Access to experimental medicines for TB: ethical and human rights considerations.

The revised edition of the WHO's Ethics Guidance for the Implementation of the TB Strategy has added a new chapter on compassionate use (CU) and expanded access (EA) to TB drugs. CU and EA programmes authorise access to drugs that have not yet received marketing approval outside of clinical trials. They are aimed at allowing researchers access to investigational drugs in the absence of complete evidence of efficacy and safety to patients with multidrug-resistant (MDR) or rifampicin-resistant TB (RR-TB) when no other treatment options are available. In doing so, the guidance acknowledged the urgent necessity to offer these patients all possible treatments in respect of considerations of justice, human rights, human dignity, autonomy of the individual and protection of the community. Regulators are in general willing to accept a higher level of uncertainty in the risk-benefit assessment of medicines for life-threatening diseases when there is an unmet medical need. This attests to a paradigm change, which this article argues should also apply to allow for effective access to experimental TB medicines. Furthermore, in this article, we analyse the challenges connected to the establishment of a secure and effective regime of access to experimental drugs in the context of MDR/RR-TB as well as the ethical principles and human rights arguments in favour of the development of such programmes.

Ethics and benefits of systematic screening for active tuberculosis.

Systematic screening for active tuberculosis (TB) provides public health benefits and is part of the End TB Strategy. However, two of WHO's generic principles for screening for disease state that the natural history of the disease in question must be well understood and that there must be benefits to earlier treatment. TB fulfills the first of these only in part, the other has been less well documented. This paper considers the ethical implications of uncertain individual benefits from screening and the current research gaps.

Ultrafast dynamics of strongly correlated fermions-nonequilibrium Green functions and selfenergy approximations.

This article presents an overview on recent progress in the theory of nonequilibrium Green functions (NEGF). We discuss applications of NEGF simulations to describe the femtosecond dynamics of various finite fermionic systems following an excitation out of equilibrium. This includes the expansion dynamics of ultracold atoms in optical lattices following a confinement quench and the excitation of strongly correlated electrons in a solid by the impact of a charged particle. NEGF, presently, are the only ab initio quantum approach that is able to study the dynamics of correlations for long times in two and three dimensions. However, until recently, NEGF simulations have mostly been performed with rather simple selfenergy approximations such as the second-order Born approximation (SOA). While they correctly capture the qualitative trends of the relaxation towards equilibrium, the reliability and accuracy of these NEGF simulations has remained open, for a long time. Here we report on recent tests of NEGF simulations for finite lattice systems against exact-diagonalization and density-matrix-renormalization-group benchmark data. The results confirm the high accuracy and predictive capability of NEGF simulations-provided selfenergies are used that go beyond the SOA and adequately include strong correlation and dynamical-screening effects. With an extended arsenal of selfenergies that can be used effectively, the NEGF approach has the potential of becoming a powerful simulation tool with broad areas of new applications including strongly correlated solids and ultracold atoms. The present review aims at making such applications possible. To this end we present a selfcontained introduction to the theory of NEGF and give an overview on recent numerical applications to compute the ultrafast relaxation dynamics of correlated fermions. In the second part we give a detailed introduction to selfenergies beyond the SOA. Important examples are the third-order approximation, the [Formula: see text] approximation, the T-matrix approximation and the fluctuating-exchange approximation. We give a comprehensive summary of the explicit selfenergy expressions for a variety of systems of practical relevance, starting from the most general expressions (general basis) and the Feynman diagrams, and including also the important cases of diagonal basis sets, the Hubbard model and the differences occuring for bosons and fermions. With these details, and information on the computational effort and scaling with the basis size and propagation duration, readers will be able to choose the proper basis set and straightforwardly implement and apply advanced selfenergy approximations to a broad class of systems.

A reliable method to reduce collagen scar formation in the lesioned rat spinal cord.

Following traumatic injury, the formation of a glial scar and deposition of extracellular matrix (ECM) contributes to the regeneration failure in the adult mammalian central nervous system (CNS). Using a postcommissural fornix transection as a brain lesion model in rat, we have previously shown that the collagenous basement membrane (BM) at the lesion site is a major impediment for axon regeneration. Deposition of BM in this lesion model can be delayed by administration of the iron chelator 2,2'-bipyridine (BPY), an inhibitor of prolyl 4-hydroxylase (PH), a key enzyme of collagen biosynthesis. To examine whether this potential therapeutic approach is transferable to other CNS regions, we have chosen the mechanically lesioned rat spinal cord to investigate the effects of BPY administration on BM formation. Due to the close proximity of the lesion zone to meningeal fibroblasts, a cell-type secreting large amounts of collagen IV, BM deposition was much more extensive in the spinal cord than in the brain lesion. Neither immediate injections nor continuous application of BPY resulted in a detectable reduction of BM formation in the spinal cord. Only a combination of anti-scarring treatments including (i) injection of the more potent PH inhibitor [2,2'-bipyridine]-5,5'-dicarboxylic acid (BPY-DCA), (ii) selective inhibition of fibroblast proliferation and ECM production by 8-Br-cAMP, and (iii) continuous application of BPY-DCA, reduced the lesion-induced BM significantly. The present results clearly demonstrate, that the exclusive application of BPY according to a protocol designed for treatment of brain lesions is not sufficient to reduce BM formation in the lesioned adult rat spinal cord.

Preservation and detection of lesion-induced collagenous scar in the CNS depend on the method of tissue processing.

After traumatic injury, adult central nervous system (CNS) axons fail to regenerate. We have previously shown that one major impediment for axon regeneration is the basement membrane (BM) forming at the lesion center, by means of a wound healing collagenous scar, after lesioning the postcommisural fornix of the adult rat [Eur. J. Neurosci. 11 (1999) 632] [6]. This BM consists of a supramolecular network of collagen type IV, laminin (LN), nidogen, and associated proteoglycans [Crit. Rev. Biochem. Mol. Biol. 27 (1992) 93] [5]. Following axotomy, axons of the proximal stump of the transected postcommissural fornix fail to cross the lesion site. This regenerative failure is spatially and temporally highly correlated with the appearance of BM in the lesion site [Restor. Neurol. Neurosci. 15 (1999) 1] [7]. However, if the deposition of BM is prevented, the injured axons: (i) regenerate in their former pathway, (ii) are conductive across and behind the lesion site, and (iii) form chemical synapses in their target area, the mammillary body [Eur. J. Neurosci. 11 (1999) 632]. The developing BM is surrounded by neuropil and can easily be stained immunohistochemically using anti-collagen IV antibodies on fresh frozen sections (10 microm). To examine a clinically more relevant model of traumatic CNS injuries we developed a transection model of the thoracic dorsal corticospinal tract (CST) in the rat spinal cord. In contrast to fornix lesion this transection is performed in close proximity to the meninges. This involves the BM being completely washed out if fresh frozen tissue is used on slides. If the animals are sacrificed by perfusion with aldehydes the collagen IV and the LN antigen are masked by the fixative. To restore the correct immunohistochemical staining pattern (BM, blood vessels) a special protocol including an enzyme digestion is necessary. If thick sections are stained free floating, the tissue is destroyed due to the enzyme treatment. Here we present a method to prevent loss of the lesion-induced BM and to perform the correct immunohistochemical stainings of BM proteins in the traumatically injured spinal cord.

The collagenous lesion scar--an obstacle for axonal regeneration in brain and spinal cord injury.

After CNS trauma a sheet-like, collagen type IV (Coll IV) immunopositive basement membrane (BM) develops in the lesion zone as well as at newly formed blood vessels. The basic scaffold of this BM is composed of Coll IV, laminin and nidogen but numerous other proteins some of which are discussed to be inhibitory for axonal regeneration, i.e. chondroitin- and heparansufate-proteoglycans, are associated with BM. This review will focus on the collagenous wound healing scar, discuss its composition and summarize the experimental results that demonstrate its role in the failure of axonal regeneration in the injured mammalian CNS.

Effects of schwann cell suspension grafts on axon regeneration in subacute and chronic CNS traumatic injuries.

In a previous study, we have shown that microtransplanted Schwann cell suspensions foster structural recovery of the acutely transected postcommissural fornix. The emphasis of the present study was to examine whether subacutely and chronically injured axons also demonstrate significant responsiveness to implanted Schwann cells. Microinjected suspensions of cultured Schwann cells i) elicited a growth response and attracted axons in a subacute and chronic traumatic lesion but ii) failed to stimulate regrowth of the postcommissural fornix projection at any nonacute postlesion stage. In conclusion, the single intervention strategy of Schwann cell microimplantation is not sufficient to ensure regeneration of the subacutally or chronically transected postcommissural fornix. The use of Schwann cells as stimulators of axon regrowth depends on the neuronal cell type and the appropriate postinjury time point.

Basal membrane-depleted scar in lesioned CNS: characteristics and relationships with regenerating axons.

The lesion scar formed after CNS injury is an impediment to axonal regeneration and leads to growth arrest or misrouting of sprouting axons. Our previous study showed that pharmacological reduction of basal membrane formation within the scar can overcome this scar impermeability [Stichel C. C. et al. (1999) Eur. J. Neurosci. 11, 632-646]. The aim of the present study was to characterize the basal membrane-depleted scar and to analyse its relationships with penetrating axons. The experiments comprised two groups of animals in which the left postcommissural fornix was transected; in addition, one group received a local immediate injection of the collagen IV-reducing agent dipyridyl, while the other group received an injection of phosphate-buffered saline. Immunohistochemical methods were used to characterize scar formation and scar-axon relationships. Animals receiving dipyridyl showed reduction of collagen IV-immunopositive basal membrane in the lesion center, which was accompanied by: (i) a decrease in laminin, as well as chondroitin and heparan sulfate proteoglycan, deposition in the lesion center; (ii) an increase in chondroitin and keratan sulfate proteoglycan expression in the perilesional area; (iii) a typical activation pattern of astrocytes and microglia/macrophages; (iv) axons regenerating through this modified scar were closely associated with various glial cell types and crossed a prominent chondroitin/keratan sulfate proteoglycan matrix. Our results suggest that neither the formation of a reactive astroglial network nor the accumulation of microglia/macrophages or the deposition of chondroitin and keratan sulfate proteoglycans in the perilesional area represent a barrier to regrowing axons. The present approach demonstrates that the lesion-induced basal membrane itself is the primary determinant of scar impermeability.

Inhibition of collagen IV deposition promotes regeneration of injured CNS axons.

Scarring impedes axon regrowth across the lesion site and is one major extrinsic constraint to effective regeneration in the adult mammalian central nervous system. In the present study we determined whether specific biochemical or immunochemical modulation of one major component of the scar, the basal membrane (BM), would provide a means to stimulate axon regeneration in the mechanically transected postcommissural fornix of the adult rat. Basal membrane developed within the first 2 weeks after transection in spatiotemporal coincidence with the abrupt growth arrest of spontaneously regrowing axons. Local injection of anticollagen IV antibodies or alpha, alpha'-dipyridyl, an inhibitor of collagen triple helix formation and synthesis, significantly reduced lesion-induced BM deposition. This treatment allowed massive axon elongation across the lesion site. Anterograde tracing provided unequivocal evidence that regenerating axons follow their original pathway, reinnervate the appropriate target, the mammillary body, and become remyelinated with compact myelin. Presynaptic electrophysiological recordings of regenerated fibre tracts showed recovery to nearly normal conduction properties. Our results indicate that lesion-induced BM is an impediment for successful axonal regeneration and its reduction is a prerequisite and sufficient condition for regrowing axons to cross the lesion site.

Lack of immune responses to immediate or delayed implanted allogeneic and xenogeneic Schwann cell suspensions.

Previous studies have shown that Schwann cell implantation offers a potential therapeutic approach to a variety of neurodegenerative disorders and traumatic injuries. In a clinically relevant paradigm, however, the implantation of autologous Schwann cells is problematic and the use of heterogenetic Schwann cells will be required. In the present study we addressed this important issue and analysed the immunogenicity and survival of allogeneic and xenogeneic Schwann cell suspension grafts in a prelesioned CNS fiber tract, the transected postcommissural fornix of the adult Wistar rat. Cultured Schwann cells from Wistar rat or human peripheral nerve were injected either immediately or after a delay into the transection site and the spatio-temporal pattern of leukocyte infiltration and of major histocompatibility antigen expression was characterized and semiquantified with immunocytochemical methods. Our main findings are that (1) invasive cerebral lesions induce the expression of MHC class I and II antigens, but only sparse infiltration of T-lymphocytes, (2) both allogeneic and xenogeneic discordant Schwann cell suspension grafts, from either neonatal or adult peripheral nerve, survive without any overt signs of rejection for up to 10 weeks after implantation; and (3) delayed implantation procedures have no effect on immune responses to allogeneic Schwann cell grafts. These results demonstrate that there is no marked ongoing immune reactions to heterogenetic Schwann cell suspension grafts and that long-term survival of cross-species Schwann cell grafts can be achieved in the absence of any immunsuppressive treatment. Thus the conditions for functional transplantation of Schwann cells across immunological barriers seem to be favourable and will have implications for future cross-species studies, and possibly also for clinical application.