Achieving large ends with limited means: grand strategy in global health

Unprecedented attention is focused on global health, with a four-fold increase in development assistance in the last 15 years and the scope of global health expanding beyond infectious disease to include chronic disease and health systems strengthening. As the global impact of health is more widely understood, it has become a crucial element of international relations, economic development, and foreign affairs. At this potential leverage point in the global health movement, the application of grand strategy is of critical importance. Grand strategy, i.e., the development and implementation of comprehensive plans of action to achieve large ends with limited means, has been refined through centuries of international relations and the management of states but has been inadequately applied to global health policy and implementation. We review key principles of grand strategy and demonstrate their applicability to a central global health issue: maternal mortality. The principles include: start with the end in mind, take an ecological approach, recognize that tactics matter, use positive deviance to characterize practical solutions and foster scale-up, and integrate timely intelligence and data into health interventions and improvement efforts. We advocate for the greater use of grand strategy in global health.

Perceptions of gain following spinal cord injury: a qualitative analysis

BACKGROUND

Significant research has focused on psychological difficulties following spinal cord injury (SCI), and there is a small prevalence of individuals who experience distress after injury. However, the converse is that many adjust well to injury and rate their quality of life highly. Despite this, there has been a comparative dearth of research investigating positive psychological outcomes after SCI, perceived by individuals living with this disability.

OBJECTIVE

To explore individuals' perceptions of gain following the experience of SCI.

METHODS

Participants, who had sustained an SCI between the ages 16 and 83, responded to an open-ended written question: "What do you think you have gained from the experience of spinal cord injury?" This was administered at 4 time points post injury: 6 weeks, 12 weeks, 1 year, and 2 years.

RESULTS

Participants' responses were analyzed qualitatively using the framework of thematic analysis. Thirteen themes were identified: relationships, appreciation of relationships, perspective and appreciation of life, new goals or priorities, understanding of SCI or disability, appreciation of health or health care, changed personality, opportunity or challenge, knowledge of SCI or body, newly acquired skills, spirituality, acceptance, and nothing. Descriptive statistics were incorporated in the presentation of the data.

CONCLUSIONS

This study provides evidence that a broad range of positive as well as negative psychological outcomes are possible following SCI. More research is needed to better understand the process through which these outcomes arise and to inform how such outcomes may be communicated to persons experiencing this type of injury.

Planning and structuring spinal cord injury rehabilitation: the needs assessment checklist

The study aimed to evaluate the Needs Assessment Checklist (NAC) as a clinically appropriate assessment tool for use during spinal cord injury (SCI) rehabilitation. Data were obtained during routine clinical assessments from 193 patients admitted to the National Spinal Injuries Centre, UK, from September 2007 to November 2009. Reliability analyses yielded high internal consistency coefficients (mean α = .889, SD .051), and the mean item internal validity correlation was .534 (SD .136). All subscales of the NAC were found to be highly significant to change between administrations (mean P <.001). Several differences were found on the NAC subscales with respect to gender, age, and mobility. Pain and psychological issues were associated with poorer rehabilitation outcomes. The NAC is demonstrated to be a clinically reliable assessment tool that can be used to structure rehabilitation progress by the generation of person-centered goals. The results highlight the importance of assessing psychological issues and pain during SCI rehabilitation.

Continuing with life as normal:: positive psychological outcomes following spinal cord injury

BACKGROUND

Research into the psychological sequelae of spinal cord injury (SCI) has focused on reports of psychological distress, despite the low prevalence rates of mental health difficulties. Positive psychological frameworks have begun to explore how some individuals do not report psychological distress, while appraisals have been posited as possible mediators of psychological outcome. Research into positive psychological outcomes in people with SCI is still in its infancy.

OBJECTIVE

To provide a description of the positive psychological outcomes experienced by people reporting low levels of psychological distress, to generate an understanding of how these individuals explain their positive outcomes, and to consider the implications for research, theory, and practice.

METHOD

Six participants (2 female, 4 male) reporting low levels of psychological distress were interviewed using a semi-structured interview schedule exploring their experiences. Interpretative phenomenological analysis was used to analyze data.

RESULTS

THREE SUPERORDINATE THEMES WERE IDENTIFIED: "living a normal life, just doing things differently," "overcoming challenges: determination to succeed," and "using the resources available to me." The description and explanation of a positive psychological outcome was complex. For participants, positive psychological outcomes did not exclude experiencing psychological difficulty; moreover, they described an ability to overcome difficulty. Challenge-focused appraisals, social support, and meaningful activity were identified by participants as being important to psychological outcome.

CONCLUSIONS

Positive psychological outcomes following SCI are complex, and research and theory need to better understand the experience of individuals following SCI in order to inform clinical practice.

Carbon-14 transfer into potato plants following a short exposure to an atmospheric 14CO2 emission: observations and model predictions

To improve the understanding of the environmental (14)C behaviour, the International Atomic Energy Agency (IAEA) coordinated a Tritium and C-14 Working Group (T&C WG) in its EMRAS (Environmental Modelling for Radiation Safety) programme. One of the scenarios developed in the frame of T&C WG involved the prediction of time dependent (14)C concentrations in potato plants. The experimental data used in the scenario were obtained from a study in which potatoes (Solanum tuberosum cv. Romano) were exposed to atmospheric (14)CO(2) in a wind tunnel. The observations were used to test models that predict temporal changes in (14)C concentrations in leaves at each sampling time for each experiment and (14)C concentrations in tubers at the final harvest of each experiment. The experimental data on (14)C dynamics in leaves are poorly reproduced by most of the models, but the predicted concentrations in tubers are in good agreement with the observations.

Examination of the communication interface between students with severe to profound and multiple intellectual disability and educational staff during structured teaching sessions

BACKGROUND

Individuals with severe to profound and multiple intellectual disability (S-PMID) tend to function at the earlier stages of communication development. Variable and highly individual means of communicating may present challenges to the adults providing support in everyday life. The current study aimed to examine the communication interface between students with S-PMID and educational staff.

METHOD

An in-depth, observational study of dyadic interaction in a class within the secondary part of a special school was conducted. The designated educational level was Key Stage 3 under the National Curriculum of England, which is typically for children from age 11 to 14 years attending a state school. There were four student-teacher dyads in the class. The students had multiple impairments with severely limited communication skills. Video capture of dyadic interaction was conducted during five English lessons and sampled to 2.5 min per dyad per lesson. The video footage was transcribed into standard orthography, detailing the vocal and non-vocal aspects. A coding framework guided by the principles of structural-functional linguistics was used to determine the nature of dyadic interaction, comprising linguistic moves, functions and communicative modalities. The relative contributions of student and teacher to the interaction were examined.

RESULTS

Significant differences were found between the students and educational staff on the majority of the measures. The teachers dominated the interaction, occupying significantly more turns than the students. Teacher turns contained significantly more initiations and follow-up moves than the students, who used more response moves. Teacher communication mainly served the functions of requesting and information giving. Feedback and scripted functions were also significantly greater among teacher turns, with only limited occurrence among the students. Self- or shared-expression was greatest among the students. The modalities of speech, touch, singing and objects were used by the teachers for the purpose of communication, whereas vocalisation and gesture were used by the students.

CONCLUSIONS

Despite differences in the availability of communication skills, both student and teacher were able to make their respective contributions to the interaction during classroom activity. Features of the student-teacher interface retained critical features seen in studies of more able individuals with intellectual disability. Scaffolding provided by teachers appears to be relevant to the communicative contributions of individuals functioning at the earliest stages of communication. The coding framework based on structural-functional linguistics provides some new potential for examining and enhancing the communication interface between individuals with S-PMID and the people who support them.

In vivo imaging and quantification of carbonic anhydrase IX expression as an endogenous biomarker of tumor hypoxia

Carbonic anhydrase IX (CA IX) is a transmembrane protein that has been shown to be greatly upregulated under conditions of hypoxia in many tumor cell lines. Tumor hypoxia is associated with impaired efficacy of cancer therapies making CA IX a valuable target for preclinical and diagnostic imaging. We have developed a quantitative in vivo optical imaging method for detection of CA IX as a marker of tumor hypoxia based on a near-infrared (NIR) fluorescent derivative of the CA IX inhibitor acetazolamide (AZ). The agent (HS680) showed single digit nanomolar inhibition of CA IX as well as selectivity over other CA isoforms and demonstrated up to 25-fold upregulation of fluorescent CA IX signal in hypoxic versus normoxic cells, which could be blocked by 60%-70% with unlabeled AZ. CA IX negative cell lines (HCT-116 and MDA-MB-231), as well as a non-binding control agent on CA IX positive cells, showed low fluorescent signal under both conditions. In vivo FMT imaging showed tumor accumulation and excellent tumor definition from 6-24 hours. In vivo selectivity was confirmed by pretreatment of the mice with unlabeled AZ resulting in >65% signal inhibition. HS680 tumor signal was further upregulated >2X in tumors by maintaining tumor-bearing mice in a low oxygen (8%) atmosphere. Importantly, intravenously injected HS680 signal was co-localized specifically with both CA IX antibody and pimonidazole (Pimo), and was located away from non-hypoxic regions indicated by a Hoechst stain. Thus, we have established a spatial correlation of fluorescence signal obtained by non-invasive, tomographic imaging of HS680 with regions of hypoxia and CA IX expression. These results illustrate the potential of HS680 and combined with FMT imaging to non-invasively quantify CA IX expression as a hypoxia biomarker, crucial to the study of the underlying biology of hypoxic tumors and the development and monitoring of novel anti-cancer therapies.

Immediate breast reconstruction and psychological adjustment in women who have undergone surgery for breast cancer: a preliminary study

Current debate exists regarding the timing of reconstructive surgery following mastectomy for breast cancer, with research pointing in favour of immediate reconstruction. This cross-sectional study sought to compare the psychological outcome of breast cancer treatment in women who had either received mastectomy and immediate reconstruction using autogenous tissue (n = 30), or mastectomy alone (n = 34), and also determine adjustment factors in this population as a whole. Participants completed measures of depression, anxiety, body image, self-esteem, coping and perceived social support at a time point 3 - 15 months after initial surgery. No significant differences were revealed between the two groups on any of the outcome measures. Poor body image, low self-esteem, and a tendency to use coping strategies characterized by helpless/hopelessness and anxious preoccupation, rather than fighting spirit, were highly predictive of distress. Reasons for the lack of differences between the two groups are explored.

Abstract 3949: In vivo imaging of tumor hypoxia by a new near-infrared fluorescent carbonic anhydrase IX-targeted agent

Carbonic anhydrase IX (CA IX), a cell surface enzyme involved in tumor cell acidification, is induced during tumor hypoxia (lack of oxygen) in many different types of tumors. CA IX expression is correlated to tumor cell proliferation and metastasis, poor prognosis, and resistance to therapeutic intervention, making CA IX an important biomarker in the study of hypoxia, tumor cell proliferation, and therapy. Therefore, determination of CAIX expression and identification of hypoxic tumors in vivo are critical for cancer research and treatments. We have designed and synthesized a near-infrared (NIR) fluorescent agent (VM3219) for in vivo detection and quantification of a cell surface biomarker of hypoxia, CA IX based on a well-known CA IX inhibitor, acetazolamide. VM3219 was characterized extensively in HeLa cells and in mouse HeLa tumor xenografts. Preliminary chemical and biochemical characterization of VM3219 showed excellent CA IX selectivity and affinity. In vitro, VM3219 detected 4-7-fold up-regulation of CA IX in live hypoxic HeLa cells as visualized by fluorescence microscopy and quantified by flow cytometry. VM3219 fluorescence signals were blocked by 80% when cells were pre-incubated with unlabeled acetazolamide. Fluorescent signal of VM3219 was low in normoxic HeLa cells and was comparable to the signal that were detected by using a non-binding control agent (VM3182) incubated with normoxic or hypoxic cells. In vivo imaging by fluorescence molecular tomography (FMTTM) showed that approximately 5% of the injected dose (2 nmol VM3219) was retained in the tumor tissues after 24 h (100 -120 pmol), 10-20-fold more than measured with a non-binding control agent. Tumor fluorescence was blocked &gt;65% by prophylactic acetazolamide treatment. Maintenance of tumor-bearing mice on low oxygen (8%), as compared to normally housed tumor bearing mice (20% oxygen), induced a &gt;2X (∼250 pmol) increase in VM3219 tumor fluorescence signal suggesting that CAIX expression was up-regulated within tumors by low oxygen. In tissue sections, VM3219 signal was shown to be specifically co-localized in the tumor hypoxic regions with CA IX antibody and Hypoxyprobe (pimonidazole), and the signal was away from non-hypoxic regions as determined by Hoechst stain. In conclusion, VM3219 is a new non-invasive tumor hypoxia imaging agent that offers a tool for specific imaging of a biologically important hypoxia biomarker, CA IX.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 3949. doi:1538-7445.AM2012-3949

What about us? Children's experiences of living with a sibling with spinal cord injury

Spinal cord injury is a life transforming condition that is thought to have an impact on the entire family of the affected individual. The needs and psychological outcomes of siblings of children with spinal cord injury (SCI) have not been researched. The current study focuses on the experiences of children living with a brother or sister with SCI. Eight participants (4 male, 4 female) aged between 7 and 18 years were interviewed using a semi-structured interview, concentrating on their unique experiences and understandings of having a brother or sister with SCI. The qualitative method of Interpretative Phenomenological Analysis (IPA) was used to analyze the data and three main themes were identified: "Life interrupted", "What about me?" and "My safety net". Results are discussed in relation to attachment and coping and adjustment theories. The discussion also highlights the clinical implications for siblings and parents of children affected by SCI, and for professionals who work within pediatric SCI settings.

Appraisals, coping and adjustment pre and post SCI rehabilitation: a 2-year follow-up study

STUDY DESIGN

Longitudinal, multi-wave panel design.

OBJECTIVES

To explore the changes in and the relationships between appraisals and coping with mood, functioning and quality-of-life (QOL) pre- and post-rehabilitation for acute spinal cord injury (SCI).

SETTING

The data collected was part of an ongoing study from specialist units in selected British, Swiss, German and Irish SCI centres.

METHODS

Questionnaires (Functional Independence, QOL, Mood, Appraisals, Coping and Support) were administered to 232 patients at 12 weeks post injury and sent to participants at 1 and 2 years post injury by post.

RESULTS

Significant changes were observed in various outcome measures between 12 weeks and 1 year post injury, with little significant change occurring during the following year. Appraisals and coping at 12 weeks post injury were significantly related to outcome scores and also contributed significantly to the variance in QOL, mood and stress-related growth at 2 years post injury.

CONCLUSION

The study provides further evidence for the link between appraisals, coping and subsequent adjustment to injury. Suggestion is made for the potential benefit of early assessment and intervention for patients at risk of poor adjustment to SCI.

Florbetapir f-18: a histopathologically validated Beta-amyloid positron emission tomography imaging agent

Florbetapir F-18 is a molecular imaging agent combining high affinity for β-amyloid, pharmacokinetic properties that allow positron emission tomography (PET) imaging within a convenient time after dose administration, and the wide availability of the radionuclide fluorine-18. Florbetapir F-18 is prepared by nucleophilic radiofluorination in approximately 60 minutes with a decay-corrected yield of 20%-40% and with a specific activity typically exceeding 100 Ci/mmol. The florbetapir F-18 dissociation constant (K(d)) for binding to β-amyloid in brain tissue from Alzheimer's disease (AD) patients was 3.7 ± 0.3 nmol/L, and the maximum binding capacity (B(max)) was 8800 ± 1600 fmol/mg protein. Autoradiography studies have shown that florbetapir F-18 selectively binds to β-amyloid aggregates in AD patient brain tissue, and the binding intensity is correlated with the density of β-amyloid quantified by standard neuropathologic techniques. Studies in animals revealed no safety concerns and rapid and transient normal brain uptake (6.8% injected dose/g at 2 minutes and 1.9% injected dose/g at 60 minutes in the mouse). Florbetapir F-18 has been well-tolerated in studies of more than 2000 human subjects. Biodistribution studies in humans revealed predominantly hepatobiliary excretion. The whole body effective dose was 7 mSv from a dose of 370 MBq. The pharmacokinetic of florbetapir F-18 make it possible to obtain a PET image with a brief (10 minutes) acquisition time within a convenient time window of 30-90 minutes after dose administration. Clinical studies have demonstrated a clear correlation between in vivo PET imaging with florbetapir F-18 and postmortem histopathologic quantitation of β-amyloid in the brain.

Psychological contributions to functional independence: a longitudinal investigation of spinal cord injury rehabilitation

OBJECTIVES

To investigate the contribution of prerehabilitation appraisals of spinal cord injury (SCI) and patient's coping strategies to the variance in functional independence postdischarge.

DESIGN

Longitudinal, cohort study. Patients aged 16 and older and sustaining an SCI were recruited from English- and German-speaking specialist spinal injuries centers. Measures of appraisals, coping strategies, mood, and functional independence were administered on commencing active rehabilitation (12-weeks postinjury) and following hospital discharge (1-y postinjury).

SETTING

Specialist SCI rehabilitation centers in England, Germany, Switzerland, and Ireland.

PARTICIPANTS

Patients (N=127) completed questionnaires at both time points. Sample age ranged between 17.5 and 64.5 years with a mean age of 39.3 years. Demographic and injury characteristics were similar to those reported in international statistics databases.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

FIM (motor subscale).

RESULTS

Injury characteristics, age, sex, current depression, and the utilization of the coping strategy, social reliance, at 12-weeks postinjury explained 33.5% of the variance in motor FIM at 1-year postinjury. Strong relationships were found between appraisals, coping styles, mood, and functional outcomes.

CONCLUSIONS

The coping strategy, social reliance, was found to contribute significantly when explaining the variance in functional outcomes. Suggestions were made to assess appraisals and coping strategies early in rehabilitation in order to provide effective interventions and additional support to those scoring highly on negative coping styles. Further research is recommended to provide support for the relationship between dependent coping strategies and functional outcomes.

Mutations in the N-terminal actin-binding domain of filamin C cause a distal myopathy

Linkage analysis of the dominant distal myopathy we previously identified in a large Australian family demonstrated one significant linkage region located on chromosome 7 and encompassing 18.6 Mbp and 151 genes. The strongest candidate gene was FLNC because filamin C, the encoded protein, is muscle-specific and associated with myofibrillar myopathy. Sequencing of FLNC cDNA identified a c.752T>C (p.Met251Thr) mutation in the N-terminal actin-binding domain (ABD); this mutation segregated with the disease and was absent in 200 controls. We identified an Italian family with the same phenotype and found a c.577G>A (p.Ala193Thr) filamin C ABD mutation that segregated with the disease. Filamin C ABD mutations have not been described, although filamin A and filamin B ABD mutations cause multiple musculoskeletal disorders. The distal myopathy phenotype and muscle pathology in the two families differ from myofibrillar myopathies caused by filamin C rod and dimerization domain mutations because of the distinct involvement of hand muscles and lack of pathological protein aggregation. Thus, like the position of FLNA and B mutations, the position of the FLNC mutation determines disease phenotype. The two filamin C ABD mutations increase actin-binding affinity in a manner similar to filamin A and filamin B ABD mutations. Cell-culture expression of the c.752T>C (p.Met251)Thr mutant filamin C ABD demonstrated reduced nuclear localization as did mutant filamin A and filamin B ABDs. Expression of both filamin C ABD mutants as full-length proteins induced increased aggregation of filamin. We conclude filamin C ABD mutations cause a recognizable distal myopathy, most likely through increased actin affinity, similar to the pathological mechanism of filamin A and filamin B ABD mutations.