Schistosome immunology: more questions than answers

The past 30 years have seen research on the immunology of schistosomiasis move to encompass studies of responses in naturally exposed human populations, in addition to the studies in animal model systems. While animal systems still retain an important place in research on the immunology of schistosomiasis, recent debate has centred on aspects of human immunological responses that may or may not be associated with resistance or susceptibility to infection. In this article, Paul Hagan, Patricia Ndhlovu and David Dunne take stock of the present state of knowledge and offer their views on prospects for the future.     

Introduction to placebo effects in medicine: mechanisms and clinical implications

The field of placebo research has made considerable progress in the last years and it has become a major focus of interest. We know now that the placebo effect is a real neurobiological phenomenon and that the brain's 'inner pharmacy' is a critical determinant for the occurrence of psychobiological and behavioural changes relevant to healing processes and well-being. However, harnessing the advantages of placebo effects in healthcare is still a challenge. The first part of the theme issue summarizes and discusses the various kinds of placebo mechanisms across medical fields, thereby not only focusing on two main explanatory models-expectation and conditioning theory-but also taking into account empathy and social learning, emotion and motivation, spirituality and the healing ritual. The second part of the issue focuses on questions related to transferring knowledge from placebo research into clinical practice and discusses implications for the design and interpretation of clinical trials, for the therapeutic settings in daily patient care, and for future translational placebo research.     

The structure of the phloem--still more questions than answers

Long-distance assimilate distribution in higher plants takes place in the enucleate sieve-tube system of the phloem. It is generally accepted that flow of assimilates is driven by an osmotically generated pressure differential, as proposed by Ernst Münch more than 80?years ago. In the period between 1960 and 1980, the pressure flow hypothesis was challenged when electron microscopic images suggested that sieve tubes contain obstructions that would prevent passive flow. This led to the proposal of alternative translocation mechanisms. However, most investigators came to the conclusion that obstructions in the sieve-tube path were due to preparation artifacts. New developments in bioimaging have vastly enhanced our ability to study the phloem. Unexpectedly, in vivo studies challenge the pressure-flow hypothesis once again. In this review we summarize current investigations of phloem structure and function and discuss their impact on our understanding of long-distance transport in the phloem.     

Telomere biology of trypanosomatids: more questions than answers

Trypanosomatids are severe pathogens in developing countries, where they affect both humans and domestic animals. Factors intrinsic to the host, the toxicity or subcurative effects of the available antiparasite medication and the low perspective of potential vaccines favor research on novel candidates for drug target. Telomeres are essential for the survival of most eukaryotes. In trypanosomatids, events such as antigenic variation and/or gene conversion and duplication occur at telomeric positions, possibly facilitating genome rearrangement. Understanding the role that telomere maintenance might play in the cell life span of trypanosomatids has important implications for therapeutics of parasitic diseases.     

The mechanism of receptor-mediated endocytosis: more questions than answers.

Receptor-mediated endocytosis occurs via clathrin-coated pits and is therefore coupled to the dynamic cycle of assembly and disassembly of the coat constituents. These coat proteins comprise part, but certainly not all, of the machinery involved in the recognition of membrane receptors and their selective packaging into transport vesicles for internalization. Despite considerable knowledge about the biochemistry of coated vesicles and purified coat proteins, little is known about the mechanisms of coated pit assembly, receptor-sorting and coated vesicle formation. Cell-free assays which faithfully reconstitute these events provide powerful new tools with which to elucidate the overall mechanism of receptor-mediated endocytosis.     

The role of TNF in parasitic diseases: Still more questions than answers

The inhibition of TNF with therapeutic monoclonal antibodies or antibody/receptor fusion proteins in rheumatoid arthritis still constitutes the benchmark for a successful intervention in an ongoing auto-immune-inflammatory disease and underlines the importance of this cytokine. TNF plays a central role in the defence against intracellular infections and is responsible for the promotion of different aspects of the innate immune response such as inflammatory cell recruitment and cell differentiation. While this cytokine generally displays pro-inflammatory activities supporting the early stages of the inflammatory response, it has been demonstrated to be especially important during infection with intracellular pathogens and, consequently, leishmaniasis of TNF^−/− mice ends fatally. However, the specific activities of TNF that confer protection are not yet fully understood. This review will summarize the current understanding of TNF function and signalling, and will discuss recent work in the models of malaria, toxoplasmosis, trypanosomiasis and leishmaniasis with particular emphasis on work with gene-deficient mouse models.     

Compromised ethical principles in randomised clinical trials of distant, intercessory prayer

The effects of distant, intercessory prayer on health outcomes have been studied in a range of randomised, blinded clinical trials. However, while seeking the evidentiary status accorded this 'gold standard' methodology, many prayer studies fall short of the requirements of the World Medical Association's Declaration of Helsinki for the ethical conduct of trials involving human subjects. Within a sample of 15 such studies published in the medical literature, many were found to have ignored or waived key ethical precepts, including adequate standards of care, patient confidentiality and informed consent. Prayer was considered in most studies to pose negligible or no risk to subjects, despite the fact that no clear mechanism of action nor any safety monitoring procedures were described. As a result, many studies did not meet basic ethical standards required of clinical trials of biophysical interventions, making application of their results ethically problematic. If investigators wish their data to adequately inform the use or rejection of intercessory prayer to improve health, these shortcomings should be addressed in future studies.     

Views on artificial intelligence (AI) assisted clinical trials

It is of interest to document the views of medical professionals on the application of artificial intelligence (using known data for the prediction of unknown events) in clinical trials using a web survery with a structured questionnaire from 377 subjects. The questionnaire contained 17 statements which were categorised into awareness (1,2 statements), perception (3-10 statements) and opinion (11-17 statements). The data obtained was compared between the subjects using two tailed Fisher''s exact test with p-value <0.05 for data significance analysis. Data shows that majority of professionals have possitive views on the application of artificial intelligence in clinical trials. This will accelarrate the drug evaluation process. However, the use of emerging tools such as AI will not replace human subjects in this context.     

Antidepressants versus placebo in major depression: an overview

Although the early antidepressant trials which included severely ill and hospitalized patients showed substantial drug‐placebo differences, these robust differences have not held up in the trials of the past couple of decades, whether sponsored by pharmaceutical companies or non‐profit agencies. This narrowing of the drug‐placebo difference has been attributed to a number of changes in the conduct of clinical trials. First, the advent of DSM‐III and the broadening of the definition of major depression have led to the inclusion of mildly to moderately ill patients into antidepressant trials. These patients may experience a smaller magnitude of antidepressant‐placebo differences. Second, drug development regulators, such as the U.S. Food and Drug Administration and the European Medicines Agency, have had a significant, albeit underappreciated, role in determining how modern antidepressant clinical trials are designed and conducted. Their concerns about possible false positive results have led to trial designs that are poor, difficult to conduct, and complicated to analyze. Attempts at better design and patient selection for antidepressant trials have not yielded the expected results. As of now, antidepressant clinical trials have an effect size of 0.30, which, although similar to the effects of treatments for many other chronic illnesses, such as hypertension, asthma and diabetes, is less than impressive.     

EAAT expression by macrophages and microglia: still more questions than answers

Glutamate is the main excitatory amino acid, but its presence in the extracellular milieu has deleterious consequences. It may induce excitotoxicity and also compete with cystine for the use of the cystine–glutamate exchanger, blocking glutathione neosynthesis and inducing an oxidative stress-induced cell death. Both mechanisms are critical in the brain where up to 20% of total body oxygen consumption occurs. In normal conditions, the astrocytes ensure that extracellular concentration of glutamate is kept in the micromolar range, thanks to their coexpression of high-affinity glutamate transporters (EAATs) and glutamine synthetase (GS). Their protective function is nevertheless sensitive to situations such as oxidative stress or inflammatory processes. On the other hand, macrophages and microglia do not express EAATs and GS in physiological conditions and are the principal effector cells of brain inflammation. Since the late 1990s, a number of studies have now shown that both microglia and macrophages display inducible EAAT and GS expression, but the precise significance of this still remains poorly understood. Brain macrophages and microglia are sister cells but yet display differences. Both are highly sensitive to their microenvironment and can perform a variety of functions that may oppose each other. However, in the very particular environment of the healthy brain, they are maintained in a repressed state. The aim of this review is to present the current state of knowledge on brain macrophages and microglial cells activation, in order to help clarify their role in the regulation of glutamate under pathological conditions as well as its outcome.     

Evaluating a science diversity program at UC Berkeley: more questions than answers

For the past three decades, much attention has been focused on developing diversity programs designed to improve the academic success of underrepresented minorities, primarily in mathematics, science, and engineering. However, ethnic minorities remain underrepresented in science majors and careers. Over the last 10 years, the Biology Scholars Program (BSP), a diversity program at the University of California (UC), Berkeley, has worked to increase the participation and success of students majoring in the biological sciences. A quantitative comparison of students in and out of the program indicates that students in BSP graduate with a degree in biology at significantly higher rates than students not in BSP regardless of race/ethnicity. Furthermore, students who are in BSP have statistically lower high school grade point averages (GPAs) and Scholastic Achievement Test (SAT) scores than students not in BSP. African-American and Hispanic students who join BSP graduate with significantly higher UC Berkeley biology GPAs than non-BSP African-American and Hispanic students, respectively. Majority (Asian and White) students in BSP graduate with statistically similar UC GPAs despite having lower SAT scores than non-BSP majority students. Although BSP students are more successful in completing a biology degree than non-program members, the results raise a series of questions about why the program works and for whom.     

International ethical regulations on placebo-use in clinical trials: a comparative analysis

The ethical aspects of placebo control in clinical trials have been extensively and controversially debated in the last decade. However, a thorough analytical comparison of the different existing international regulations, their terminologies and their ethical principles concerning placebo, is still missing. The central issue in the ongoing controversy is the justification of placebo-use, if proven treatment exists. All present versions of the examined guidelines propose such justifications, but each guideline differs from the others in relevant details. Therefore the conditions justifying placebo-use according to each guideline are the focus of our attention. We will first propose a formalized general principle that defines the ethical acceptability of placebo-use. Then we will analyse three categories of conditions put forward by the different documents: the risk of harm or burden, compelling scientific reasons, and the availability of proven treatment. The analysis shows important normative discrepancies and contradictions between the examined guidelines. Especially striking is the fact that some guidelines allow the participants in clinical trials to be exposed to a risk of serious harm, while others do not. Finally, we try to show how the normative difference of each guideline could influence the decision of researchers or IRBs concerning the ethical acceptability of placebo-use.