Introducing an Ethics Framework for health priority-setting in South Africa on the path to universal health coverage

BACKGROUND

South Africa (SA) has embarked on a process to implement universal health coverage (UHC) funded by National Health Insurance (NHI). The 2019 NHI Bill proposes creation of a health technology assessment (HTA) body to inform decisions about which interventions NHI funds will cover under UHC. In practice, HTA often relies mainly on economic evaluations of cost-effectiveness and budget impact, with less attention to the systematic, specific consideration of important social, organisational and ethical impacts of the health technology in question. In this context, the South African Values and Ethics for Universal Health Coverage (SAVE-UHC) research project recognised an opportunity to help shape the health priority-setting process by providing a way to take account of multiple, ethically relevant considerations that reflect SA values. The SAVE-UHC Research Team developed and tested an SA-specific Ethics Framework for HTA assessment and analysis.

OBJECTIVES

To develop and test an Ethics Framework for use in the SA context for health priority-setting.

METHODS

The Framework was developed iteratively by the authors and a multidisciplinary panel (18 participants) over a period of 18 months, using the principles outlined in the 2015 NHI White Paper as a starting point. The provisional Ethics Framework was then tested with multi-stakeholder simulated appraisal committees (SACs) in three provinces. The membership of each SAC roughly reflected the composition of a potential SA HTA committee. The deliberations and dedicated focus group discussions after each SAC meeting were recorded, analysed and used to refine the Framework, which was presented to the Working Group for review, comment and final approval.

RESULTS

This article describes the 12 domains of the Framework. The first four (Burden of the Health Condition, Expected Health Benefits and Harms, Cost-Effectiveness Analysis, and Budget Impact) are commonly used in HTA assessments, and a further eight cover the other ethical domains. These are Equity, Respect and Dignity, Impacts on Personal Financial Situation, Forming and Maintaining Important Personal Relationships, Ease of Suffering, Impact on Safety and Security, Solidarity and Social Cohesion, and Systems Factors and Constraints. In each domain are questions and prompts to enable use of the Framework by both analysts and assessors. Issues that arose, such as weighting of the domains and the availability of SA evidence, were discussed by the SACs.

CONCLUSIONS

The Ethics Framework is intended for use in priority-setting within an HTA process. The Framework was well accepted by a diverse group of stakeholders. The final version will be a useful tool not only for HTA and other priority-setting processes in SA, but also for future efforts to create HTA methods in SA and elsewhere.

[Association between obesity with the diversity and genus of gut microbiota in school-aged children]

Objective: To analyze the diversity differences of gut microbiota between school-aged obese children and normal-weight children and identify the characteristic flora in obese children to provide some evidence for the subsequent study of the following study-related mechanisms and the prevention and treatment of obesity in school-aged children. Methods: This study was based on a cohort established in a primary school in Jiading district, Shanghai, 2016. Sixty-three children, including 43 boys and 20 girls, who were obese during the three years from 2016 to 2018, were enrolled in the obesity group. Among children who were average weight for three years, a total of 63 were selected as the control group, with matching with the obese ones in a 1 to 1 way according to age, sex and class. The primary characteristics, diet status, breastfeeding, and other information of children were collected by questionnaire. Fecal samples of participants in both groups were collected, and 16S rDNA sequencing was performed. Operable taxon units clustering according to 97% similarity and species annotation were based on the quality-optimized sequences. The difference in the diversity and genius of gut microbiota among children in the obesity and control groups were analyzed. The α diversity indices, including Ace, Chao1, Shannon, and Simpson index, were calculated. The β diversity was presented based on unweighted Unifrac distance and weighted Unifrac space by principal coordinate analysis. The differences in β diversity between the two groups were compared by similarity analysis (ANOSIM).The differences in genus distribution between the two groups were selected by STAMP software. The association of obesity with the α diversity and genus with significant differences were analyzed by the generalized linear model (GLM). Results: The Ace and Chao1 index in the obesity group was significantly lower than those in the control group (The P values were 0.026 and 0.039, respectively). There was no significant difference in Shannon and Simpson index between the two groups (The P values were 0.879 and 0.922, respectively). The results of ANOSIM showed differences in gut microbiota between the two groups (R>0), but the group contribution was not significant (unweighted Unifrac distance: R=0.006, P=0.223; weighted Unifrac distance: R=0.010, P=0.134). Among the obese group, the relative abundance of Prevotella and Sarcina was highest in the endemic genus. The STAMP results showed that the relative lots of 15 genera were significantly different between the two groups (P<0.05). The results of GLM showed that, compared with the control group, the obesity group had a lower level of the relative abundance in Akkermansia muciniphila, while a higher level in Coprococcus_3, Ruminococcus, Agathobacter and Collinsella. After stratification by sex, the Chao1 index was also lower in the obese boys than that in the normal-weight boys. However, the obese girls only had a higher level in Coprococcus_3 than the ordinary weight girls. Conclusions: Compared with children with average weight, obese children had lower α diversity of gut microbiota and lower relative abundance of dominant probiotics but had a higher relative lot of genus associated with metabolic disorders, inflammation promotion, and metabolism rate reduction.

[Prenatal diagnosis and clinical outcomes of 297 fetuses with conotruncal defects]

Objective: To analyze the prenatal diagnosis results and pregnancy outcomes of conotruncal defects (CTD) fetuses, and to explore the correlation between the CTD and chromosome diseases. Methods: A total of 297 cases of invasive prenatal diagnosis and chromosome analysis were collected at the Prenatal Diagnosis Center of Guangzhou Women and Children's Medical Center due to CTD from January 1st, 2011 to December 31th, 2019. According to ultrasonic diagnosis, CTD fetuses were divided into 6 subtypes: tetralogy of Fallot (109 cases), pulmonary atresia (30 cases), transposition of the great arteries (77 cases), double outlet right ventricle (53 cases), truncus arteriosus (14 cases) and interrupted aortic arch (14 cases). According to whether they were combined with intracardiac or extracardiac abnormalities, they were divided into simple group (134 cases), combined with other intracardiac abnormalities group (86 cases), combined with extracardiac abnormalities group (20 cases), combined with intracardiac and extracardiac abnormalities group (37 cases) and only combined with ultrasound soft marker group (20 cases), the last 4 groups were referred as non-simple types. The chromosome test results and pregnancy outcomes of each type and group were analyzed retrospectively. Results: Among the 297 CTD fetuses, the chromosome abnormality rate was 17.5% (52/297). There were 21 cases of abnormal chromosome number, 28 cases of pathogenetic copy number variantions and 3 cases of mosaics. All the 19 cases of micropathogenic fragments smaller than 5 Mb were detected by chromosomal microarray analysis (CMA). Among all the subtypes of CTD, the chromosomal abnormality rate of truncus arteriosus was the highest, at 7/14; while the rate of transposition of the great arteries was the lowest, at 5.2% (4/77). There were significant differences in the rate of chromosomal abnormalities between simple and non-simple types [10.4% (14/134) vs 23.3% (38/163); χ²=8.428, P=0.004]. In each group, the chromosomal abnormality rate was the highest in the combined with intracardiac and extracardiac abnormalities group, at 37.8% (14/37), and the lowest in the simple group, at 10.4% (14/134). There was no significant difference in the rate of chromosomal abnormalities in all subtypes of simple group (all P>0.05). Among 112 cases of live birth, 1 case was 22q11.2 microdeletion syndrome, 5 cases of postnatal clinical diagnosis and prenatal ultrasound diagnosis were not completely consistent, 5 cases died after birth. Conclusions: The incidence of chromosomal abnormalities is high in fetuses with CTD. CTD fetuses with concurrent extrapardiac malformations are more likely to incorporate chromosomal abnormalities. CMA technology could be used as a first-line genetic detection method for CTD. After excluding chromosomal abnormalities, most of the children with CTD have good prognosis.

[Papillary renal neoplasm with reverse polarity: a clinicopathological analysis]

Objective: To study the clinical pathological characteristics, immunophenotype, molecular changes and prognosis of the papillary renal neoplasm with reverse polarity (PRNRP). Methods: Nine cases of PRNRP, diagnosed from 2013 to 2019, were retrieved from the Department of Pathology of Nanjing Jinling Hospital, Nanjing University School of Medicine. Histomorphology, immunophenotype and molecular genetics were analyzed with review of the literatures. Results: There were five male and four female patients, aged from 49 to 70 years, with an average age of 60.1 years. During a mean follow-up of 29 months, one patient died for other cause, and the others survived without disease. Microscopically, the tumor cells arranged in papillary structure with a fibrovascular core, the surface of which was covered with a single layer of cuboidal or columnar cells. The most prominent feature was that the tumor nuclei located at the top of the cytoplasm far from the basement membrane, and they were monotonous in size and arranged neatly with no or few nucleoli. Immunohistochemically, all nine cases of PRNRP showed diffuse positive expression of CK7 and E-cadherin, various degrees of P504s expression, and no expression of CD10 and CD117, with a Ki-67 index of 1%-3%. Unlike other papillary renal cell carcinoma, the nine cases of PRNRP all showed characteristic positive expression of GATA3. The fluorescence in situ hybridization assay showed that the majority of PRNRPs (8/9) did not have triploids on chromosomes 7 and 17. The sequencing of the KRAS gene confirmed the presence of a nonsense KRAS mutation in 8 of the 9 cases. Conclusions: PRNRP is a subtype of papillary renal cell carcinoma with characteristic morphological, immunophenotypic and molecular features, and indolent behaviors. More data are needed to define PRNRP as "carcinoma", and a definitive diagnosis of PRNRP is of great significance for proper treatment choice and accurate prognostication.

Genetic Variants miR-126, miR-146a, miR-196a2, and miR-499 in Polycystic Ovary Syndrome

Introduction: Alterations in certain microRNAs (miRNAs) and their target genes have reported in polycystic ovary syndrome (PCOS) and other disease of the female reproductive system, and so may be potential biomarkers. We hypothesised alterations in the prevalence of four miRNAs single nucleotide polymorphism (SNP) variants miR-126 rs4636297, miR-146a rs2910164, miR-196a2 rs11614913, and miR-499 rs3746444 in women with PCOS in comparison to healthy controls.

Methods: SNPs in the four miRNAs were determined in 385 patients and 385 controls by standard RT-PCR techniques.

Results: SNPs in miR-126 and miR-246a were significant linked with PCOS under the allelic, dominant, co-dominant, and recessive models (all p ≤ 0.01). The SNP in miR-499 was linked to PCOS in allelic (T, p = 0.002), dominant (p = 0.035) and recessive (p = 0.003) models. The SNPs -196a was significant linked to PCOS only in the recessive model (p = 0.037). Combining these SNPs in miR-499, mi146a, miR-196a and miR-126 respectively into allele haplotypes found highly significant odds ratios (95% CI) of 0.40 (0.29–0.54) (p < 0.001) for the C-G-C-G haplotype, and 0.46 (0.30–0.70) (p = 0.002) for the C-C-C-A haplotype (p = 0.002) for PCOS.

Conclusion: Single SNPs and haplotype combinations in certain SNPs in miR-126, miR-146a, miR-196a2 and miR-499 are strongly linked to PCOS, and so may be useful predictors of this condition.

Relations of Variety and Quantity of Dietary Proteins Intake from Different Sources with Mortality Risk: A Nationwide Population-Based Cohort

OBJECTIVES

The relations of variety and quantity of dietary proteins intake from different sources with mortality risk were still controversial. We aimed to examine the associations of variety and quantity of different sourced proteins with all-cause mortality risk in adults and older adults.

MATERIALS AND METHODS

17,310 participants (mean age was 44.0 [SD: 15.9] years and 51.0% were females) with utilizable data from the China Health and Nutrition Survey were included. Dietary intake was collected using three consecutive 24-h dietary recalls combined with a household food inventory. The variety score of protein sources was defined as the number of proteins consumed at the appropriate level, accounting for both types and quantity of proteins. The primary outcome was all-cause mortality.

RESULTS

Over a median follow-up of 9.0 years, 1324 (7.6%) death cases were reported. There were reversed J-shaped relationships of percentages energy from total protein, and protein from legume with all-cause mortality; U-shaped relationships of proteins from unprocessed red meat, processed red meat, poultry and whole grain with all-cause mortality; L-shaped relationships of proteins from egg and fish with all-cause mortality; and a reversed L-shaped relationship of protein from refined grain with all-cause mortality (all P values for nonlinearity < 0.001). Moreover, there was a significant inverse association between the variety score of protein sources with overall mortality risk (per score increment, HR, 0.69; 95%CI, 0.66-0.72).

CONCLUSIONS

Greater variety of proteins with appropriate quantity from different food sources was associated with significantly lower risk of mortality in Chinese adults and older adults.

Prediction and verification of survival in patients with non-small-cell lung cancer based on an integrated radiomics nomogram

AIM

To develop and validate a nomogram to predict 1-, 2-, and 5-year survival in patients with non-small-cell lung cancer (NSCLC) by combining optimised radiomics features, clinicopathological factors, and conventional image features extracted from three-dimensional (3D) computed tomography (CT) images.

MATERIALS AND METHODS

A total of 172 patients with NSCLC were selected to construct the model, and 74 and 72 patients were selected for internal validation and external testing, respectively. A total of 828 radiomics features were extracted from each patient's 3D CT images. Univariable Cox regression and least absolute shrinkage and selection operator (LASSO) regression were used to select features and generate a radiomics signature (radscore). The performance of the nomogram was evaluated by calibration curves, clinical practicability, and the c-index. Kaplan-Meier (KM) analysis was used to compare the overall survival (OS) between the two subgroups.

RESULT

The radiomics features of the NSCLC patients correlated significantly with survival time. The c-indexes of the nomogram in the training cohort, internal validation cohort, and external test cohort were 0.670, 0.658, and 0.660, respectively. The calibration curves showed that the predicted survival time was close to the actual survival time. Decision curve analysis shows that the nomogram could be useful in the clinic. According to KM analysis, the 1-, 2- and 5-year survival rates of the low-risk group were higher than those of the high-risk group.

CONCLUSION

The nomogram, combining the radscore, clinicopathological factors, and conventional CT parameters, can improve the accuracy of survival prediction in patients with NSCLC.

Single nucleotide polymorphisms rs102313, rs118231 and rs201832 of CTEP TaqIB gene correlated with lipid metabolism abnormalities and cerebral infarction in patients with atherosclerosis

OBJECTIVE

The purpose of this study was to investigate the correlations of cholesterol ester transfer protein (CTEP) TaqIB gene polymorphism with lipid metabolism abnormalities and cerebral infarction (CI) in patients with atherosclerosis (AS).

PATIENTS AND METHODS

A case-control study was conducted on 100 AS patients complicated with (CI) as AS+CI group, and 200 AS patients with matched age, gender and race as controls (AS group). Single nucleotide polymorphisms (SNPs) rs102313, rs118231 and rs201832 in the promoter region of CTEP TaqIB gene were classified by conformational differential gel electrophoresis. Then, Chi-square test was carried out to determine whether the distribution frequency of CTEP TaqIB genotypes conforms to the law of genetic equilibrium. In the meantime, the correlations of gene polymorphisms and allelotypes in the promoter region of CTEP TaqIB with CI and lipid metabolism abnormalities in AS patients were analyzed.

RESULTS

Hardy-Weinberg genetic equilibrium analysis showed that the three polymorphisms of CTEP TaqIB gene were in accordance with the genetic equilibrium distribution (p>0.05). Moreover, the results of gene association analysis revealed that the polymorphisms rs102313 and rs118231 and allelotypes in the promoter region of CTEP TaqIB gene were correlated with CI in AS patients (p<0.05). Specifically, AS patients with GG genotype and allele G at rs102313 and those with TT genotype and allele T at rs118231 had a higher risk of CI (p<0.05). Besides, the polymorphism rs102313 in the promoter region of CTEP TaqIB gene was markedly related to lipid metabolism abnormalities in AS patients (p<0.05).

CONCLUSIONS

The polymorphisms rs102313 and rs118231 in the promoter region of CTEP TaqIB gene are associated with CI in AS patients, and the polymorphism rs102313 is remarkably correlated with lipid metabolism abnormalities in AS patients.

Nanoscale Electrostatic Modulation of Mega-Ampere Electron Current in Solid-Density Plasmas

Transport of high-current relativistic electron beams in dense plasmas is of interest in many areas of research. However, so far the mechanism of such beam-plasma interaction is still not well understood due to the appearance of small time- and space-scale effects. Here we identify a new regime of electron beam transport in solid-density plasma, where kinetic effects that develop on small time and space scales play a dominant role. Our three-dimensional particle-in-cell simulations show that in this regime the electron beam can evolve into layered short microelectron bunches when collisions are relatively weak. The phenomenon is attributed to a secondary instability, on the space- and timescales of the electron skin depth (tens of nanometers) and few femtoseconds of strong electrostatic modulation of the microelectron current filaments formed by Weibel-like instability of the original electron beam. Analytical analysis on the amplitude, scale length, and excitation condition of the self-generated electrostatic fields is clearly validated by the simulations.

[Association between serum uric acid to creatinine ratio and metabolic syndrome based on community residents in Chashan town, Dongguan city]

Objective: To analyze the association between serum uric acid to creatinine ratio (SUA/Cr) and metabolic syndrome among community residents in Chashan town, Dongguan city. Methods: Participants were from the prospective cohort study of chronic diseases in natural populations in South China conducted in Chashan town, Dongguan city from 2018 to 2019. A total of 11 334 participants with complete data were included by using convenient sampling method. Demographic characteristics, lifestyle and health status were collected through questionnaire and physical examination. The venous blood of the subjects was collected to detect the levels of serum uric acid, creatinine and blood lipid. All participants were divided into four groups (Q1-Q4) according to the quartile of SUA/Cr level. The relationship between SUA/Cr and metabolic syndrome and its components (abdominal obesity, high triglyceride, low level of high density lipoprotein cholesterol, hypertension and abnormal glucose metabolism) were analyzed by using logistic regression model. Results: The mean age of 11 334 participants was (49.52±10.02) years. Male participants accounted for 44.2% (5 015/11 334). The prevalence of metabolic syndrome was 31.2% (3 532/11 334), and the level of SUA/Cr was 5.17±1.53. The prevalence of metabolic syndrome in group Q1-Q4 was 22.3% (631/2 834), 26.5% (752/2 833), 34.9% (988/2 833) and 41.0% (1 161/2 834), respectively. After adjusting for relevant confounding factors, the result of logistic regression model showed that compared with group Q1, the risk of metabolic syndrome in group Q2-Q4 was significantly higher, with OR (95%CI) values about 1.41 (1.23-1.60), 2.19 (1.93-2.49) and 3.01 (2.65-3.42) respectively. The risk of each component of metabolic syndrome in group Q2-Q4 was higher (P_trend<0.001). The SUA/Cr level of participants with normal uric acid level was significantly positively correlated with metabolic syndrome. The risk of metabolic syndrome increased with the increase of SUA/Cr level, but there was the same trend without significant differences in patients with hyperuricemia (P_interaction=0.008). Conclusion: There is a positive correlation between SUA/Cr level and the risk of metabolic syndrome among community residents in Chashan town, Dongguan city.

Reverse osmosis concentrate treatment by microbubble ozonation-biological activated carbon process: Organics removal performance and environmental impact assessment

Reverse osmosis (RO) is being used in many water reclamation facilities to produce high quality water that can be reused for different purposes. As a part of the RO process, a reject stream is produced as the reverse osmosis concentrate (ROC), which contains elevated levels of contaminants compared to the source water. Effective treatment and safe disposal of ROC via cost-effective means is very challenging. This study aims to develop a robust microbubble ozonation-biological process for industrial ROC treatment with a target effluent chemical oxygen demand (COD) lower than 60 mg/L. As compared to macrobubble ozonation, microbubble ozonation exhibited better ozone dissolution and 29% higher COD removal efficiency with the same ozone dosage. Under the optimum operating conditions with ozone dosage of 30 mg/L, ROC natural pH of 8.67 and ozonation duration of 1 h, microbubble ozonation achieved 42% COD removal efficiency while increasing the BOD₅/COD ratio (ratio of biological oxygen demand over 5 days to the corresponding chemical oxygen demand) in ROC from 0.042 to 0.216. A biological activated carbon (BAC) column with an empty bed contact time (EBCT) of 120 min was combined with microbubble ozonation for continuous ROC treatment. Over the 100-day operation, the combined system performed consistent organics removal with an average effluent COD of 45 mg/L. Both LC-OCD data and fluorescence EEM spectra confirmed humic substances were the dominant organic species in ROC. Ozone pre-treatment could achieve significant removal of humic substances in raw ROC. ATP analysis found that ozone pre-treatment enhanced BAC biofilm activity by around 5 folds. 5 min acute toxicity assessment with Aliivibrio fischeri showed 4 times reduction of bioluminescence inhibition in ozone treated ROC. From the environmental point of view, Life cycle assessment (LCA) results demonstrated that Ozone-BAC system had significant environmental burdens on climate change and human toxicity due to the electricity production process. These environmental impacts can be mitigated by optimizing the ozonation process with reduced ozone dosage or utilizing renewable energy sources for electricity generation.

Introduction to DOK2 and its potential role in cancer

Cancer is a complex, multifactorial disease that modern medicine ultimately aims to overcome. Downstream of tyrosine kinase 2 (DOK2) is a well-known tumor suppressor gene, and a member of the downstream protein DOK family of tyrosine kinases. Through a search of original literature indexed in PubMed and other databases, the present review aims to extricate the mechanisms by which DOK2 acts on cancer, thereby identifying more reliable and effective therapeutic targets to promote enhanced methods of cancer prevention and treatment. The review focuses on the role of DOK2 in multiple tumor types in the lungs, intestines, liver, and breast. Additionally, we discuss the potential mechanisms of action of DOK2 and the downstream consequences via the Ras/MPAK/ERK or PI3K/AKT/mTOR signaling pathways.

The Polygenic and Monogenic Basis of Paediatric Fractures

PURPOSE OF REVIEW

Fractures are frequently encountered in paediatric practice. Although recurrent fractures in children usually unveil a monogenic syndrome, paediatric fracture risk could be shaped by the individual genetic background influencing the acquisition of bone mineral density, and therefore, the skeletal fragility as shown in adults. Here, we examine paediatric fractures from the perspective of monogenic and complex trait genetics.

RECENT FINDINGS

Large-scale genome-wide studies in children have identified ~44 genetic loci associated with fracture or bone traits whereas ~35 monogenic diseases characterized by paediatric fractures have been described. Genetic variation can predispose to paediatric fractures through monogenic risk variants with a large effect and polygenic risk involving many variants of small effects. Studying genetic factors influencing peak bone attainment might help in identifying individuals at higher risk of developing early-onset osteoporosis and discovering drug targets to be used as bone restorative pharmacotherapies to prevent, or even reverse, bone loss later in life.