Diverse clinical and social circumstances: developing patient-centred care for DR-TB patients in South Africa

OBJECTIVE

To describe the medical, socio-economic and geographical profiles of patients with rifampicin-resistant TB (RR-TB) and the implications for the provision of patient-centred care.

SETTING

Thirteen districts across three South African provinces.

DESIGN

This descriptive study examined laboratory and healthcare facility records of 194 patients diagnosed with RR-TB in the third quarter of 2016.

RESULTS

The median age was 35 years; 120/194 (62%) of patients were male. Previous TB treatment was documented in 122/194 (63%) patients and 56/194 (29%) had a record of fluoroquinolone and/or second-line injectable resistance. Of 134 (69%) HIV-positive patients, viral loads were available for 68/134 (51%) (36/68 [53%] had viral loads of >1000 copies/ml) and CD4 counts were available for 92/134 (69%) (20/92 [22%] had CD4 <50 cells/mm3). Patients presented with varying other comorbidities, including hypertension (13/194, 7%) and mental health conditions (11/194, 6%). Of 194 patients, 44 (23%) were reported to be employed. Other socio-economic challenges included substance abuse (17/194, 9%) and ill family members (17/194, 9%). Respectively 13% and 42% of patients were estimated to travel more than 20 km to reach their diagnosing and treatment-initiating healthcare facility.

CONCLUSIONS

RR-TB patients had diverse medical and social challenges highlighting the need for integrated, differentiated and patient-centred healthcare to better address specific needs and underlying vulnerabilities of individual patients.

Patrolling the boundaries of social domains: Neural activations to violations of expectations for romantic and work relationships

According to the social domains hypothesis, we reduce the information-processing demands of complex social cues by classifying them into a limited number of domains, each with distinct sets of expectations. This requires rapid identification of violations of the boundaries between social domains. We hypothesized that these violations are likely to be associated with neural activation of the salience system. Using fMRI we compared responses of 20 adults to expected and unexpected everyday social scenarios in personal and work interactions. The vignettes exemplified different kinds of scenarios presented in the work setting, i.e., task-focused scenarios which are expected at work and scenarios with a personal focus, which are unexpected at work. The key contrast between task and personal focussed scenarios presented in the work setting was associated with fronto-insular activation. Perceived inappropriateness of the unexpected scenarios, and shorter response time to judgment of inappropriateness were also associated with fronto-insular activation, after controlling for unpleasantness. This study indicates specific neural responses to violations of expectations in different social situations. Our findings suggest that the fronto-insular region is implicated in rapid detection of behaviors that cross the boundaries of social domains, which are hypothesized to be necessary for efficient social information processing.

Healthcare provider and pregnant women's perspectives on the implementation of intermittent screening and treatment with dihydroartemisinin-piperaquine for malaria in pregnancy in western Kenya: a qualitative study

Background

In malaria endemic regions in Kenya, pregnant women are offered long-lasting insecticidal nets and intermittent preventive treatment (IPTp) with sulfadoxine–pyrimethamine (SP) at antenatal care (ANC) to prevent the adverse effects of malaria. Fears of growing SP resistance have heightened the search for alternative strategies. The implementation feasibility of intermittent screening and treatment (ISTp) with dihydroartemisinin–piperaquine (DP) in routine ANC settings was evaluated using qualitative and quantitative methods, including the exploration of healthcare provider and pregnant women’s perceptions.

Methods

Qualitative methods included data from 13 focus group discussions (FGDs) with pregnant women and 43 in-depth interviews with healthcare providers delivering ANC services. FGDs were conducted with women who had received either ISTp-DP or current policy (IPTp-SP). Thematic analysis was used to explore experiences among women and providers and findings were used to provide insights into results of the parallel quantitative study.

Results

Women were accepting of testing with rapid diagnostic tests (RDTs) and receiving treatment if malaria positive. Providers perceived DP to be an effective drug and well tolerated by women. Some providers indicated a preference for test and treat strategies to reduce unnecessary exposure to medication in pregnancy, others preferred a hybrid strategy combining screening at every ANC visit followed by IPTp-SP for women who tested negative, due to the perception that RDTs missed some infections and concerns about the growing resistance to SP. Testing with RDTs during ANC was appreciated as it was perceived to reduce wait times. The positive attitude of healthcare providers towards ISTp supports findings from the quantitative study that showed a high proportion (90%) of women were tested at ANC. There were concerns about affordability of DP and the availability of sufficient RDT stocks.

Conclusion

In ANC settings, healthcare providers and pregnant women found ISTp-DP to be an acceptable strategy for preventing malaria in pregnancy when compared with IPTp-SP. DP was considered an effective anti-malarial and a suitable alternative to IPTp-SP in the context of SP resistance. Despite providers’ lack of confidence in RDT results at current levels of sensitivity and specificity, the quantitative findings show their willingness to test women routinely at ANC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-03826-8.

AB0548 EFFECTIVENESS OF IXEKIZUMAB IN PATIENTS WITH PSORIATIC ARTHRITIS: RESULTS FROM A REAL-WORLD EUROPEAN SURVEY

Background:

Limited real world (RW) data are available for IL-17A blocker ixekizumab (Ixe), approved for psoriatic arthritis (PsA) in EU Feb 2018.

Objectives:

Describe RW outcomes for PsA patients (pts) receiving Ixe.

Methods:

Cross-sectional, observational study of PsA pts treated with Ixe in the 2020 Adelphi PsA Plus Program (FR, DE, ES & UK). Rheumatologists recruited the first 6 consecutive consulting Ixe pts and provided demographics, PsA manifestations, clinical measures (66 swollen joint count (SJC), 68 tender joint count (TJC), psoriasis area and severity index [PASI], body surface area [BSA] affected by psoriasis [PsO]), rheumatologist-recorded pt measures (skin/joint pain & fatigue [0-10 numeric rating scales (NRS)], health assessment questionnaire [HAQ-DI]) & prescribed dose. All outcomes recorded for pts with scores available at Ixe initiation (II) & at last assessment (LA).

Results:

124 rheumatologists provided data for 698 Ixe pts, mean age 49 years (19-79), 48% female, mean BMI 27 (18-44), 56% dermatologist co-managed and mean time diagnosed 6 years (0-35). At Ixe initiation, 78% of pts with known BSA had concomitant mod-sev-PsO defined as BSA≥10% (mean 19.8, n=428) and mean PASI 26.3 (n=164). The predominant PsA phenotype was polyarthritic in 49% (n=345), mono/oligoarthritic in 30% (n=208), axial in 12% (n=81) and enthesitic in 8% (n=55). Previous treatment before Ixe included ≥1 conventional synthetic DMARD (csDMARD) for 71% of pts. Of bio-experienced pts (57%), 40% had received ≥2 biologics. Mean Ixe treatment duration (n=698) 39.4 weeks (wks, 0-170), of which 575 (82%) had received >12 wks of Ixe. 71% of pts received label recommended dose (80mg every 4wks). 52% pts received csDMARD in combination with Ixe. In the RW, Ixe improved TJC, SJC, joint pain, BSA, fatigue and HAQ-DI, Table 1.

Table 1.

Outcomes for pts receiving Ixe >12weeks (n=575)

OverallBSA ≥10% at Ixe initiationMod-sev-PsO physician judgementPredominant mono/oligo arthritisPredominant polyarthritisWith csDMARDWithout csDMARDBSA, n35627025498184188168mean [SD]Ixe initiation (II)19.8 [14.8]24.7 [13.5]23.1 [13.6]17.4 [15.0]20.9 [15.0]21.8 [15.0]17.4 [14.2]Last Assessment (LA)6.6 [7.5]9.3 [8.7]7.9 [7.9]5.0 [6.0]7.6 [8.4]7.3 [7.9]5.9 [7.1]Mean weeks on Ixe43414150414146TJC*, n125728639725669mean [SD, %<5]II12.2 [10.6, 29]14.4 [11.3, 18]12.9 [11.1, 21]6.4 [8.2, 59]15.4 [10.8, 12]13.0 [9.9, 25]11.5 [11.1, 32]LA4.1 [6.4, 77]5.2 [7.7, 71]3.6 [6.3, 80]1.1 [1.4, 97]6.2 [7.7, 64]3.4 [3.9, 73]4.6 [7.8, 80]SJC*, n1458210244846085mean [SD, %<5]II14.8 [13.5, 33]18.8 [14.4, 22]16.3 [13.8, 26]7.2 [8.5, 68]18.2 [13.6, 12]14.5 [12.0, 37]15.1 [14.8, 31]LA4.8 [8.7, 79]7.0 [10.7, 66]5.1 [9.3, 75]0.9 [1.9, 95]6.6 [9.0, 68]3.1 [7.8, 90]5.9 [9.1, 71]Joint pain (NRS 0-10), n575270349166291294281mean [SD]II6.6 [1.7]6.7 [1.7]6.7 [1.7]6.2 [1.8]7.0 [1.5]6.6 [1.7]6.6 [1.6]LA2.7 [1.9]3.0 [2.1]2.8 [2.0]2.1 [1.6]3.0 [2.1]2.8 [1.9]2.5 [1.9]Fatigue (NRS 0-10), n575270349166291294281mean [SD]II5.4 [2.5]5.8 [2.4]5.7 [2.5]4.7 [2.5]5.7 [2.4]5.7 [2.4]5.1 [2.5]LA2.6 [2.1]2.7 [2.1]2.7 [2.2]2.0 [1.9]2.9 [2.2]2.7 [2.1]2.6 [2.1]HAQ DI, n59414210283128mean [SD, %<0.5]II1.8 [0.7, 5]1.9 [0.6, 0]1.8 [0.7, 2]1.9 [0.7, 10]1.8 [0.8, 7]1.9 [0.6, 3]1.7 [0.8, 7]LA0.8 [0.6, 41]0.8 [0.6, 32]0.8 [0.7, 45]0.7 [0.7, 60]0.7 [0.6, 36]0.7 [0.5, 32]0.7 [0.8, 50]

*Additional analysis for pts whose fatigue/joint pain rating improved (from ≥4 at Ixe initiation to ≤3 at LA), their mean TJC was 2.7 & SJC 4.3 at LA for fatigue, TJC 1.7 & SJC 2.7 at LA for joint pain.

When BSA was not recorded, physician judgement of PsO severity was used. No imputation of missing data.

Conclusion:

We report RW outcome data amongst pts treated with Ixe including mono/oligo arthritis and a limited sample of enthesitis and dactylitis pts. Our results are consistent with clinical trial populations across disease domains, including an improvement in joint pain.

Disclosure of Interests:

William Tillett Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc. and UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc. and UCB, Grant/research support from: AbbVie, Celgene, Eli Lilly & company, Janssen and UCB, Victoria Navarro-Compán Speakers bureau: AbbVie, BMS, Janssen, Eli Lilly & Co, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: AbbVie, BMS, Janssen, Eli Lilly & Co, MSD, Novartis, Pfizer, Roche and UCB, Grant/research support from: AbbVie, BMS, Janssen, Eli Lilly & Co, MSD, Novartis, Pfizer, Roche and UCB, Nicola Booth: None declared., Thorsten Holzkaemper Shareholder of: Eli Lilly & Company, Employee of: Eli Lilly & Company, Julie Hill Shareholder of: Eli Lilly & Company, Employee of: Eli Lilly & Company, Ennio Lubrano Speakers bureau: Alfa-Sigma, Abbvie, Galapagos, Janssen Cilag, Lilly., Consultant of: Alfa-Sigma, Abbvie, Galapagos, Janssen Cilag, Lilly., Tamas Truer Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company.

Drug-resistant tuberculosis patient care journeys in South Africa: a pilot study using routine laboratory data

SETTING: Thirteen districts in Eastern Cape (EC), KwaZulu-Natal (KZN) and Western Cape (WC) Provinces, South Africa.OBJECTIVE: To pilot a methodology for describing and visualising healthcare journeys among drug-resistant tuberculosis (DR-TB) patients using routine laboratory records.DESIGN: Laboratory records were obtained for 195 patients with laboratory-detected rifampicin-resistant TB (RR-TB) during July-September 2016. Health facility visits identified from these data were plotted to visualise patient healthcare journeys. Data were verified by facility visits.RESULTS: In the 9 months after the index RR-TB sample was collected, patients visited a mean of 2.3 health facilities (95% CI 2.1-2.6), with 9% visiting ≥4 facilities. The median distance travelled by patients from rural areas (116 km, interquartile range [IQR] 50-290) was greater than for urban patients (51 km, IQR 9-140). A median of 21% of patient's time was spent under the care of primary healthcare facilities: this was respectively 6%, 37% and 39% in KZN, EC and WC. Journey patterns were generally similar within districts. Some reflected a semi-centralised model of care where patients were referred to regional hospitals; other journeys showed greater involvement of primary care.CONCLUSION: Routine laboratory data can be used to explore DR-TB patient healthcare journeys and show how the use of healthcare services for DR-TB varies in different settings.

Upgrade of the gated laser entrance hole imager G-LEH-2 on the National Ignition Facility

A major upgrade has been implemented for the ns-gated laser entrance hole imager on the National Ignition Facility (NIF) to obtain high-quality data for Hohlraum physics study. In this upgrade, the single "Furi" hCMOS sensor (1024 × 448 pixel arrays with two-frame capability) is replaced with dual "Icarus" sensors (1024 × 512 pixel arrays with four-frame capability). Both types of sensors were developed by Sandia National Laboratories for high energy density physics experiments. With the new Icarus sensors, the new diagnostic provides twice the detection area with improved uniformity, wider temporal coverage, flexible timing setup, and greater sensitivity to soft x rays (<2 keV). These features, together with the fact that the diagnostic is radiation hardened and can be operated on the NIF for high neutron yield deuterium-triterium experiments, enable significantly greater return of data per experiment.

Adoption of evidence-based global policies at the national level: intermittent preventive treatment for malaria in pregnancy and first trimester treatment in Kenya, Malawi, Mali and The Gambia

In 2012, the World Health Organization (WHO) updated its policy on intermittent preventive treatment in pregnancy with sulphadoxine-pyrimethamine (IPTp-SP). A global recommendation to revise the WHO policy on the treatment of malaria in the first trimester is under review. We conducted a retrospective study of the national policy adoption process for revised IPTp-SP dosing in four sub-Saharan African countries. Alongside this retrospective study, we conducted a prospective policy adoption study of treatment of first trimester malaria with artemisinin combination therapies (ACTs). A document review informed development and interpretation of stakeholder interviews. An analytical framework was used to analyse data exploring stakeholder perceptions of the policies from 47 in-depth interviews with a purposively selected range of national level stakeholders. National policy adoption processes were categorized into four stages: (1) identify policy need; (2) review the evidence; (3) consult stakeholders and (4) endorse and draft policy. Actors at each stage were identified with the roles of evidence generation; technical advice; consultative and statutory endorsement. Adoption of the revised IPTp-SP policy was perceived to be based on strong evidence, support from WHO, consensus from stakeholders; and followed these stages. Poor tolerability of quinine was highlighted as a strong reason for a potential change in treatment policy. However, the evidence on safety of ACTs in the first trimester was considered weak. For some, trust in WHO was such that the anticipated announcement on the change in policy would allay these fears. For others, local evidence would first need to be generated to support a change in treatment policy. A national policy change from quinine to ACTs for the treatment of first trimester malaria will be less straightforward than experienced with increasing the IPTp dosing regimen despite following the same policy processes. Strong leadership will be needed for consultation and consensus building at national level.

Strangled by Dr Strangelove? Anarchic hand following a posterior cerebral artery territory ischemic stroke

Anarchic hand is a rare condition where the complex movements of one hand appear to be goal directed and smoothly executed and yet are unintended and unwanted. Unlike alien hand syndrome, the patients recognise that the affected hand is part of their own body. They know the hand is theirs, but they deny having control over its actions. The syndrome has been reported after surgery on the corpus callosum and with brain tumours, aneurysms, degenerative diseases of the brain and uncommonly with stroke. We present a case of a 74-year-old man who developed an anarchic right hand following thrombolysis for a posterior cerebral artery territory ischemic stroke.

Risk Factors for Relapsing Remitting Multiple Sclerosis

Relapsing remitting is the most common type of multiple sclerosis, affecting approximately 85% of all patients. Previous evidence has suggested that the risk factors for developing relapsing remitting multiple sclerosis is multifactorial. Similarly, it has been suggested that these factors also influence the risk of relapse. This article critically appraises and evaluates a systematic review that examined multiple factors associated with the risk of relapse for relapsing remitting multiple sclerosis.

Cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine versus single screening and treatment for the control of malaria in pregnancy in Papua, Indonesia: a provider perspective analysis from a cluster-randomised trial

BACKGROUND

Malaria infection during pregnancy is associated with serious adverse maternal and birth outcomes. A randomised controlled trial in Papua, Indonesia, comparing the efficacy of intermittent preventive treatment with dihydroartemisinin-piperaquine with the current strategy of single screening and treatment showed that intermittent preventive treatment is a promising alternative treatment for the reduction of malaria in pregnancy. We aimed to estimate the incremental cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine compared with single screening and treatment with dihydroartemisinin-piperaquine.

METHODS

We did a provider perspective analysis. A decision tree model was analysed from a health provider perspective over a lifetime horizon. Model parameters were used in deterministic and probabilistic sensitivity analyses. Simulations were run in hypothetical cohorts of 1000 women who received intermittent preventive treatment or single screening and treatment. Disability-adjusted life-years (DALYs) for fetal loss or neonatal death, low birthweight, moderate or severe maternal anaemia, and clinical malaria were calculated from trial data and cost estimates in 2016 US dollars from observational studies, health facility costings and public procurement databases. The main outcome measure was the incremental cost per DALY averted.

FINDINGS

Relative to single screening and treatment, intermittent preventive treatment resulted in an incremental cost of US$5657 (95% CI 1827 to 9448) and 107·4 incremental DALYs averted (-719·7 to 904·1) per 1000 women; the average incremental cost-effectiveness ratio was $53 per DALY averted.

INTERPRETATION

Intermittent preventive treatment with dihydroartemisinin-piperaquine offers a cost-effective alternative to single screening and treatment for the prevention of the adverse effects of malaria infection in pregnancy in the context of the moderate malaria transmission setting of Papua. The higher cost of intermittent preventive treatment was driven by monthly administration, as compared with single-administration single screening and treatment. However, acceptability and feasibility considerations will also be needed to inform decision making.

FUNDING

Medical Research Council, Department for International Development, and Wellcome Trust.

Intermittent screening and treatment with dihydroartemisinin-piperaquine for the prevention of malaria in pregnancy: implementation feasibility in a routine healthcare system setting in western Kenya

Background

Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended for preventing malaria in pregnancy in areas of moderate-to-high transmission in sub-Saharan Africa. However, due to increasing parasite resistance to SP, research on alternative strategies is a priority. The study assessed the implementation feasibility of intermittent screening and treatment (ISTp) in the second and third trimester at antenatal care (ANC) with malaria rapid diagnostic tests (RDTs) and treatment of positive cases with dihydroartemisinin-piperaquine (DP) compared to IPTp-SP in western Kenya.

Methods

A 10-month implementation study was conducted in 12 government health facilities in four sub-counties. Six health facilities were assigned to either ISTp-DP or IPTp-SP. Evaluation comprised of facility audits, ANC observations, and exit interviews. Intermediate and cumulative effectiveness analyses were performed on all processes involved in delivery of ISTp-DP including RDT proficiency and IPTp-SP ± directly observed therapy (DOT, standard of care). Logistic regression was used to identify predictors of receiving each intervention.

Results

A total of 388 and 389 women were recruited in the ISTp-DP and IPTp-SP arms, respectively. For ISTp-DP, 90% (289/320) of eligible women received an RDT. Of 11% (32/289) who tested positive, 71% received the correct dose of DP and 31% the first dose by DOT, and only 6% were counselled on subsequent doses. Women making a sick visit and being tested in a facility with a resident microscopist were more likely to receive ISTp-DP (AOR 1.78, 95% CI 1.31, 2.41; and AOR 3.75, 95% CI 1.31, 2.40, respectively). For IPTp-SP, only 57% received a dose of SP by DOT. Payment for a laboratory test was independently associated with receipt of SP by DOT (AOR 6.43, 95% CI 2.07, 19.98).

Conclusions

The findings indicate that the systems effectiveness of ANC clinics to deliver ISTp-DP under routine conditions was poor in comparison to IPTp-SP. Several challenges to integration of ISTp with ANC were identified that may need to be considered by countries that have introduced screening at first ANC visit and, potentially, for future adoption of ISTp with more sensitive RDTs. Understanding the effectiveness of ISTp-DP will require additional research on pregnant women’s adherence to ACT.

Deep Learning-Based Quantification of Pulmonary Hemosiderophages in Cytology Slides

Exercise-induced pulmonary hemorrhage (EIPH) is a common condition in sport horses with negative impact on performance. Cytology of bronchoalveolar lavage fluid by use of a scoring system is considered the most sensitive diagnostic method. Macrophages are classified depending on the degree of cytoplasmic hemosiderin content. The current gold standard is manual grading, which is however monotonous and time-consuming. We evaluated state-of-the-art deep learning-based methods for single cell macrophage classification and compared them against the performance of nine cytology experts and evaluated inter- and intra-observer variability. Additionally, we evaluated object detection methods on a novel data set of 17 completely annotated cytology whole slide images (WSI) containing 78,047 hemosiderophages. Our deep learning-based approach reached a concordance of 0.85, partially exceeding human expert concordance (0.68 to 0.86, mean of 0.73, SD of 0.04). Intra-observer variability was high (0.68 to 0.88) and inter-observer concordance was moderate (Fleiss' kappa = 0.67). Our object detection approach has a mean average precision of 0.66 over the five classes from the whole slide gigapixel image and a computation time of below two minutes. To mitigate the high inter- and intra-rater variability, we propose our automated object detection pipeline, enabling accurate, reproducible and quick EIPH scoring in WSI.

Modelling the incremental benefit of introducing malaria screening strategies to antenatal care in Africa

Plasmodium falciparum in pregnancy is a major cause of adverse pregnancy outcomes. We combine performance estimates of standard rapid diagnostic tests (RDT) from trials of intermittent screening and treatment in pregnancy (ISTp) with modelling to assess whether screening at antenatal visits improves upon current intermittent preventative therapy with sulphadoxine-pyrimethamine (IPTp-SP). We estimate that RDTs in primigravidae at first antenatal visit are substantially more sensitive than in non-pregnant adults (OR = 17.2, 95% Cr.I. 13.8-21.6), and that sensitivity declines in subsequent visits and with gravidity, likely driven by declining susceptibility to placental infection. Monthly ISTp with standard RDTs, even with highly effective drugs, is not superior to monthly IPTp-SP. However, a hybrid strategy, recently adopted in Tanzania, combining testing and treatment at first visit with IPTp-SP may offer benefit, especially in areas with high-grade SP resistance. Screening and treatment in the first trimester, when IPTp-SP is contraindicated, could substantially improve pregnancy outcomes.

Offering subterranean clover can reduce methane emissions compared with perennial ryegrass pastures during late spring and summer in sheep

Sheep production systems in south-west Victoria are based predominantly on perennial ryegrass pastures, resulting in highly seasonal growth and declining feed quantity and nutritive value in late spring and summer. These changes result in reduced animal performance and increased CH4 emissions per kg DM intake. A potential alternative to the feedbase used in south-west Victoria that provides high quality and quantity of feed in late spring and early summer are legume-based pastures, such as clovers and lucerne. This experiment examined the impact of legume-based pastures on the growth rates and CH4 emissions of Maternal Composite ewes during late spring and early summer. In 2014, 240 Maternal Composite ewes grazed either perennial ryegrass (Lolium perenne L.), lucerne (Medicago sativa L.), subterranean clover (Trifolium subterraneum L.) or arrowleaf clover (Trifolium vesiculosum Savi.) pastures for 6 weeks during late spring and early summer (November and December). Sheep grazing subterranean clover were heavier at the end of the experiment than sheep grazing perennial ryegrass. Methane measurements using portable accumulation chambers indicated lower daily CH4 emissions (g/day) from sheep grazing subterranean clover (23.5 g/day) than from sheep grazing lucerne (27.3 g/day) and perennial ryegrass (32.3 g/day) pastures. Methane emissions and liveweight changes appeared to be associated with the nutritive characteristics of the forage offered. Legume-based pastures provide sheep producers in south-west Victoria an option to increase growth rates and decrease CH4 emissions during a period when perennial ryegrass pastures are declining in nutritive value.

Barriers and solutions to finding rifampicin-resistant tuberculosis cases in older children and adolescents

Little is known about the barriers to post-exposure management of rifampicin-resistant tuberculosis (RR-TB) in older children and adolescents. We report on implementation lessons from a pilot programme targeting household-exposed individuals aged 6-18 years in Khayelitsha, South Africa. Barriers included misperceptions regarding risk of exposure, multiple research and implementation stakeholders, additional workload for an overburdened healthcare system, logistical issues faced by families, and insufficient human and financial resources. Solutions to these barriers are possible, but creativity and persistence are required. Our experience can guide others looking to roll-out care for children and adolescents exposed to RR-TB.

Distinct chromatin structures at the monoamine oxidase-A promoter correlate with allele-specific expression in SH-SY5Y cells

Monoamine oxidase-A (MAOA) metabolises monoamines and is implicated in the pathophysiology of psychiatric disorders. A polymorphic repetitive DNA domain, termed the uVNTR (upstream variable number tandem repeat), located at the promoter of the MAOA gene is a risk factor for many of these disorders. MAOA is on the X chromosome suggesting gender could play a role in regulation. We analysed MAOA regulation in the human female cell line, SH-SY5Y, which is polymorphic for the uVNTR. This heterozygosity allowed us to correlate allele-specific gene expression with allele-specific transcription factor binding and epigenetic marks for MAOA. Gene regulation was analysed under basal conditions and in response to the mood stabiliser sodium valproate. Both alleles were transcriptionally active under basal growth conditions; however, the alleles showed distinct transcription factor binding and epigenetic marks at their respective promoters. Exposure of the cells to sodium valproate resulted in differential allelic expression which correlated with allele-specific changes in distinct transcription factor binding and epigenetic marks at the region encompassing the uVNTR. Biochemically our model for MAOA promoter function has implications for gender differences in gene × environment responses in which the uVNTR has been implicated as a genetic risk.