Unmasking the truth: Experimental evidence of facemask compliance in Bangladesh, Kenya, and Nigeria during the COVID-19 pandemic

High levels of compliance with public health measures are critical to ensure a successful response to the COVID-19 pandemic and other public health emergencies. However, most data on compliance are self-reported and the tendency to overreport due to social desirability could yield biased estimates of actual compliance. A list experiment is a widely used method to estimate social desirability bias in self-reported estimates of sensitive behaviours. We estimate rates of compliance with facemask mandates in Kenya, Nigeria, and Bangladesh using data from phone surveys conducted in March-April 2021. Data on compliance were collected from two different survey modules: a self-reported compliance module (stated) and a list experiment (elicited). We find large gaps between stated and elicited rates of facemask wearing for different groups depending on specific country contexts and high levels of overreporting of facemask compliance in self-reported surveys: there was an almost 40 percentage point gap in Kenya, 30 percentage points in Nigeria, and 20 percentage points in Bangladesh. We also observe differences in rates of self-reported facemask wearing among key groups but not using the elicited responses from the list experiment, which suggest that social desirability bias may vary by demographics. Data collected from self-reported surveys may not be reliable to monitor ongoing compliance with public health measures. Moreover, elicited compliance rates indicate levels of mask wearing are likely much lower than those estimated using self-reported data.

Food insecurity and COVID-19 risk in low- and middle-income countries

The COVID-19 pandemic prompted social distancing, workplace closures, and restrictions on mobility and trade that had cascading effects on economic activity, food prices, and employment in low- and middle-income countries. Using longitudinal data from Bangladesh, Kenya, and Nigeria covering a period from October 2020 to April 2021, the paper assesses whether knowledge of a person infected with COVID-19 is associated with food insecurity, job loss and business closures, and coping strategies to smooth consumption. The likelihood of households to experience food insecurity at the extensive and intensive margins increased among those who knew an infected person in Bangladesh and Kenya.

Consent Requirements for Testing Health Policies: An Intercontinental Comparison of Expert Opinions

Individual informed consent is a central requirement for clinical research on human subjects, yet whether and how consent requirements should apply to health policy experiments (HPEs) remains unclear. HPEs test and evaluate public health policies prior to implementation. We interviewed 58 health experts in Tanzania, Bangladesh and Germany on informed consent requirements for HPEs. Health experts across all countries favored a strong evidence base, prior information to the affected populations, and individual consent for ‘risky’ HPEs. Differences pertained to individual risk perception, how and when consent by group representatives should be obtained and whether HPEs could be treated as health policies. The study adds to representative consent options for HPEs, yet shows that more research is needed in this field – particularly in the present Covid-19 pandemic which has highlighted the need for HPEs nationally and globally.

Visual Storytelling for Knowledge Translation: A Study on BRAC’s Novel Health Loans in Protecting the Poor Against Health and Asset Vulnerability In Bangladesh

Knowledge Translation (KT) is a dynamic and iterative process that includes synthesizing, disseminating, exchanging, and ethically sound application of knowledge to improve health and strengthen the health care system. It facilitates sharing the information generated through research outcomes with the public, the policymakers, or others for further scaling up or continuation of the interventions. Literature suggests a substantial gap exists in communicating with the decision-makers. BRAC JPGSPH produced a documentary/video that iterates how BRAC’s revised medical treatment loan program (MTL+) works with its microcredit clients and modalities. After reviewing all possible options for communication, the video was chosen as the best knowledge translation tool. The video creation and dissemination process are comprised of four phases: pre-production, production, post-production, and exhibition. The video production team reviewed documents and articles and conducted multiple interviews before developing the script. Later, a series of interviews were taken with the beneficiaries who receive medical treatment loans, mid-level, senior managers at BRAC, and researchers. After the production, the director, with a professional editor, edited the video. Over three hours of footage was viewed and ultimately compiled into a six-minute-long video documentary. The audience for the video was more expansive than narrow; from potential beneficiaries to policymakers and every group of stakeholders in between, the video was well-understood. The new MTL+ was integrated into the main program and would be scaled up soon.

Mandatory employer-sponsored health financing scheme for semiformal workers in Bangladesh: An experimental assessment

In this study, we present findings from an experimental evaluation of a mandatory employer-sponsored health insurance scheme in Bangladesh. We randomly introduced the scheme to female artisans to understand the impacts on healthcare utilisation, expenditure and subjective well-being using both survey and administrative data. Our findings suggest that the scheme broke even; however, it covered only six percent of the overall health expenditure and 16 percent of the hospitalisation costs. We find higher inpatient care utilisation, particularly among women, and in favour of empanelled hospitals causally associated with the intervention, consistent with the design of the scheme. We do not find significant healthcare savings or improvement in subjective well-being, consistent with low coverage. The findings suggest the scheme to be financially sustainable and it changes the healthcare seeking behaviours as the scheme incentivises. However, meaningful savings and protection against catastrophic health expenditures will require a higher level of coverage.

Effective Demand for In-Line Chlorination Bundled with Rental Housing in Dhaka, Bangladesh

Delivering safe water in cities of lower- and middle-income countries remains elusive even where there is a piped supply. Passive, in-line chlorination upstream of the point of water collection reduces child diarrhea without the behavior change required for point-of-use water treatment products or manual chlorine dispensers. We conducted a price experiment to measure effective demand (willingness and ability to pay) for an in-line chlorination service using tablet chlorinators among 196 landlords of rental housing properties in Dhaka, Bangladesh. We offered a 12-month subscription using Becker-DeGroot-Marschak auctions with real money payments. The service consistently delivered chlorinated water and satisfied tenants. Landlords' effective demand for in-line chlorination was similar to or greater than that for point-of-use treatment products and manual chlorine dispensers previously documented among Dhaka households. Over the service period, landlords renting to low-income households had lower effective demand than those renting to middle-income households despite similar initial rates of payment across both groups. Making in-line chlorination financially viable for the lowest-income consumers would likely require service cost reductions, subsidies, or both. Our findings suggest that even revealed preference experiments may overestimate the effective demand needed to sustain water supply improvements, especially in low-income populations, if they only measure demand once.

A distress-continuum, disorder-threshold model of depression: a mixed-methods, latent class analysis study of slum-dwelling young men in Bangladesh

BACKGROUND

Binary categorical approaches to diagnosing depression have been widely criticized due to clinical limitations and potential negative consequences. In place of such categorical models of depression, a 'staged model' has recently been proposed to classify populations into four tiers according to severity of symptoms: 'Wellness;' 'Distress;' 'Disorder;' and 'Refractory.' However, empirical approaches to deriving this model are limited, especially with populations in low- and middle-income countries.

METHODS

A mixed-methods study using latent class analysis (LCA) was conducted to empirically test non-binary models to determine the application of LCA to derive the 'staged model' of depression. The study population was 18 to 29-year-old men (n = 824) from an urban slum of Bangladesh, a low resource country in South Asia. Subsequently, qualitative interviews (n = 60) were conducted with members of each latent class to understand experiential differences among class members.

RESULTS

The LCA derived 3 latent classes: (1) Severely distressed (n = 211), (2) Distressed (n = 329), and (3) Wellness (n = 284). Across the classes, some symptoms followed a continuum of severity: 'levels of strain', 'difficulty making decisions', and 'inability to overcome difficulties.' However, more severe symptoms such as 'anhedonia', 'concentration issues', and 'inability to face problems' only emerged in the severely distressed class. Qualitatively, groups were distinguished by severity of tension, a local idiom of distress.

CONCLUSIONS

The results indicate that LCA can be a useful empirical tool to inform the 'staged model' of depression. In the findings, a subset of distress symptoms was continuously distributed, but other acute symptoms were only present in the class with the highest distress severity. This suggests a distress-continuum, disorder-threshold model of depression, wherein a constellation of impairing symptoms emerge together after exceeding a high level of distress, i.e., a tipping point of tension heralds a host of depression symptoms.

Type 1 diabetes genetic risk score discriminates between monogenic and Type 1 diabetes in children diagnosed at the age of <5 years in the Iranian population

AIM

To examine the extent to which discriminatory testing using antibodies and Type 1 diabetes genetic risk score, validated in European populations, is applicable in a non-European population.

METHODS

We recruited 127 unrelated children with diabetes diagnosed between 9 months and 5 years from two centres in Iran. All children underwent targeted next-generation sequencing of 35 monogenic diabetes genes. We measured three islet autoantibodies (islet antigen 2, glutamic acid decarboxylase and zinc transporter 8) and generated a Type 1 diabetes genetic risk score in all children.

RESULTS

We identified six children with monogenic diabetes, including four novel mutations: homozygous mutations in WFS1 (n=3), SLC19A2 and SLC29A3, and a heterozygous mutation in GCK. All clinical features were similar in children with monogenic diabetes (n=6) and in the rest of the cohort (n=121). The Type 1 diabetes genetic risk score discriminated children with monogenic from Type 1 diabetes [area under the receiver-operating characteristic curve 0.90 (95% CI 0.83-0.97)]. All children with monogenic diabetes were autoantibody-negative. In children with no mutation, 59 were positive to glutamic acid decarboxylase, 39 to islet antigen 2 and 31 to zinc transporter 8. Measuring zinc transporter 8 increased the number of autoantibody-positive individuals by eight.

CONCLUSIONS

The present study provides the first evidence that Type 1 diabetes genetic risk score can be used to distinguish monogenic from Type 1 diabetes in an Iranian population with a large number of consanguineous unions. This test can be used to identify children with a higher probability of having monogenic diabetes who could then undergo genetic testing. Identification of these individuals would reduce the cost of treatment and improve the management of their clinical course.

Health shock and preference instability: assessing health-state dependency of willingness-to-pay for corrective eyeglasses

BACKGROUND

Differences in contingent valuation (CV) estimates for identical healthcare goods can cast considerable doubt on the true economic measures of consumer preferences. Hypothetical nature of CV methods can potentially depend on the salience, context and perceived relevance of the good or service under consideration. Thus, the high demand elasticity for healthcare goods warrants careful selection of study population as the contexts of valuation significantly changes after experiencing health shock.

METHODS

In this study, using triple-bounded dichotomous choice (TBDC) experiments, we test how negative health shock (namely, being diagnosed with refractive errors), can alter preference over a common health good (namely, corrective eyeglasses). We compared elicited WTP of diagnosed patients with a synthetically constructed comparable cohort without the same health shock, controlling for the possible self-selection using a number of matching techniques based on the observable socio-demographic characteristics.

RESULTS

The consumers diagnosed with vision problems exhibit a rightward shift in their demand curve compared to observationally identical consumers without such problems resulting in about 17% higher consumer surplus. The consumers without the health shock are willing to pay about BDT 762.4 [95% CI: BDT 709.9 - BDT 814.9] for corrective eyeglasses, which gets 15-30% higher for the matched with-health-shock consumers. Multivariable analyses suggest more educated and wealthier individuals are willing to pay respectively BDT 208 and BDT 119 more for corrective eyeglasses. We have tested the models for different matching protocols. Our results are fairly robust to alternate specifications and various matching techniques.

CONCLUSION

The preferences for healthcare goods, such as eyeglasses, can significantly depend upon the respondent being diagnosed with refractive errors. Our findings have implications for general cost-benefit analyses often relying on WTP, which can vary depending on the contexts. There are also increasing interests in cost recovery models, which require understanding the demand for healthcare goods and services. We find eliciting the demand needs to consider the health status of the population from which the respondents are sampled.

Willingness to Pay for Cataract Surgeries Among Patients Visiting Eye Care Facilities in Dhaka, Bangladesh

BACKGROUND

Cataract is the leading cause of avoidable blindness globally. It is estimated that 89% of people with visual impairment live in low- and middle-income countries where the cost of cataract surgery represents a major barrier for accessing these services. Developing self-sustaining healthcare programs to cater the unmet demands warrants a better understanding of patients' willingness to pay (WTP) for their services.

OBJECTIVES

Using a sample of patients visiting eye care facilities in Dhaka, Bangladesh, we estimate WTP for two different cataract extraction techniques, namely small incision cataract surgery (SICS) and phacoemulsification.

METHODS

We used contingent valuation (CV) approach and elicited WTP through double-bounded dichotomous choice experiments. We interviewed 556 randomly selected patients (283 for SICS and 273 for phacoemulsification) from five different eye care hospitals of Dhaka. In this paper, we estimated the mean and marginal WTP using interval regression models. We also compared the estimated WTP and stated demand for cataract surgeries against the prevailing market prices of SICS and phacoemulsification.

RESULTS

We found the mean WTP of BDT 7579 (US$93) for SICS and BDT 10,208 (US$126) for phacoemulsification are equivalent to 12 and 16 days of household income, respectively. Household income and assets appeared as the major determinants of WTP for cataract surgeries. However, we did not find any significant association with gender, occupation, and household size among other socioeconomic characteristics. Comparisons between market prices and average WTP suggest it is possible to have a viable market for SICS, but a subsidy-based model for phacoemulsification will be financially challenging because of low WTP and high costs.

CONCLUSION

Our findings suggest lower-cost SICS can potentially provide patients access to surgeries to treat cataract conditions. Moreover, price discrimination and cross-subsidization could be a viable strategy to increase the service-uptake as well as ensure financial sustainability.

Social network analysis of psychological morbidity in an urban slum of Bangladesh: a cross-sectional study based on a community census

OBJECTIVES

To test whether social ties play any roles in mitigating depression and anxiety, as well as in fostering mental health among young men living in a poor urban community.

SETTING

A cohort of all young men living in an urban slum in Dhaka, the capital of Bangladesh.

PARTICIPANTS

All men aged 18-29 years (n=824) living in a low-income urban community at the time of the survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

Unspecified psychological morbidity measured using the General Health Questionnaire, 12-item (GHQ-12), where lower scores suggest better mental status.

RESULTS

The GHQ scores (mean=9.2, SD=4.9) suggest a significant psychological morbidity among the respondents. However, each additional friend is associated with a 0.063 SD lower GHQ score (95% CI -0.106 to -0.021). Between centrality measuring the relative importance of the respondent within his social network is also associated with a 0.103 SD lower GHQ score (95% CI -0.155 to -0.051), as are other measures of social network ties. Among other factors, married respondents and recent migrants also report a better mental health status.

CONCLUSIONS

Our results underscore the importance of social connection in providing a buffer against stress and anxiety through psychosocial support from one's peers in a resource-constraint urban setting. Our findings also suggest incorporating a social network and community ties in designing mental health policies and interventions.

Trends and determinants of inequities in childhood stunting in Bangladesh from 1996/7 to 2014

BACKGROUND

We explore long-term trends and determinants of socioeconomic inequities in chronic childhood undernutrition measured by stunting among under-five children in Bangladesh. Given that one in three children remain stunted in Bangladesh, the socioeconomic mapping of stunting prevalence may be critical in designing public policies and interventions to eradicate childhood undernutrition.

METHODS

Six rounds of Bangladesh Demographic and Health Survey data are utilized, spanning the period 1996/97 to 2014. Using recognized measures of absolute and relative inequality (namely, absolute and relative difference, concentration curve and index), we quantify trends, and decompose changes in the concentration index to identify factors that best explain observed dynamics.

RESULTS

Despite remarkable improvements in average nutritional status over the last two decades, socio-economic inequalities have persisted, and according to some measures, even worsened. For example, expressed as rate-ratios, the relative inequality in under-five stunting increased by 56% and the concentration index more than doubled between 1996/97 and 2014. Decomposition analyses find that wealth and maternal factors such as mothers' schooling and short stature are major contributors to observed socio-economic inequalities in child undernutrition and their changes over time.

CONCLUSIONS

Reflecting on recent success around socioeconomic and gender equity in child mortality, and the weak legacy of nutrition policy in Bangladesh, we suggest that nutrition programming energies be focused specifically on the most disadvantaged and applied at scale to close socioeconomic gaps in stunting prevalence.

Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development

By disaggregating gains in child health in Bangladesh over the past several decades, significant improvements in gender and socioeconomic inequities have been revealed. With the use of a social determinants of health approach, key features of the country's development experience can be identified that help explain its unexpected health trajectory. The systematic equity orientation of health and socioeconomic development in Bangladesh, and the implementation attributes of scale, speed, and selectivity, have been important drivers of health improvement. Despite this impressive pro-equity trajectory, there remain significant residual inequities in survival of girls and lower wealth quintiles as well as a host of new health and development challenges such as urbanisation, chronic disease, and climate change. Further progress in sustaining and enhancing equity-oriented achievements in health hinges on stronger governance and longer-term systems thinking regarding how to effectively promote inclusive and equitable development within and beyond the health system.

Ovarian Cyst Enlargement in a 14 Year Old Female with Persistent Ascities, Severe Hypothyroidism and Elevated Serum CA-125 Level

A 14 year old female complained of abdominal pain and distention with vomiting. The physical exam showed thyroid enlargement and ascites. The imaging evaluation demonstrated a large ovarian cyst. Laboratory tests depicted hypothyroidism and marked elevation of Carbohydrate antigen 125 (CA-125) levels. As the bone age was 10 years, more retarded than the chronological age, Van Wyk and Grumbach syndrome was suspected. Treatment with thyroid hormone was initiated and the condition improved dramatically with disappearance of symptoms and signs 5 weeks later.

Changes in glitazone use among office-based physicians in the U.S., 2003-2009

OBJECTIVE

Little is known regarding recent changes in glitazone use.

RESEARCH DESIGN AND METHODS

Interrupted time series analyses of nationally representative office-visit data using IMS Health's National Disease and Therapeutic Index.

RESULTS

From 2003 through 2005, glitazone use increased steadily. From February 2005 to January 2007, rosiglitazone use decreased by 16% (95% CI -20 to -11) annually; pioglitazone use increased at an annual rate of 14% (9-18). During a period of Food and Drug Administration (FDA) advisories, rosiglitazone use declined sharply from 0.42 million monthly treatment visits (February 2007) to 0.13 million monthly visits (May 2008). Pioglitazone use remained stable, accounting for approximately 5.8 million physician visits (77% of all glitazone use) where a treatment was used during the final 12 months of observation.

CONCLUSIONS

The combined effect of scientific publications, advisories, and media exposure was associated with a substantial decrease in rosiglitazone use. Despite a class-level FDA advisory, pioglitazone use was not similarly affected.

Impact of FDA black box advisory on antipsychotic medication use

BACKGROUND

In April 2005, the US Food and Drug Administration (FDA) issued an advisory and subsequent black box warning regarding the risks of atypical anti psychotic use among elderly patients with dementia. The impact of these warnings on atypical drug use is unknown.

METHODS

We used quasi-experimental, interrupted time-series analyses to examine nationally representative data from IMS Health's National Disease and Therapeutic Index from January 2003 through December 2008. The primary measurement from this audit of office-based physicians was the use of an atypical antipsychotic agent. We quantified the impact of the advisory on atypical antipsychotic use among all individuals and those 65 years or older with dementia.

RESULTS

From January 2003 to March 2005, mentions of total atypical antipsychotic drugs increased at an annual rate of 34%, and among patients with dementia, 16%. In the year prior to the FDA advisory, there were approximately 13.6 million atypical drug mentions, including 0.8 million among those with dementia. In the year following the advisory, atypical drug mentions fell 2% overall and 19% among those with dementia. In 2004, 19% (0.8 of 4.1 million) of drug mentions for dementia were for an atypical agent. By 2008, this proportion decreased to 9% (0.4 of 4.3 million). Atypical drug use slowed for both FDA-approved and off-label indications and declined through 2008 for all populations examined.

CONCLUSION

The FDA advisory was associated with decreases in the use of atypical antipsychotics, especially among elderly patients with dementia.

Impact of family structure on stimulant use among children with attention-deficit/hyperactivity disorder

OBJECTIVE

To examine the impact of family structure on pharmacologic stimulant use among children with attention-deficit/hyperactivity disorder (ADHD).

DATA SOURCE

Nationally representative, population-based sample of the National Health Interview Survey from 1997 to 2003 linked with drug event files from the Medical Expenditure Panel Survey from 1998 to 2005.

STUDY DESIGN

Stepwise multivariate logistic regression was used to examine the likelihood of stimulant use for each individual during 2 years of observation after adjustment for sociodemographic, health, and family characteristics. Stratified analyses were also conducted to examine whether family characteristics had different impacts within single-mother and dual-parent households.

PRINCIPAL FINDINGS

Stimulant use varied based on children's sociodemographic and health characteristics. In multivariate analyses, associations between children's household structure, parental education, and stimulant use appeared to be mediated by children's access to care and health status. However, in full multivariate models, there remained a robust positive association between family size and stimulant use.

CONCLUSIONS

These findings highlight the influence that nonclinical factors such as family size may have in mediating the use of pharmacologic therapies for children.

Assaying the presence of histone-like protein HU in Halobacillus karajensis

Histone-Like Proteins (HLPs) in bacteria are small basic proteins that contribute to the control of gene expression, recombination, DNA replication and compressing the bacterial DNA in the nucleoid. Among the HLPs, HU protein as a dimer plays an important role in binding to DNA and bending it. In this study, we showed that a 9.5-10 kDa protein with the same electrophoretic mobility as HU exists in Halobacillus karajensis which is a novel gram positive moderate halophile bacterium that was recently isolated from surface saline soil of the Karaj Region, Iran. The genes encoding HU protein were also assayed during this study by Polymerase Chain Reaction.

Cost savings associated with filling a 3-month supply of prescription medicines

BACKGROUND

Many patients are burdened by prescription costs, and patients, providers and policy makers may attempt to reduce these costs by substituting 3-month for 1-month supplies of medicines.

OBJECTIVES

To measure the difference in out-of-pocket and total costs among patients receiving different quantities of the same prescription drug used to treat a chronic condition, and to examine patient and health system characteristics associated with the use of a 3-month supply.

METHODS

Data were pooled from the 2000-5 Medical Expenditure Panel Survey, a nationally representative survey of the US non-institutionalized civilian population, to compare prescription drug expenditures for medicines dispensed as both 3-month and 1-month supplies. Logistic regression was used to model correlates associated with 3-month use. The main outcome measures were the mean monthly out-of-pocket and total costs expressed in year 2005 values.

RESULTS

Forty-four percent of prescriptions examined were dispensed as 3-month supplies. The average (95% CI) monthly total and out-of-pocket costs for a 1-month supply were $US42.72 (42.01, 43.42) and $US20.44 (19.99, 20.89), respectively, while the corresponding monthly costs for a 3-month supply were $US37.95 (37.26, 38.64) and $US15.10 (14.68, 15.53). After adjustment for potential confounders, this represented a 29% decrease in out-of-pocket costs and an 18% decrease in total prescription costs through the use of a 3-month rather than a 1-month supply. Eighty percent of patients achieved some cost savings from a 3-month supply and there was considerable variation in the amount saved. There were no marked differences in the characteristics of individuals using 3-month versus 1-month supplies.

CONCLUSIONS

Although such opportunities are not universally available, these findings quantify the cost savings that patients in the US can achieve through filling larger quantities of a prescription for a chronic condition.

The effect of the Medicare Part D prescription benefit on drug utilization and expenditures

BACKGROUND

Information about the effect of the Medicare Part D Prescription Drug Benefit on drug utilization and expenditures is limited.

OBJECTIVE

To estimate changes in prescription utilization and out-of-pocket expenditures attributable to Part D among a sample of persons eligible for the benefit.

DESIGN

Generalized estimating equations were used to estimate changes in expenditures and utilization among beneficiaries. A control group was included to control for secular trends unrelated to the Part D benefit.

SETTING

National pharmacy chain representing approximately 15% of all U.S. retail pharmacy sales.

PARTICIPANTS

Persons age 66 to 79 years (those eligible for Part D) and a control group of persons age 60 to 63 years (those ineligible for Part D). The final sample represented approximately 5.1 million unique beneficiaries and 1.8 million unique control individuals.

MEASUREMENTS

Prescription utilization (measured in pill-days) and out-of-pocket expenditures, as determined from pharmacy claims from September 2004 to April 2007.

RESULTS

During the penalty-free Part D enrollment period (January 2006 to May 2006), average monthly drug utilization increased by 1.1% (95% CI, 0.5% to 1.7%; P < 0.001) and out-of-pocket expenditures decreased by 8.8% (CI, 6.6% to 11.0%; P < 0.001). After enrollment stabilized (June 2006 to April 2007), average monthly drug utilization increased by 5.9% (CI, 5.1% to 6.7%; P < 0.001) and out-of-pocket expenditures decreased by 13.1% (CI, 9.6% to 16.6%; P = 0.003). Compared with eligible nonenrollees, enrollees had higher out-of-pocket expenditures and utilization at baseline but experienced significantly larger decreases in expenditures and increases in utilization after enrollment.

LIMITATIONS

Analyses were limited to claims within 1 pharmacy chain. The effect of the "doughnut hole" and the effect of changes on clinical outcomes were not evaluated.

CONCLUSION

The Medicare Part D prescription benefit resulted in modest increases in average drug utilization and decreases in average out-of-pocket expenditures among Part D beneficiaries. Further research is needed to examine patterns among other beneficiaries and to evaluate the effect of these changes on health outcomes.

Interaction of a low mobility group protein, LMG160, with deoxyribonucleic acid

A fraction of low mobility group (LMG) nonhistone protein designated LMG(160) was isolated from rat liver chromatin by preparative gel electrophoresis and its interaction with DNA was studied using thermal denaturation and DNA-cellulose affinity chromatography techniques. The results showed that LMG(160) with an isoelecteric point of 5-5.5 was bound to DNA and decreased its melting temperature. Increasing ionic strengths decreased this effect. DNA-cellulose affinity chromatography showed the affinity of LMG(160) to double stranded DNA was higher than that to single stranded DNA, since it required 0.6 M NaCl for elution. The results suggest that LMG(160) protein preferentially binds to double stranded DNA destabilizes it and the binding is electrostatic.

The effects of daunomycin antibiotic on histone H(1): thermal denaturation and fluorescence spectroscopy studies

Using thermal denaturation and fluorescence spectroscopy, we have investigated the interaction of antitumor antibiotic, daunomycin, with calf thymus histone H(1) under several ionic strengths. The results show that daunomycin binds to histone H(1) and increases its melting temperature. Increasing ionic strength elevates this effect. Fluorescence emission data show that the interaction of daunomycin with histone H(1) decreases the emission intensity at 325 nm and induces hyperchromicity in the emission spectrum of the drug. The results suggest that histone H(1) can be considered as a new target for drug action at the chromatin level.

Dose and time dependent effects of caffeine on superoxide release, cell survival and DNA fragmentation of alveolar macrophages from rat lung

In this study, the effect of two concentration ranges of the cAMP phosphodiesterase inhibitor, caffeine, on alveolar macrophage function was investigated by measuring survival rate, superoxide anion production and DNA fragmentation. The results show caffeine induced apoptosis in alveolar macrophages in a dose dependent manner. The survival rate of the cells exposed to low concentrations of caffeine (<5 mM) increased remarkably with a peak at 2.5 mM. At this concentration, caffeine failed to affect superoxide anion production and DNA degradation. However, at higher concentrations (5-20 mM), at which the viability was higher than the control, a significant increase in both superoxide production and DNA degradation, as judged by agarose gel and diphenylamine reaction, was obtained for 3 and 24 h of culture. The effect of caffeine on survival rate was also time dependent. At low caffeine concentrations, macrophages survived with a viability of 90-97% after 3 days. At moderate concentrations, the cells maintained viability up to 24 h but at concentrations higher than 20 mM, caffeine inhibited cell survival and killed a fraction of the population. The results suggest that low concentrations of caffeine prevent apoptosis of macrophages, whereas at moderate concentrations caffeine induces apoptosis in these cells. The results are discussed in relation to the mechanism of cAMP.

Lead nitrate induced apoptosis in alveolar macrophages from rat lung

In this work we have attempted to characterize the programmed cell death (apoptosis) in alveolar macrophages exposed to various concentrations of lead nitrate. It was found that after 3 h of exposure a significant increase in superoxide anion production was observed, i.e. the number of trypan blue - exculding cells, was unchanged (< or = 95%) with any dose of lead employed. Agarose gel electrophoresis and diphenylamin reaction analysis revealed the occurrence of internucleosomal DNA fragmentation evaluated using cytological analysis by fluorescence dyes, suggesting that lead nitrate at low concentrations and short periods of exposure leads macrophages into apoptosis. However, time course studies showed that beyond 3 h, toxicity occurs, which could be attenuated by phosphodiesterase inhibitors, such as caffeine, suggesting a possible mechanism involving cAMP.

Daunomycin-induced unfolding and aggregation of chromatin

Using equilibrium dialysis and sedimentation velocity analysis, we have characterized the binding of the anti-tumor drug daunomycin to chicken erythrocyte chromatin before and after depletion of linker histones and to its constitutive DNA under several ionic strengths (5, 25, and 75 mM NaCl). The equilibrium dialysis experiments reveal that the drug binds cooperatively to both the chromatin fractions and to the DNA counterpart within the range of ionic strength used in this study. A significant decrease in the binding affinity was observed at 75 mM NaCl. At any given salt concentration, daunomycin exhibits higher binding affinity for DNA than for linker histone-depleted chromatin or chromatin (in decreasing order). Binding of daunomycin to DNA does not significantly affect the sedimentation coefficient of the molecule. This is in contrast to binding to chromatin and to its linker histone-depleted counterpart. In these instances, preferential binding of the drug to the linker DNA regions induces an unfolding of the chromatin fiber that is followed by aggregation, presumably because of histone-DNA interfiber interactions.

Effects of anthracycline antibiotic, daunomycin on thymus chromatin: the role of chromosomal proteins

1. We have examined the effect of antitumour antibiotic daunomycin on calf thymus chromatin employing u.v./vis spectroscopic and hydrodynamic techniques. The experiments were undertaken to determine the influence of added drug on DNA-protein complex. 2. The results show that the binding of drug to chromatin is dose dependent and a DNA to drug ratio below 1:100 leaves small oligonucleotides in the supernatant, however, at higher ratios chromatin occurs aggregation. 3. Analysis of both the proteins and DNA reveals that daunomycin induces chromatin condensation by cross linking between its components suggesting that chromosomal proteins play a significant role in this process.

Inhibitory role of alveolar macrophages in colony-stimulating factor production by the lung tissue from bacillus Calmette-Guérin-treated animals

Production of colony-stimulating factors (CSF) by lung tissue from rats injected by bacillus Calmette-Guérin (BCG) and the role of alveolar macrophages (AM) in this process was studied. Injection of BCG at 10, 100, or 1,000 mg/kg changed the CSF production by the lung in a time-dependent manner. Maximum stimulation was observed at 10 mg/kg and 3 days of interval between BCG injection and animal sacrifice. Longer periods or higher concentrations had no effect or actually depressed CSF production. BCG injection also changed the number of AM in a time- and dose-dependent manner. When AM from BCG-treated animals were lavaged out and the AM-depleted lung tissues were cultured, an increase in CSF production with respect to controls was observed at 10 mg/kg of BCG. On the other hand, in control animals removal of AM had no effect on CSF production by the lung. The results suggest that BCG treatment alters the number of AM and CSF production by the lung. AM, in BCG-injected animals, inhibit CSF production by the lung tissue while in non-injected animals they do not play any role in this process.

Effects of hyperthermia on the colony-stimulating factor production by the lung

Hyperthermic treatment of the murine lung in the range of 40-46 degrees C inhibited the production of colony-stimulating factors by the lung in vitro. This inhibition was dose dependent. Thermodynamic analysis was used to determine the activation energies. The Arrhenius plot contained a transition at 43 degrees C. At temperatures below and above the transition temperature, the activation energies were 40.49 and 197 kcal/mole, respectively. Below the transition temperature, the effect of hyperthermia was characterized by a delayed response represented by the broad initial shoulder of the hyperthermic dose-response curves. To investigate the mechanism of hyperthermia-induced reduction of the colony-stimulating factor production, the effect of hyperthermia on the protein synthesis by the lung was also studied. The results indicated an immediate response to hyperthermia, characterized by the absence of the initial shoulder and the high slope of the hyperthermic dose response curves. The corresponding Arrhenius plot did not have any transition point. The single activation energy calculated was 97.25 kcal/mole. It is concluded that the hyperthermic depression of the colony-stimulating factor production by the lung cannot be explained solely on the basis of the effects of hyperthermia on the protein synthesis.

The effect of indomethacin on colony-stimulating-factor production by the lung

In this study, indomethacin was used to investigate the production of colony-stimulating-factor by the lung tissue. Addition of various concentrations of indomethacin (10(-5)-1 mg/ml) to the lung culture showed that it enhances CSF production in a dose dependent manner. The number of colonies reached a maximum at 1 microgram/ml and gradually diminished at higher concentrations. Addition of exogenous E-series prostaglandins alone had no effect on the CSF activity of normal lung. However, in the presence of indomethacin, E-series prostaglandins reversed the enhancing effect produced by indomethacin. On the other hand, cAMP or its dibutyryl derivative also increased CSF production. Removal of alveolar macrophages from the lung by lavaging had no effect on the CSF production by the lung but reduced the enhancing effect of indomethacin by 50%. The results suggest that indomethacin stimulates CSF production and that this process is partially regulated by prostaglandins and cAMP.

Structural studies on two high-mobility-group proteins from calf thymus, HMG-14 and HMG-20 (ubiquitin), and their interaction with DNA

High mobility group (HMG) protein 14, which, like HMG-17, has been implicated in the structure of 'active chromatin' is shown by 270-MHz NMR and by circular dichroism to be in a disordered conformation in free solution. At low ionic strength protein HMG-14 binds to DNA by weak attachment of the N-terminal half of the molecule and is released by 0.3 M NaCl, the ionic strength at which the protein is extracted from chromatin. The protein HMG-20 (ubiquitin), a constituent of the conjugate protein A 24, is shown to be a highly stable compact globular protein that remains folded over a pH range of 1--13 and has a half-denaturation temperature of 85 degrees C when thermally denatured. Circular dichroism indicates 28% helix and 12% beta sheet. Despite having 15% basic residues it binds only very weakly to DNA. A detailed study of the folding of ubiquitin has been made by a combination of several NMR approaches, including decoupling, nuclear Overhauser enhancement and titration. Several line assignments have been made and it is shown that, although the tyrosine and histidine are buried residues, they are not adjacent to one another nor are they close to either of the phenylalanines, of which at least one is also a buried residue.

Studies on the tissue specificity of the high-mobility-group non-histone chromosomal proteins from calf

The high-mobility-group (HMG) non-histone chromosomal proteins from calf thymus, liver, spleen and kidney were extracted, and fractionated by CM-Sephadex chromatography and trichloroacetic acid precipitation. The isolated proteins HMG 1, HMG 2 and HMG 17 from the tissues were compared by polyacrylamide-gel electrophoresis, isoelectric focusing and amino acid analysis. The results show that the three proteins are very similar in the tissues studied, implying a lack of tissue specificity.