Developing more participatory and accountable institutions for health: identifying health system research priorities for the Sustainable Development Goal-era

Health policy and systems research (HPSR) is vital to guiding global institutions, funders, policymakers, activists and implementers in developing and enacting strategies to achieve the Sustainable Development Goals. We undertook a multi-stage participatory process to identify priority research questions relevant to improving accountability within health systems. We conducted interviews (n = 54) and focus group discussions (n = 2) with policymakers from international and national bodies (ministries of health, other government agencies and technical support institutions) across the WHO regions. Respondents were asked to reflect on challenges and current policy discussions related to health systems accountability, and to identify their pressing research needs. We also conducted an overview of reviews (n = 34) to determine the current status of knowledge on health systems accountability and to identify any gaps. We extracted research questions from the policymaker interviews and focus groups (70 questions) and from the overview of reviews (112 questions), and synthesized these into 36 overarching questions. Using the online platform Co-Digital, we invited researchers from around the world to refine and then rank the questions according to research importance. The questions that emerged amongst the top priorities focused on political factors that mediate the adoption or effectiveness of accountability initiatives, processes and incentives that facilitate the acceptability of accountability mechanisms among frontline healthcare providers, and the national governance reforms and contexts that enhance provider accountability. The process revealed different underlying conceptions of social accountability and how best to promote it, with some researchers and policymakers focusing on specific interventions and others embracing a more systems-oriented approach to understanding accountability, the multiple forms that it can take, how these interact with each other and the importance of power and underlying social relations. The findings from this exercise identify HPSR funding priorities and future areas for evidence production and policy engagement.

Maturation of adenovirus primes the protein nano-shell for successful endosomal escape

The ability of adenoviruses to infect a broad range of species has spurred a growing interest in nanomedicine to use adenovirus as a cargo delivery vehicle. While successful maturation of adenovirus and controlled disassembly are critical for efficient infection, the underlying mechanisms regulating these processes are not well understood. Here, we present Atomic Force Microscopy nanoindentation and fatigue studies of adenovirus capsids at different maturation stages to scrutinize their dynamic uncoating properties. Surprisingly, we find that the early intermediate immature (lacking DNA) capsid is mechanically indistinguishable in both break force and spring constant from the mature (containing DNA) capsid. However, mature and immature capsids do display distinct disassembly pathways, as revealed by our mechanically-induced fatigue analysis. The mature capsid first loses the pentons, followed by either long-term capsid stability or abrupt and complete disassembly. However, the immature capsid has a stable penton region and undergoes a stochastic disassembly mechanism, thought to be due to the absence of genomic pressure. Strikingly, the addition of the genome alone is not sufficient to achieve penton destabilization as indicated by the penton stability of the maturation-intermediate mutant, G33A. Full penton destabilization was achieved only when the genome was present in addition to the successful maturation-linked proteolytic cleavage of preprotein VI. Therefore these findings strongly indicate that maturation of adenovirus in concert with genomic pressure induces penton destabilization and thus, primes the capsid for controlled disassembly. This latter aspect is critical for efficient infection and successful cargo delivery.

Fission program at n_TOF

Since its start in 2001 the n_TOF collaboration developed a measurement program on fission, in view of advanced fuels in new generation reactors. A special effort was made on measurement of cross sections of actinides, exploiting the peculiarity of the n_TOF neutron beam which spans a huge energy domain, from the thermal region up to GeV. Moreover fission fragment angular distributions have also been measured. An overview of the cross section results achieved with different detectors is presented, including a discussion of the 237Np case where discrepancies showed up between different detector systems. The results on the anisotropy of the fission fragments and its implication on the mechanism of neutron absorption, and in applications, are also shown.

Study of the photon strength functions and level density in the gamma decay of the n + 234U reaction

The accurate calculations of neutron-induced reaction cross sections are relevant for many nuclear applications. The photon strength functions and nuclear level densities are essential inputs for such calculations. These quantities for 235U are studied using the measurement of the gamma de-excitation cascades in radiative capture on 234U with the Total Absorption Calorimeter at n_TOF at CERN. This segmented 4π gamma calorimeter is designed to detect gamma rays emitted from the nucleus with high efficiency. This experiment provides information on gamma multiplicity and gamma spectra that can be compared with numerical simulations. The code DICEBOXC is used to simulate the gamma cascades while GEANT4 is used for the simulation of the interaction of these gammas with the TAC materials. Available models and their parameters are being tested using the present data. Some preliminary results of this ongoing study are presented and discussed.

Accelerated Hypertriglyceridemia in Patients on Continuous Ambulatory Peritoneal Dialysis - A Preventable Abnormality

Increasing hypertriglyceridemia is a recognised complication of CAPD. To investigate the etiology lipid clearance studies using the intravenous fat tolerance test were performed in control subjects and in uremic patients before and after six months CAPD treatment. Oral carbohydrate intake was restricted and the use of hypertonic dialysate kept to a minimum. Although serum triglycerides were elevated in the uremic patients before CAPD (3.1 ± 0.3 mMol/L) no further increase occurred during therapy. Oral carbohydrate intake was restricted to 240–250 Gms/24 hrs and hypertonic dialysate to 5.7 ± 4.1% of the total. There were no significant changes in fractional removal rate of lipid. Therefore further increases in serum triglycerides in CAPD may be prevented by simple dietary manoeuvres.

Potential exposure to Australian bat lyssavirus is unlikely to prevent future bat handling among adults in South East Queensland

Despite ongoing public health messages about the risks associated with bat contact, the number of potential exposures to Australian bat lyssavirus (ABLV) due to intentional handling by members of the general public in Queensland has remained high. We sought to better understand the reasons for intentional handling among these members of the public who reported their potential exposure to inform future public health messages. We interviewed adults who resided in a defined geographic area in South East Queensland and notified potential exposure to ABLV due to intentional handling of bats by telephone between 1 January 2012 and 31 December 2013. The participation rate was 54%. Adults who reported they had intentionally handled bats in South East Queensland indicated high levels of knowledge and perception of a moderately high risk associated with bats with overall low intentions to handle bats in the future. However, substantial proportions of people would attempt to handle bats again in some circumstances, particularly to protect their children or pets. Fifty-two percent indicated that they would handle a bat if a child was about to pick up or touch a live bat, and 49% would intervene if a pet was interacting with a bat. Future public health communications should recognize the situations in which even people with highrisk perceptions of bats will attempt to handle them. Public health messages currently focus on avoidance of bats in all circumstances and recommend calling in a trained vaccinated handler, but messaging directed at adults for circumstances where children or pets may be potentially exposed should provide safe immediate management options.

Three-point transfusion risk score in hepatectomy

BACKGROUND

Perioperative red blood cell transfusions are required in up to 23 per cent of patients undergoing hepatectomy. Previous research has developed three transfusion risk scores to assess risk of perioperative red blood cell transfusion. Here, the performance of these transfusion risk scores was evaluated in a multicentre cohort of patients who underwent hepatectomy and compared with that of a simplified transfusion risk score.

METHODS

A database of patients undergoing hepatectomy at four specialized centres between 2008 and 2012 was developed. External validity was assessed by discrimination and calibration. Discrimination was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC). Calibration was evaluated by the degree of agreement between predicted and actual red blood cell transfusion probabilities. A simplified transfusion risk score using variables common to the three models was created, and discrimination and calibration were evaluated.

RESULTS

There were 1287 patients included in this study, with 341 (26·5 per cent) receiving a red blood cell transfusion. Discriminative ability was similar between the three transfusion risk scores, with AUCs of 0·66-0·68 and good calibration. A new three-point risk score was developed based on factors present in all models: haemoglobin 12·5 g/dl or less, primary liver malignancy and major resection (at least 4 segments). Discriminative ability and calibration of the three-point model were similar to those of the three existing models, with an AUC of 0·66.

CONCLUSION

The three-point transfusion risk score simplifies assessment of perioperative transfusion risk in hepatectomy without sacrificing predictive ability.

c-MYC is a radiosensitive locus in human breast cells

Ionising radiation is a potent human carcinogen. Epidemiological studies have shown that adolescent and young women are at increased risk of developing breast cancer following exposure to ionising radiation compared with older women, and that risk is dose-dependent. Although it is well understood which individuals are at risk of radiation-induced breast carcinogenesis, the molecular genetic mechanisms that underlie cell transformation are less clear. To identify genetic alterations potentially responsible for driving radiogenic breast transformation, we exposed the human breast epithelial cell line MCF-10A to fractionated doses of X-rays and examined the copy number and cytogenetic alterations. We identified numerous alterations of c-MYC that included high-level focal amplification associated with increased protein expression. c-MYC amplification was also observed in primary human mammary epithelial cells following exposure to radiation. We also demonstrate that the frequency and magnitude of c-MYC amplification and c-MYC protein expression is significantly higher in breast cancer with antecedent radiation exposure compared with breast cancer without a radiation aetiology. Our data also demonstrate extensive intratumor heterogeneity with respect to c-MYC copy number in radiogenic breast cancer, suggesting continuous evolution at this locus during disease development and progression. Taken together, these data identify c-MYC as a radiosensitive locus, implicating this oncogenic transcription factor in the aetiology of radiogenic breast cancer.

Computed tomographic features of feline sino-nasal and sino-orbital aspergillosis

Feline upper respiratory tract aspergillosis (URTA) occurs as two distinct anatomical forms, namely, sino-nasal aspergillosis (SNA) and sino-orbital aspergillosis (SOA). An emerging pathogen, Aspergillus felis, is frequently involved. The pathogenesis of URTA, in particular the relationship between the infecting isolate and outcome, is poorly understood. In this study, computed tomography was used to investigate the route of fungal infection and extension in 16 cases (SNA n = 7, SOA n = 9) where the infecting isolate had been identified by molecular testing. All cases had nasal cavity involvement except for one cat with SNA that had unilateral frontal sinus changes. There was a strong association between the infecting species and anatomic form (P = 0.005). A. fumigatus infections remained within the sino-nasal cavity, while cryptic species infections were associated with orbital and paranasal soft-tissue involvement and with orbital lysis. Cryptic species were further associated with a mass in the nasal cavity, paranasal sinuses or nasopharynx. Orbital masses showed heterogeneous contrast enhancement, with central coalescing hypoattenuating foci and peripheral rim enhancement. Severe, cavitated turbinate lysis, typical of canine SNA, was present only in cats with SNA. These findings support the hypothesis that the nasal cavity is the portal of entry for fungal spores in feline URTA and that the route of extension to involve the orbit is via direct naso-orbital communication from bone lysis. Additionally, a pathogenic role for A. wyomingensis and a sinolith in a cat with A. udagawae infection are reported for the first time.

Epidemiology and ecology of H3N8 canine influenza viruses in US shelter dogs

BACKGROUND

H3N8 canine influenza virus (CIV) infection might contribute to increased duration of shelter stay for dogs. Greater understanding of factors contributing to CIV within shelters could help veterinarians identify control measures for CIV.

OBJECTIVES

To assess community to shelter dog CIV transmission, estimate true prevalence of CIV, and determine risk factors associated with CIV in humane shelters.

ANIMALS

5,160 dogs upon intake or discharge from 6 US humane shelters, December 2009 through January 2012.

METHODS

A cross-sectional study was performed with prospective convenience sampling of 40 dogs from each shelter monthly. Nasal swabs and serum samples were collected. Hemagglutination inhibition and real-time reverse transcriptase-polymerase chain reaction assays were performed for each nasal and serum sample. True prevalence was estimated by stochastic latent class analysis. Logistic regression was used to identify risk factors associated with CIV shedding and seropositivity.

RESULTS

Nasal swabs were positive from 4.4% of New York (NY), 4.7% of Colorado (CO), 3.2% of South Carolina, 1.2% of Florida, and 0% of California and Texas shelter dogs sampled. Seropositivity was the highest in the CO shelter dogs at 10%, and NY at 8.5%. Other shelters had 0% seropositivity. Information-theoretic analyses suggested that CIV shedding was associated with region, month, and year (model weight = 0.95) and comingling/cohousing (model weight = 0.92).

CONCLUSIONS AND CLINICAL IMPORTANCE

Community dogs are a likely source of CIV introduction into humane shelters and once CIV has become established, dog-to-dog transmission maintains the virus within a shelter.