV) and clinician experience, values and preferences, reviewed by an interprofessional team for Grading of Recommendations Assessment, Development, and Evaluation (GRADE) (quality) rating and revision and then circulated to PLHIV and clinicians for external endorsement and final refinement. We then devised overarching recommendations to broadly guide rehabilitation with older adults living with HIV. RESULTS: This synthesis yielded 8 overarching and 52 specific recommendations. Thirty-six specific recommendations were derived from 108 moderate-level or high-level research articles (meta-analyses and systematic reviews) that described the effectiveness of rehabilitation interventions for comorbidities that may be experienced by older adults with HIV. Recommendations addressed rehabilitation interventions across eight health conditions: bone and joint disorders, cancer, stroke, cardiovascular disease, mental health challenges, cognitive impairments, chronic obstructive pulmonary disease and diabetes. Sixteen specific recommendations were derived from 42 research articles specific to rehabilitation with older adults with HIV. The quality of evidence from which these recommendations were derived was either low or very low, consisting primarily of narrative reviews or descriptive studies with small sample sizes. Recommendations addressed approaches to rehabilitation assessment and interventions, and contextual factors to consider for rehabilitation with older adults living with HIV. CONCLUSIONS: These evidence-informed recommendations provide a guide for rehabilitation with older adults living with HIV.

Variations in the contouring of organs at risk: test case from a patient with oropharyngeal cancer.

PURPOSE: Anatomy contouring is critical in radiation therapy. Inaccuracy and variation in defining critical volumes will affect everything downstream: treatment planning, dose-volume histogram analysis, and contour-based visual guidance used in image-guided radiation therapy. This study quantified: (1) variation in the contouring of organs at risk (OAR) in a clinical test case and (2) corresponding effects on dosimetric metrics of highly conformal plans. METHODS AND MATERIALS: A common CT data set with predefined targets from a patient with oropharyngeal cancer was provided to a population of clinics, which were asked to (1) contour OARs and (2) design an intensity-modulated radiation therapy plan. Thirty-two acceptable plans were submitted as DICOM RT data sets, each generated by a different clinical team. Using those data sets, we quantified: (1) the OAR contouring variation and (2) the impact this variation has on dosimetric metrics. New technologies were employed, including a software tool to quantify three-dimensional structure comparisons. RESULTS: There was significant interclinician variation in OAR contouring. The degree of variation is organ-dependent. We found substantial dose differences resulting strictly from contouring variation (differences ranging from -289% to 56% for mean OAR dose; -22% to 35% for maximum dose). However, there appears to be a threshold in the OAR comparison metric beyond which the dose differences stabilize. CONCLUSIONS: The effects of interclinician variation in contouring organs-at-risk in the head and neck can be large and are organ-specific. Physicians need to be aware of the effect that variation in OAR contouring can play on the final treatment plan and not restrict their focus only to the target volumes.

Variation in external beam treatment plan quality: An inter-institutional study of planners and planning systems.

PURPOSE: This study quantifies variation in radiation treatment plan quality for plans generated by a population of treatment planners given very specific plan objectives. METHODS AND MATERIALS: A "Plan Quality Metric" (PQM) with 14 submetrics, each with a unique value function, was defined for a prostate treatment plan, serving as specific goals of a hypothetical "virtual physician." The exact PQM logic was distributed to a population of treatment planners (to remove ambiguity of plan goals or plan assessment methodology) as was a predefined computed tomographic image set and anatomic structure set (to remove anatomy delineation as a variable). Treatment planners used their clinical treatment planning system (TPS) to generate their best plan based on the specified goals and submitted their results for analysis. RESULTS: One hundred forty datasets were received and 125 plans accepted and analyzed. There was wide variability in treatment plan quality (defined as the ability of the planners and plans to meet the specified goals) quantified by the PQM. Despite the variability, the resulting PQM distributions showed no statistically significant difference between TPS employed, modality (intensity modulated radiation therapy versus arc), or education and certification status of the planner. The PQM results showed negligible correlation to number of beam angles, total monitor units, years of experience of the planner, or planner confidence. CONCLUSIONS: The ability of the treatment planners to meet the specified plan objectives (as quantified by the PQM) exhibited no statistical dependence on technologic parameters (TPS, modality, plan complexity), nor was the plan quality statistically different based on planner demographics (years of experience, confidence, certification, and education). Therefore, the wide variation in plan quality could be attributed to a general "planner skill" category that would lend itself to processes of continual improvement where best practices could be derived and disseminated to improve the mean quality and minimize the variation in any population of treatment planners.

Chronic care model implementation in the California State Prison System.

The chronic care model (CCM) deployed through a learning collaborative strategy, such as the Institute for Healthcare Improvement's Breakthrough Series (BTS), is a widely adopted approach to improve care that has guided clinical quality initiatives nationally and internationally. The BTS collaborative approach has been used to improve chronic conditions at national and state levels and in single health care delivery systems but not in correctional health care. Combining the CCM with a learning collaborative strategy in prison health care is a new frontier. This article describes the adoption of the CCM using a learning collaborative approach in the California prison system under the mandate of a federal receivership and elucidates some barriers to implementation. Results from the first phase of a pilot study were positive in terms of benefit/ cost analysis and suggest financial and political viability to continue the program.

Nonfinancial factors associated with decreased plasma viral load testing in Ontario, Canada.

OBJECTIVE: To examine whether individual characteristics were associated with differential use of viral load testing when testing is available without charge to all HIV-positive patients with provincial health insurance. METHODS: Individuals enrolled in the HIV Ontario Observational Database with complete medication records and health insurance numbers for linkage were studied. Generalized estimating equation regression models were used to examine the relationship between time-varying covariates such as plasma viral load levels, CD4 counts, and antiretroviral regimen characteristics and the number of days between viral load tests and the occurrence of an interval of >or=6 or 9 months between tests. RESULTS: A total of 1032 individuals were included in the analysis with a median follow-up of 4.6 years and a median of 18 viral load tests. In multivariate analyses, clinically important gaps in viral load testing were more likely among injection drug users (odds ratio [OR]=1.86, P<0.0001), in more recent years (P<0.01) and for individuals not using antiretrovirals (OR=1.70, P<0.0001) and less likely among individuals using >4 antiretrovirals (OR=0.62, P<0.0001). Results were similar when the outcome was the number of days between tests. CONCLUSIONS: Injection drug users, younger individuals, and residents of Toronto used fewer viral load tests than other individuals, even when financial barriers to testing were removed.