Improving the quality of care of children in community clinics: an intervention and evaluation in Bangladesh

SETTING

Community health care providers (CHCPs) in 40 rural community clinics of Comilla district, Bangladesh, were trained using a newly developed case-management job aid based on the World Health Organization Integrated Management of Childhood Illness and a communication guide.

OBJECTIVES

To assess 1) the change in knowledge of the CHCPs after training; 2) the absolute quality of care provided by the CHCPs (determined as the proportion of children aged <5 years [under-fives] correctly diagnosed, treated and referred); and 3) the consultation behaviour of the CHCPs.

DESIGN

Change in knowledge was assessed by tests pre-and post-training. The quality of care was determined by reassessments at the clinic exit by a medical officer, without a baseline comparison. Consultation behaviour was assessed through direct observation. The study was performed during 2014-2015.

RESULTS

The mean standard knowledge score of the CH-CPs increased from 19 to 25 (P < 0.001). Of 1490 under-fives examined, 91% were correctly diagnosed, 86% were correctly treated and 99.5% received a correct referral decision. The CHCPs performed well on most of the measures of good communication, although one third did not explain the diagnosis and treatment to patients.

CONCLUSION

The training was effective in changing knowledge. The CHCPs applied the knowledge gained and provided good quality care. Following these results, the Bangladesh Ministry of Health and Family Welfare has scaled up the training nationwide. The lessons learnt should be useful for other countries.

Immune Modulation with Thymosin Alpha 1 Treatment

Thymosin alpha 1 (Ta1) is a peptide originally isolated from thymic tissue as the compound responsible for restoring immune function to thymectomized mice. Ta1 has a pleiotropic mechanism of action, affecting multiple immune cell subsets that are involved in immune suppression. Ta1 acts through Toll-like receptors in both myeloid and plasmacytoid dendritic cells, leading to activation and stimulation of signaling pathways and initiation of production of immune-related cytokines. Due to the immune stimulating effects of Ta1, the compound would be expected to show utility for treatment of immune suppression, whether related to aging or to diseases such as infection or cancer. Extensive studies in both the preclinical and clinical setting will be summarized in the subsequent sections. These studies have demonstrated improvements in immune system cell subsets and the potential of Ta1 for the treatment of a range of diseases.

Multiplex PCR and Microarray for Detection of Swine Respiratory Pathogens

Porcine respiratory disease complex (PRDC) is one of the most important health concerns for pig producers and can involve multiple viral and bacterial pathogens. No simple, single‐reaction diagnostic test currently exists for the simultaneous detection of major pathogens commonly associated with PRDC. Furthermore, the detection of most of the bacterial pathogens implicated in PRDC currently requires time‐consuming culture‐based methods that can take several days to obtain results. In this study, a novel prototype automated microarray that integrates and automates all steps of post‐PCR microarray processing for the simultaneous detection and typing of eight bacteria and viruses commonly associated with PRDC is described along with associated multiplex reverse transcriptase PCR. The user‐friendly assay detected and differentiated between four viruses [porcine reproductive and respiratory syndrome virus (PRRSV), influenza A virus, porcine circovirus type 2, porcine respiratory corona virus], four bacteria (Mycoplasma hyopneumoniae, Pasteurella multocida, Salmonella enterica serovar Choleraesuis, Streptococcus suis), and further differentiated between type 1 and type 2 PRRSV as well as toxigenic and non‐toxigenic P. multocida. The assay accurately identified and typed a panel of 34 strains representing the eight targeted pathogens and was negative when tested with 34 relevant and/or closely related non‐target bacterial and viral species. All targets were also identified singly or in combination in a panel of clinical lung samples and/or experimentally inoculated biological material.

Behaviour change techniques and contraceptive use in low and middle income countries: a review

We aimed to identify effective behaviour change techniques to increase modern contraceptive use in low and middle income countries (LMICs). Literature was identified in Global Health, Web of Science, MEDLINE, PsycINFO and Popline, as well as peer reviewed journals. Articles were included if they were written in English, had an outcome evaluation of contraceptive use, modern contraceptive use, contraceptive initiation/uptake, contraceptive adherence or continuation of contraception, were a systematic review or randomised controlled trial, and were conducted in a low or middle income country. We assessed the behaviour change techniques used in each intervention and included a new category of male partner involvement. We identified six studies meeting the inclusion criteria. The most effective interventions were those that involve male partner involvement in the decision to initiate contraceptive use. The findings also suggest that providing access to contraceptives in the community promotes their use. The interventions that had positive effects on contraceptive use used a combination of behaviour change techniques. Performance techniques were not used in any of the interventions. The use of social support techniques, which are meant to improve wider social acceptability, did not appear except in two of the interventions. Our findings suggest that when information and contraceptives are provided, contraceptive use improves. Recommendations include reporting of behaviour change studies to include more details of the intervention and techniques employed. There is also a need for further research to understand which techniques are especially effective.

Irish GP attitudes towards sickness certification and the 'fit note'

BACKGROUND

Sickness certification poses significant challenges to most general practitioners (GPs). As an alternative form of certification, in 2010, the UK implemented the 'fit note', which focuses on returning to work after illness. It has been well received in the UK but little is known of non-UK GP attitudes towards the fit note.

AIMS

To evaluate the challenges Irish GPs experience with the current sickness certification system and their attitudes towards the fit note.

METHODS

A questionnaire assessing attitudes, practices and preferences regarding the fit note was developed, piloted and posted to a representative sample of Irish GPs selected by systematic sampling. Descriptive statistics, chi-square tests and binary logistic regression were used to analyse the results.

RESULTS

Of 305 GPs surveyed, 64% (196) completed the survey. Ninety per cent (177) of responders reported a lack of available rehabilitation services for patients on sick leave and 66% (124) reported adverse effects of sickness certification on therapeutic relationships with patients. Those who indicated a preference for introducing the fit note (53%; 104) were significantly more likely to endorse both an excessive focus on disability [odds ratio (OR) = 3.16] and lack of GP training (OR = 2.04) in the sickness certification process.

CONCLUSIONS

Difficulties associated with sickness certification are apparent at GP-patient, GP-employer and GP-health service levels. Addressing these will require intervention at each of these levels and may be facilitated by challenging the assumption that illness equates to disability.

Plasma levels of mannan-binding lectin-associated serine proteases MASP-1 and MASP-2 are elevated in type 1 diabetes and correlate with glycaemic control

There is increasing evidence that the complement system plays an important role in diabetes and the development of diabetic vascular complications. In particular, mannan-binding lectin (MBL) levels are elevated in diabetes patients, and diabetes patients with diabetic nephropathy have higher MBL levels than diabetes patients with normal renal function. The MBL-associated serine proteases (MASPs) MASP-1, MASP-2 and MASP-3 and MBL-associated protein MAp44 have not yet been studied in diabetes patients. We therefore measured plasma levels of MASP-1, MASP-2, MASP-3 and MAp44 in 30 children with type 1 diabetes mellitus (T1DM) and 17 matched control subjects, and in 45 adults with T1DM and 31 matched control subjects. MASP-1 and MASP-2 levels were significantly higher in children and adults with T1DM than in their respective control groups, whereas MASP-3 and MAp44 levels did not differ between patients and controls. MASP-1 and MASP-2 levels correlated with HbA1c, and MASP levels decreased when glycaemic control improved. Because MASP-1 and MASP-2 have been shown to interact directly with blood coagulation, elevated levels of these proteins may play a role in the enhanced thrombotic environment and consequent vascular complications in diabetes.

Differential expression of the adaptor protein HSH2 inversely affects class-switched antibody production and antibody-secreting cell generation (LYM7P.617)

Hematopoietic Src homology 2 domain (HSH2) is a conserved adapter protein that exhibits differential expression in peripheral B cell subsets. The reason for this differential expression is not clear. Therefore, to assess the impact of differential HSH2 expression on B cell function, we employed mouse models expressing either high or low levels of HSH2. Following immunization with either TI or TD antigens, we observed a marked alteration in class-switched antibody (Ab) production that inversely correlated with HSH2 levels, with the greatest effect being on IgG3. Furthermore, in vitro and in vivo we observed a decreased number of class-switched Ab-secreting cells (ASC) in the HSH2hi mice and an increase in ASCs in the HSH2lo mice. Overall, these data show that HSH2 levels inversely correlate with class-switched Ab production likely through alteration of class-switched B cell differentiation into ASCs. This novel function of HSH2 reveals its importance in B cell biology. Because HSH2 acts as a potential rheostat able to modulate the production of class-switched B cells depending on its expression level, this highlights the potential for HSH2 to play an important role in disease processes involving class-switched Abs and for vaccine development where generation of class-switched high-affinity Abs is the goal.

Regulation of the HSH2 adaptor protein turnover via an indirect NF-κB-dependent mechanism is involved in determining the nature of the class switched antibody response. (IRM10P.609)

The Hematopoietic SH2 containing adaptor protein (HSH2) is differentially expressed in mature, peripheral B cell subpopulations, exhibiting low level expression in germinal center (GC) B cells versus high-level expression in B1 and marginal zone B cells. Studies have demonstrated an inverse relationship between its expression and the production of class-switched antibodies due to effects on terminal differentiation. Therefore, delineation of molecular mechanism that controls its expression is critical for understanding the class-switched antibody response. Studies demonstrated that upregulation of HSH2 following TNF family receptor or TLR-mediated signals, as well as its maintenance, requires NF-κB activity. Using both pharmacological and genetic approaches, it was shown that the canonical pathway is critical for maintenance of HSH2 expression. Inhibition of NF-kB selectively results in the rapid loss of HSH2, whereas actinomycin D and cycloheximide treatment do not. Analysis of the canonical pathway revealed that maintenance of HSH2 requires translocation of NF-κB to the nucleus. Because HSH2 mRNA levels are not altered under any conditions, it is hypothesized that NF-κB indirectly regulates the function of a short-lived protease that regulates HSH2 expression at the protein. These results reveal a potentially novel mechanism, in which NF-κB regulates HSH2 expression via one or more proteases and may represent a novel paradigm for controlling GC B cell function.

Calcitonin gene-related peptide: physiology and pathophysiology

Calcitonin gene-related peptide (CGRP) is a 37-amino acid neuropeptide. Discovered 30 years ago, it is produced as a consequence of alternative RNA processing of the calcitonin gene. CGRP has two major forms (α and β). It belongs to a group of peptides that all act on an unusual receptor family. These receptors consist of calcitonin receptor-like receptor (CLR) linked to an essential receptor activity modifying protein (RAMP) that is necessary for full functionality. CGRP is a highly potent vasodilator and, partly as a consequence, possesses protective mechanisms that are important for physiological and pathological conditions involving the cardiovascular system and wound healing. CGRP is primarily released from sensory nerves and thus is implicated in pain pathways. The proven ability of CGRP antagonists to alleviate migraine has been of most interest in terms of drug development, and knowledge to date concerning this potential therapeutic area is discussed. Other areas covered, where there is less information known on CGRP, include arthritis, skin conditions, diabetes, and obesity. It is concluded that CGRP is an important peptide in mammalian biology, but it is too early at present to know if new medicines for disease treatment will emerge from our knowledge concerning this molecule.

Production of class switched antibody secreting cells and antibody is inversely correlated with expression of the adaptor protein HSH2 (IRM8P.712)

Control and HSH2 transgenic (HSH2-Tg) mice were compared to mice that express approximately 1/6th the normal level of HSH2 (HSH2-Lo) to determine if there is an inverse relationship between HSH2 expression and class switched antibody (Ab) production. In contrast to HSH2-Tg mice, HSH2-Lo mice have normal serum Ig titers for IgG1 and IgG2b and elevated titers of IgG3. HSH2-Lo mice also exhibit enhanced production of IgG1, and IgG2b, or IgG3 in response to challenge with either TD or TI Ag, respectively. Stimulation of B cells isolated from HSH2-Lo mice with anti-CD40 and IL-4 results in the production of significantly more antibody secreting cells (ASC) that produce IgG1 and IgE versus control B cells, whereas HSH2-Tg B cells produce significantly fewer class switched ASCs. Although HSH2 expression is associated with a modest effect on class switch recombination, changes in class switched ASC production are most closely linked to alterations in terminal differentiation of GC B cells into plasma cells. Terminal differentiation of class switched B cells from HSH2-Lo mice is significantly increased following in vitro stimulation, resulting in enhanced production of class switched ASCs compared to control B cells. Conversely, class switched B cells generated from HSH2-Tg mice exhibit a significant decrease in differentiation into ASCs in vitro. Thus, differential expression of HSH2 in the B lineage regulates multiple steps associated with the generation of class switched ASCs.

Regulation of HSH2 adaptor protein turnover via a novel NF-κB-dependent mechanism is involved in determining the nature of the class switched antibody response (IRM8P.715)

The Hematopoietic Src Homology 2 (HSH2) adaptor protein is differentially expressed in mature, peripheral B cell subpopulations; exhibiting high-level expression in B1 and marginal zone B cells versus low-level expression in germinal center B cells, independent of gene transcription. HSH2 plays an important role in regulating the production of class switched antibodies through its effect on B cell class switching and terminal differentiation. Mouse models revealed that over expression of HSH2 in the B cell lineage attenuates the class switched antibody response, whereas reduced expression accelerates the class switched response. Thus, it is of significant interest to delineate the molecular mechanisms by which expression of HSH2 is controlled. Upregulation of HSH2 expression in response to TNF receptor family and TLR agonists occurs in an NF-κB-dependent manner, yet does not involve increased transcription of the HSH2 locus based on analysis of HSH2 mRNA levels. Additionally, maintenance of HSH2 expression is dependent on NF-κB signaling. Inhibition of NF-κB results in the rapid down regulation of HSH2 with a half-life of 1 hour, which is in contrast to the results obtained following treatment with cycloheximide or actinomycin D demonstrating that mRNA for HSH2 is stable and the protein itself has a half-life greater than 12 hours. These data support the conclusion that HSH2 protein stability is regulated post-transcriptionally via a novel NF-κB-dependent mechanism.

CD19 cytoplasmic tyrosines 482 and 513 mediating binding to PI3K are sufficient to reconstitute the T-dependent humoral immune response (IRM8P.713)

CD19 is a co-stimulatory receptor on B cells that has been shown to play a critical role in regulating B cell differentiation and the humoral immune response. In mice lacking CD19 expression, B1 and marginal zone (MZ) B cell subpopulations are absent and the T-dependent humoral response is severely impaired in association with defective GC B cell generation and GC responses resulting in loss of class switching, affinity maturation and ultimately the failure to generate Ag-specific memory B cells and Ab secreting cells (ASC) that produce class switched, high affinity Abs. Previous studies have demonstrated the selective mutation of tyrosines 482 and 513 (4/5F mice) in the cytoplasmic domain of CD19 is sufficient to recapitulate the phenotype associated with complete loss of CD19 expression. In the present study, mice were generated in which CD19 is expressed containing only Y482 and Y513 in the absence of the other seven cytoplasmic tyrosine residues (4/5Y mice). Analysis of 4/5Y mice revealed that these residues alone are sufficient to restore B1 and MZ B cell development as well as the T-dependent humoral immune response. Studies to examine mice expressing CD19 with a selective mutation to either tyrosine 482 or 513 revealed a preferential requirement for tyrosine 482 to promote a normal humoral response. These data support the conclusion that CD19 predominantly contributes to normal B cell development and the T-dependent humoral response through its recruitment of PI3K.

Evaluation of antimicrobial resistance profiles of Salmonella isolates from broiler chickens at slaughter in Alberta, Canada

Antimicrobial-resistant Salmonella species are threatening to become a serious public health problem. Therefore, surveillance and prudent use of antimicrobials is needed in both the agricultural and human health sectors. The aim of this study was to describe the antimicrobial susceptibility profiles of Salmonella isolates recovered from healthy broiler chickens at slaughter from November 2004 to April 2005. Salmonella isolates recovered from 36 broiler flocks in Alberta, Canada, were serotyped and tested for antimicrobial susceptibility against 15 antimicrobials. Of 272 Salmonella isolates tested, 64.0% were resistant to one or more antimicrobials, 10.0% were resistant to three or more antimicrobials, and 1.8% were resistant to five antimicrobials. All isolates were susceptible to amikacin, amoxicillin-clavulanic acid, ceftiofur, cefoxitin, ceftriaxone, ciprofloxacin, and nalidixic acid. The highest prevalence of resistance was to tetracycline (54.8%), followed by streptomycin (24.2%) and sulfisoxazole (8.4%). The most common multiantimicrobial resistance patterns were to streptomycin-tetracycline (24.3%), streptomycin-sulfisoxazole-tetracycline (6.6%), and ampicillin-streptomycin-sulfisoxazole-tetracycline (3.7%). The strongest associations were observed between resistance to kanamycin and tetracycline (odds ratio = 65.7, P = 0.001) and to ampicillin and sulfisoxazole (odds ratio = 62.9, P = 0.001). Salmonella Hadar and Salmonella Heidelberg were the two most common serovars accounting for 40.4 and 13.6% of the total isolates, respectively. Eighty-one percent and 12.7% of Salmonella Hadar isolates and 62.0 and 8.1% of Salmonella Heidelberg isolates were resistant to 1 or more and three or more antimicrobials, respectively. The flock level prevalence of resistance ranged from 5.6% for trimethoprim-sulfamethoxazole to 83.3% for tetracycline. This study provides baseline information on antimicrobial susceptibility of Salmonella isolates of broiler chickens at slaughter in Alberta that can serve as a benchmark for future research.

An ongoing role of α-calcitonin gene-related peptide as part of a protective network against hypertension, vascular hypertrophy, and oxidative stress

α-Calcitonin gene-related peptide (αCGRP) is a vasodilator, but there is limited knowledge of its long-term cardiovascular protective influence. We hypothesized that αCGRP protects against the onset and development of angiotensin II-induced hypertension and have identified protective mechanisms at the vascular level. Wild-type and αCGRP knockout mice that have similar baseline blood pressure were investigated in the angiotensin II hypertension model for 14 and 28 days. αCGRP knockout mice exhibited enhanced hypertension and aortic hypertrophy. αCGRP gene expression was increased in dorsal root ganglia and at the conduit and resistance vessel level of wild-type mice at both time points. βCGRP gene expression was also observed and shown to be linked to plasma levels of CGRP. Mesenteric artery contractile and relaxant responses in vitro and endothelial NO synthase expression were similar in all groups. The aorta exhibited vascular hypertrophy, increased collagen formation, and oxidant stress markers in response to angiotensin II, with highest effects observed in αCGRP knockout mice. Gene and protein expression of endothelial NO synthase was lacking in the aortae after angiotensin II treatment, especially in αCGRP knockout mice. These results demonstrate the ongoing upregulation of αCGRP at the levels of both conduit and resistance vessels in vascular tissue in a model of hypertension and the direct association of this with protection against aortic vascular hypertrophy and fibrosis. This upregulation is maintained at a time when expression of aortic endothelial NO synthase and antioxidant defense genes have subsided, in keeping with the concept that the protective influence of αCGRP in hypertension may have been previously underestimated.