Protocol: identifying policy, system, and environment change interventions to enhance availability of blood for transfusion in Kenya, a mixed-methods study

BACKGROUND

Safe blood is essential for the care of patients with life-threatening anemia and hemorrhage. Low blood donation rates, inefficient testing procedures, and other supply chain disruptions in blood administration affect patients in low-resource settings across Sub-Saharan countries, including Kenya. Most efforts to improve access to transfusion have been unidimensional, usually focusing on only point along the blood system continuum, and have excluded community stakeholders from early stages of intervention development. Context-appropriate interventions to improve the availability of safe blood at the point of use in low-resource settings are of paramount importance. Thus, this protocol proposes a multifaceted approach to characterize the Kenyan blood supply chain through quantitative and qualitative analyses as well as an industrial engineering approach.

METHODS

This study will use a mixed-methods approach in addition to engineering process mapping, modeling and simulation of blood availability in Kenya. It will be guided by a multidimensional three-by-three-by-three matrix: three socioeconomic settings, three components of the blood system continuum, and three levels of urgency of blood transfusion. Qualitative data collection includes one-on-one interviews and focus group discussions with stakeholders across the continuum to characterize ground-level deficits and potential policy, systems, and environment (PSE) interventions. Prospectively-collected quantitative data will be used to estimate blood collection and transfusion of blood. We will create a process map of the blood system continuum to model the response to PSE changes proposed by stakeholders. Lastly, we will identify those PSE changes that may have the greatest impact on blood transfusion availability, accounting for differences across socioeconomic settings and levels of urgency.

DISCUSSION

Identifying and prioritizing community-driven interventions to improve blood supply in low-resource settings are of utmost importance. Varied constraints in blood collection, processing, delivery, and use make each socioeconomic setting unique. Using a multifaceted approach to understand the Kenyan blood supply and model the response to stakeholder-proposed PSE changes may lead to identification of contextually appropriate intervention targets to meet the transfusion needs of the population.

Navigating the maze of osteoarthritis treatment: A qualitative study exploring the experience of individuals with osteoarthritis in Tasmania, Australia

OBJECTIVE

Using a qualitative design this study aimed to (1) explore the experience of people living with osteoarthritis (OA), (2) gain an understanding of their navigation of the health system and, (3) explore their opinions on the role of exercise and joint replacement surgery for the management of OA.

METHODS

Purposive sampling was used to recruit 26 participants with knee OA, aged 45 years and over, from Tasmania, Australia. Semi-structured interviews were audio-recorded, transcribed, coded, and thematically analysed to document participant understanding and experience of OA and their opinions on the role of exercise and surgery in managing OA.

RESULTS

Of the 26 participants, 80% (n = 21) were female with a mean age of 66 years. The main theme identified was that individuals with knee OA were navigating a maze of OA treatments. Three related subthemes were that participants: (i) perceived their general practitioner did not have an ongoing role in their OA care, (ii) self-directed their management and, (iii) sampled from a 'smorgasbord' of treatment options, including low-value care options. Two other major themes were: the role of exercise for OA management, and surgery as a last resort.

CONCLUSION

Our findings suggest that OA patients may not be choosing consistent, high-value care for their OA. This highlights the importance of an evidence-based multi-disciplinary approach to guide patients to self-manage their OA and support their navigation of the health system. Reducing emphasis on the pathway to surgery and streamlining access to conservative management strategies may assist people to receive high-value care.

Quality of care for postpartum hemorrhage: A direct observation study in referral hospitals in Kenya

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Kenya. The aim of this study was to measure quality and timeliness of care for PPH in a sample of deliveries in referral hospitals in Kenya. We conducted direct observations of 907 vaginal deliveries in three Kenyan hospitals from October 2018 through February 2019, observing the care women received from admission for labor and delivery through hospital discharge. We identified cases of "suspected PPH", defined as cases in which providers indicated suspicion of and/or took an action to manage abnormal bleeding. We measured adherence to World Health Organization and Kenyan guidelines for PPH risk assessment, prevention, identification, and management and the timeliness of care in each domain. The rate of suspected PPH among the observed vaginal deliveries was 9% (95% Confidence Interval: 7% - 11%). Health care providers followed all guidelines for PPH risk assessment in 7% (5% - 10%) of observed deliveries and all guidelines for PPH prevention in 4% (3% - 6%) of observed deliveries. Lowest adherence was observed for taking vital signs and for timely administration of a prophylactic uterotonic. Providers did not follow guidelines for postpartum monitoring in any of the observed deliveries. When suspected PPH occurred, providers performed all recommended actions in 23% (6% - 40%) of cases. Many of the critical actions for suspected PPH were performed in a timely manner, but, in some cases, substantial delays were observed. In conclusion, we found significant gaps in the quality of risk assessment, prevention, identification, and management of PPH after vaginal deliveries in referral hospitals in Kenya. Efforts to reduce maternal morbidity and mortality from PPH should emphasize improvements in the quality of care, with a particular focus on postpartum monitoring and timely emergency response.

Bleeding, Hemorrhagic Shock, and the Global Blood Supply

Hemorrhage is responsible for at least 40% of deaths after trauma and 27% of maternal deaths worldwide. Patients with hemorrhagic shock require attentive critical care and transfusion of blood products. Access to a safe and affordable blood supply is critical to providing safe surgical care. Traumatic injury, obstetric hemorrhage, and upper gastrointestinal bleed are the main causes of severe bleeding requiring transfusion. This article discusses the presentation and management of these causes across the world and provides a brief overview of the current challenges in maintaining a global blood supply.

Assessing the global burden of hemorrhage: The global blood supply, deficits, and potential solutions

There is a critical shortage of blood available for transfusion in many low- and middle-income countries. The consequences of this scarcity are dire, resulting in uncounted morbidity and mortality from trauma, obstetric hemorrhage, and pediatric anemias, among numerous other conditions. The process of collecting blood from a donor to administering it to a patient involves many facets from donor availability to blood processing to blood delivery. Each step faces particular challenges in low- and middle-income countries. Optimizing existing strategies and introducing new approaches will be imperative to ensure a safe and sufficient blood supply worldwide.

The Global Pregnancy Collaboration (CoLab) Biobank of rare placentas

Many adverse pregnancy outcomes are the result of placental disorders. It has been difficult to decipher the root cause of many of these disorders due to an overlap in identifiable placental pathology and pregnancy outcomes. The reason for this confusion may be related to the lack of an appropriate control placenta. An ideal control placenta that is not related to adverse pregnancy outcomes is rare. We propose our pooled database at the Global Pregnancy Collaboration (CoLab) could be a solution for researchers.

Healthcare without borders: A cross-sectional study of immigrant and nonimmigrant children admitted to a large public sector hospital in the Gauteng Province of South Africa

BACKGROUND

Human migration is a worldwide phenomenon that receives considerable attention from the media and healthcare authorities alike. A significant proportion of children seen at public sector health facilities in South Africa (SA) are immigrants, and gaps have previously been noted in their healthcare provision. The objective of the study was to describe the characteristics and differences between the immigrant and SA children admitted to Kalafong Provincial Tertiary Hospital (KPTH), a large public sector hospital in the urban Gauteng Province of SA.

METHODS AND FINDINGS

A cross-sectional study was conducted over a 4-month period during 2016 to 2017. Information was obtained through a structured questionnaire and health record review. The enrolled study participants included 508 children divided into 2 groups, namely 271 general paediatric patients and 237 neonates. Twenty-five percent of children in the neonatal group and 22.5% in the general paediatric group were immigrants. The parents/caregivers of the immigrant group had a lower educational level (p < 0.0001 neonatal and paediatric), lower income (neonatal p < 0.001; paediatric p = 0.024), difficulty communicating in English (p < 0.001 neonatal and paediatric), and were more likely residing in informal settlements (neonatal p = 0.001; paediatric p = 0.007) compared to the SA group. In the neonatal group, there was no difference in the number of antenatal care (ANC) visits, type of delivery, gestational age, and birth weight. In the general paediatric group, there was no difference in immunisation and vitamin A supplementation coverage, but when comparing growth, the immigrant group had more malnutrition compared to the SA group (p = 0.029 for wasting). There was no difference in the prevalence of maternal human immunodeficiency virus (HIV) infection, with equally good prevention of mother-to-child transmission (PMTCT) coverage. There was also no difference in reported difficulties by immigrants in terms of access to healthcare (neonatal p = 0.379; paediatric p = 0.246), although a large proportion (10%) of the neonates of immigrant mothers were born outside a medical facility.

CONCLUSIONS

Although there were health-related differences between immigrant and SA children accessing in-hospital care, these were fewer than expected. Differences were found in parental educational level and socioeconomic factors, but these did not significantly affect ANC attendance, delivery outcomes, immunisation coverage, HIV prevalence, or PMTCT coverage. The immigrant population should be viewed as a high-risk group, with potential problems including suboptimal child growth. Health workers should advocate for all children in the community they are serving and promote tolerance, respect, and equal healthcare access.

Effects of emergency obstetric care training on maternal and perinatal outcomes: a stepped wedge cluster randomised trial in South Africa

Introduction

Two-thirds of maternal deaths and 40% of intrapartum-related neonatal deaths are thought to be preventable through emergency obstetric and newborn care (EmOC&NC). The effectiveness of ‘skills and drills’ training of maternity staff in EmOC&NC was evaluated.

Methods

Implementation research using a stepped wedge cluster randomised trial including 127 of 129 healthcare facilities (HCFs) across the 11 districts in South Africa with the highest maternal mortality. The sequence in which all districts received EmOC&NC training was randomised but could not be blinded. The timing of training resulted in 10 districts providing data before and 10 providing data after EmOC&NC training. Primary outcome measures derived for HCFs are as follows: stillbirth rate (SBR), early neonatal death (ENND) rate, institutional maternal mortality ratio (iMMR) and direct obstetric case fatality rate (CFR), number of complications recognised and managed and CFR by complication.

Results

At baseline, median SBR (per 1000 births) and ENND rate (per 1000 live births) were 9 (IQR 0–28) and 0 (IQR 0–9). No significant changes following training in EmOC&NC were detected for any of the stated outcomes: SBR (adjusted incidence rate ratio (aIRR) 0.97, 95% CI 0.91 to 1.05), iMMR (aIRR 1.23, 95% CI 0.80 to 1.90), ENND rate (aIRR 1.04, 95% CI 0.92 to 1.17) and direct obstetric CFR (aIRR 1.15, 95% CI 0.66 to 2.02). The number of women who were recognised to need and received EmOC was significantly increased overall (aIRR 1.14, 95% CI 1.02 to 1.27), for haemorrhage (aIRR 1.31, 95% CI 1.13 to 1.52) and for postpartum sepsis (aIRR 1.86, 95% CI 1.17 to 2.95)

Conclusion

Following EmOC&NC training, healthcare providers are more able to recognise and manage complications at time of birth. This trial did not provide evidence that the intervention was effective in reducing adverse clinical outcomes, but demonstrates randomised evaluations are feasible in implementation research.

Trial registration number

ISRCTN11224105.

Feasibility of a Ketamine Anesthesia Package in Support of Obstetric and Gynecologic Procedures in Kenya When No Anesthetist is Available

The objective was to assess the feasibility and safety of the ̳Every Second Matters for Emergency and Essential Surgery - Ketamine' (ESM-Ketamine) package in support of obstetric and gynecologic emergency and essential surgery when no anesthetist is available. A consecutive case series was conducted in twelve hospitals across five severely resource-limited counties in Kenya. 530 women underwent obstetric or gynecological operative procedures supported by non-anesthetist clinicians using the ESM-Ketamine package between November 1, 2013 and September 30, 2017. Main outcomes included reasons for ESM-Ketamine activations and ketamine-related adverse events. There were two (0.4%) prolonged (>30 seconds) oxygen desaturations below 92%. Brief oxygen desaturations (<30 seconds) below 92% occurred in 15 (2.8%) cases and 113 (21.3%) were administered diazepam to treat hallucinations or agitation. There were no ketamine-related deaths or injuries. The ESM- Ketamine package appears feasible and safe for use in support of obstetric and gynecologic surgeries when no anesthetist is available.

Cardiac diastolic function after recovery from pre-eclampsia

BACKGROUND

Pre-eclampsia is associated with significant changes to the cardiovascular system during pregnancy. Eccentric and concentric remodelling of the left ventricle occurs, resulting in impaired contractility and diastolic dysfunction. It is unclear whether these structural and functional changes resolve completely after delivery.

AIMS

The objective of the study was to determine cardiac diastolic function at delivery and one year post-partum in women with severe pre-eclampsia, and to determine possible future cardiovascular risk.

METHODS

This was a descriptive study performed at Steve Biko Academic Hospital, a tertiary referral hospital in Pretoria, South Africa. Ninety-six women with severe preeclampsia and 45 normotensive women with uncomplicated pregnancies were recruited during the delivery admission. Seventy-four (77.1%) women in the pre-eclamptic group were classified as a maternal near miss. Transthoracic Doppler echocardiography was performed at delivery and one year post-partum.

RESULTS

At one year post-partum, women with pre-eclampsia had a higher diastolic blood pressure (p = 0.001) and body mass index (p = 0.02) than women in the normotensive control group. Women with early onset pre-eclampsia requiring delivery prior to 34 weeks' gestation had an increased risk of diastolic dysfunction at one year post-partum (RR 3.41, 95% CI: 1.11-10.5, p = 0.04) and this was irrespective of whether the patient had chronic hypertension or not.

CONCLUSION

Women who develop early-onset pre-eclampsia requiring delivery before 34 weeks are at a significant risk of developing cardiac diastolic dysfunction one year after delivery compared to normotensive women with a history of a low-risk pregnancy.

Community-wide Interventions to Prevent Skin Cancer: Two Community Guide Systematic Reviews

CONTEXT

Skin cancer is a preventable and commonly diagnosed cancer in the U.S. Excessive ultraviolet radiation exposure is a known cause of skin cancer. This article presents updated results of two types of interventions evaluated in a previously published Community Guide systematic review: multicomponent community-wide interventions and mass media interventions when used alone.

EVIDENCE ACQUISITION

Studies assessing multicomponent community-wide and mass media interventions to prevent skin cancer by reducing ultraviolet radiation exposure were evaluated using Community Guide systematic review methods. Relevant studies published between 1966 and 2013 were included and analyzed for this review.

EVIDENCE SYNTHESIS

Seven studies evaluating the effectiveness of multicomponent community-wide interventions showed a median increase in sunscreen use of 10.8 (interquartile interval=7.3, 23.2) percentage points, a small decrease in ultraviolet radiation exposure, a decrease in indoor tanning device use of 4.0 (95% CI=2.5, 5.5) percentage points, and mixed results for other protective behaviors. Four studies evaluating the effectiveness of mass media interventions found that they generally led to improved ultraviolet protection behaviors among children and adults.

CONCLUSIONS

The available evidence showed that multicomponent community-wide interventions are effective in reducing the deleterious effects of ultraviolet radiation exposure by increasing sunscreen use. There was, however, insufficient evidence to determine the effectiveness of mass media interventions alone in reducing ultraviolet radiation exposure and increasing ultraviolet protection behaviors, indicating a continuing need for more research in this field to improve assessment of effectiveness.

Smartphone-based diagnostic for preeclampsia: an mHealth solution for administering the Congo Red Dot (CRD) test in settings with limited resources

OBJECTIVE

Morbidity and mortality due to preeclampsia in settings with limited resources often results from delayed diagnosis. The Congo Red Dot (CRD) test, a simple modality to assess the presence of misfolded proteins in urine, shows promise as a diagnostic and prognostic tool for preeclampsia. We propose an innovative mobile health (mHealth) solution that enables the quantification of the CRD test as a batch laboratory test, with minimal cost and equipment.

METHODS

A smartphone application that guides the user through seven easy steps, and that can be used successfully by non-specialized personnel, was developed. After image acquisition, a robust analysis runs on a smartphone, quantifying the CRD test response without the need for an internet connection or additional hardware. In the first stage, the basic image processing algorithms and supporting test standardizations were developed using urine samples from 218 patients. In the second stage, the standardized procedure was evaluated on 328 urine specimens from 273 women. In the third stage, the application was tested for robustness using four different operators and 94 altered samples.

RESULTS

In the first stage, the image processing chain was set up with high correlation to manual analysis (z-test P < 0.001). In the second stage, a high agreement between manual and automated processing was calculated (Lin's concordance coefficient ρc = 0.968). In the last stage, sources of error were identified and remedies were developed accordingly. Altered samples resulted in an acceptable concordance with the manual gold-standard (Lin's ρc = 0.914).

CONCLUSION

Combining smartphone-based image analysis with molecular-specific disease features represents a cost-effective application of mHealth that has the potential to fill gaps in access to health care solutions that are critical to reducing adverse events in resource-poor settings.

An audit of the initial resuscitation of severely ill patients presenting with septic incomplete miscarriages at a tertiary hospital in South Africa

Background

Septic incomplete miscarriages remain a cause of maternal deaths in South Africa. There was an initial decline in mortality when a strict protocol based approach and the Choice of Termination of Pregnancy Act in South Africa were implemented in this country. However, a recent unpublished audit at the Pretoria Academic Complex (Kalafong and Steve Biko Academic Hospitals) suggested that maternal mortality due to this condition is increasing. The objective of this investigation is to do a retrospective audit with the purpose of identifying the reasons for the deteriorating mortality index attributed to septic incomplete miscarriage at Steve Biko Academic Hospital.

Methods

A retrospective audit was performed on all patients who presented to Steve Biko Academic Hospital with a septic incomplete miscarriage from 1^st January 2008 to 31^st December 2010. Data regarding patient demographics, initial presentation, resuscitation and disease severity was collected from the “maternal near-miss”/SAMM database and the patient’s medical record. The shock index was calculated for each patient retrospectively.

Results

There were 38 SAMM and 9 maternal deaths during the study period. In the SAMM group 86.8% and in the maternal death group 77.8% had 2 intravenous lines for resuscitation. There was no significant improvement in the mean blood pressure following resuscitation in the SAMM group (p 0.67), nor in the maternal death group (p 0.883). The shock index before resuscitation was similar in the two groups but improved significantly following resuscitation in the SAMM group (p 0.002). Only 31.6% in the SAMM group and 11.1% in the maternal death group had a complete clinical examination, including a speculum examination of the cervix on admission. No antibiotics were administered to 21.1% in the SAMM group and to 33.3% in the maternal death group.

Conclusion

The strict protocol management for patients with septic incomplete miscarriage was not adhered to. Physicians should be trained to recognise and react to the seriously ill patient. The use of the shock index in the identification and management of the critically ill pregnant patient needs to be investigated.

Changes in coverage of sun protection in the news: threats and opportunities from emerging issues

This study aimed to determine whether there have been shifts in news coverage of sun protection issues over a 12-year period in the context of an evolving skin cancer prevention agenda. A content analysis was performed on all relevant articles (N = 552) published in the two metropolitan daily newspapers in Melbourne, Australia, from 2001 to 2012. Coding variables included theme, article type, prominence, spokesperson and topic slant. Articles were collapsed into three 4-year blocks and a series of chi-square analyses conducted to examine changes over time in coverage of topical issues (i.e. vitamin D and sunbeds) and established sun protection themes [i.e. health effects of ultraviolet (UV) exposure, education/prevention, attitudes/behaviour]. Coverage of vitamin D and sunbed issues increased over time and became more positive for sun protection objectives. The proportion of articles reporting on established sun protection themes remained steady over time (range: 36-38%) and there were no changes observed in the way these topics were presented in the news media. These results highlight that potentially competing sun protection issues that emerge over time need not pose a threat to existing skin cancer prevention programmes but instead can provide opportunities to further spread programme messages while increasing credibility.

The role of parenting in affecting the behavior and adaptive functioning of young children of HIV-infected mothers in South Africa

Prior investigations suggest that maternal HIV/AIDS poses significant challenges to young children. This study investigates the relationships between mothers' psychological functioning, parenting, and children's behavioral outcomes and functioning in a population of women living with HIV (N = 361) with a child between the ages of 6 and 10 years in Tshwane, South Africa. Utilizing path analysis, findings revealed that maternal depression is related to increased parenting stress and parent-child dysfunction, maternal coping is related to parenting style, and maternal coping, parenting style and stress, and parent-child dysfunction are associated with children's behavior and functioning, with parenting emerging as an important mediator. These findings suggest that interventions for women living with HIV and their children should not only address maternal psychological functioning (depression and coping), but should also focus on parenting, promoting a positive approach.

Shade provision for toddlers at swimming pools in Melbourne

This study assessed the UVR protection provided by shade structures over toddler pools at swimming pool centers in Melbourne. The UVR protection was measured using a combination of UV sensitive polysulfone film to derive an average value during the middle of the day (1-2 P.M.) and handheld UV meters to derive the time variability in UV protection between 11 A.M. and 3 P.M. The amount of UVR protection provided by the shade structures depended upon a number of factors such as location, size, and materials used, but generally ranged from a protection factor (PF) of 2 to ~ 16. The higher PFs were generally for larger structures or where the shade had other structures nearby. The handheld UV meter measurements showed the UV protection varied with position under the shade structure as well as with time of day. While provision of shade structures is becoming more widespread around Australia, improving the shade availability at the pool centers overall, the application of recommendations regarding the provision of shade has been followed to a varying degree by many of the pools visited in this study. In many cases, continued further improvements can be made to provide more adequate protection and further reduce UV exposures.

Behavior and psychological functioning of young children of HIV-positive mothers in South Africa

Adults with HIV are living longer due to earlier diagnosis and increased access to antiretroviral medications. Therefore, fewer young children are being orphaned and instead, are being cared for by parents who know they are HIV positive, although they may be asymptomatic. Presently, it is unclear whether the psychological functioning of these young children is likely to be affected or, alternatively, whether it is only when a mother is ill, that children suffer adverse effects. We, thus, aimed to compare the behavior and psychological functioning of young children (aged 6-10 years) of HIV-positive and HIV-negative mothers. We also aimed to examine the association between HIV status disclosure and child outcomes. This study uses cross-sectional data from the baseline assessment of a randomized controlled trial conducted in Tshwane, South Africa. Participants (n=509) and their children were recruited from area health clinics. Among the 395 mothers with HIV, 42% reported symptoms of HIV disease. Multivariate linear regression models suggested that after adjusting for socio-demographic characteristics, children of HIV-positive mothers had significantly greater externalizing behaviors than children of HIV-negative mothers. Importantly, children whose mothers were symptomatic had greater internalizing and externalizing behaviors compared with children of HIV-negative mothers, but this was not true for children of asymptomatic mothers. Additionally, among children of HIV-positive mothers, those who had been told their mothers were sick compared with children who had been told nothing had less internalizing and externalizing behaviors and improved daily living skills. This study, therefore, provides evidence that maternal HIV disease can affect the behaviors of young children in South Africa but, importantly, only when the mothers are symptomatic from their disease. Furthermore, results suggest that disclosure of maternal illness but not HIV status was associated with improved behavior and psychological functioning among young children.

An outbreak of haemolytic anaemia associated with infection of Theileria orientalis in naive cattle

CASE HISTORY

An outbreak of haemolytic anaemia occurred when 87 cattle were introduced from a presumed non-infected herd from south Otago to a herd in Northland (n=580 cows), New Zealand, where theileriosis is endemic.

CLINICAL FINDINGS

Clinical signs associated with Theileria spp. infection included lethargy, anorexia, inappetance, pale mucous membranes, and varying severity of anaemia. In the naive imported cattle, 11/29 (38%) of those tested showed haematological signs of anaemia (haematocrit (HCT) <0.25 L/L). A negative association was present between the HCT and the number of Theileria spp. organisms counted using light microscopy (correlation coefficient=-0.4; p<0.05). Haemoparasites consistent with Theileria spp. were observed on examination of a blood smear. Theileria orientalis group (Theileria buffeli/orientalis) species was confirmed using PCR and DNA sequencing, and other causes for anaemia were excluded in the most clinically severely affected cow. The 18S sequence data and phylogenetic analysis of the CoxIII sequences showed samples had the greatest similarity to T. orientalis Chitose from Japan.

DIAGNOSIS

Haemolytic anaemia associated with infection of T. orientalis.

CLINICAL RELEVANCE

Previous reports have suggested that T. orientalis group species may be non-pathogenic in healthy cattle, and an incidental finding in blood samples. However, this investigation provided evidence that in New Zealand, this pathogen is capable of causing clinical disease in cattle not necessarily debilitated by another disease. The potential for disease should be considered when naive cattle are brought in from non-endemic to endemic regions, for instance cattle from the South Island moved to regions where the vector for T. orientalis group species, Haemaphysalis longicornis, is active, and T. orientalis is present.

Correlations of inhibitor kinetics for Pneumocystis jirovecii and human dihydrofolate reductase with structural data for human active site mutant enzyme complexes

To understand the role of specific active site residues in conferring selective dihydrofolate reductase (DHFR) inhibition from pathogenic organisms such as Pneumocystis carinii (pc) or Pneumocystis jirovecii (pj), the causative agent in AIDS pneumonia, it is necessary to evaluate the role of these residues in the human enzyme. We report the first kinetic parameters for DHFR from pjDHFR and pcDHFR with methotrexate (MTX), trimethoprim (TMP), and its potent analogue, PY957. We also report the mutagenesis and kinetic analysis of active site mutant proteins at positions 35 and 64 of human (h) DHFR and the crystal structure determinations of hDHFR ternary complexes of NADPH and PY957 with the wild-type DHFR enzyme, the single mutant protein, Gln35Lys, and two double mutant proteins, Gln35Ser/Asn64Ser and Gln35Ser/Asn64Phe. These substitutions place into human DHFR amino acids found at those sites in the opportunistic pathogens pcDHFR (Q35K/N64F) and pjDHFR (Q35S/N64S). The K(i) inhibition constant for PY957 showed greatest potency of the compound for the N64F single mutant protein (5.2 nM), followed by wild-type pcDHFR (K(i) 22 nM) and then wild-type hDHFR enzyme (K(i) 230 nM). Structural data reveal significant conformational changes in the binding interactions of PY957 in the hDHFR Q35S/N64F mutant protein complex compared to the other hDHFR mutant protein complexes and the pcDHFR ternary complex. The conformation of PY957 in the wild-type DHFR is similar to that observed for the single mutant protein. These data support the hypothesis that the enhanced selectivity of PY957 for pcDHFR is in part due to the contributions at positions 37 and 69 (pcDHFR numbering). This insight will help in the design of more selective inhibitors that target these opportunistic pathogens.

Design, synthesis, and X-ray crystal structure of classical and nonclassical 2-amino-4-oxo-5-substituted-6-ethylthieno[2,3-d]pyrimidines as dual thymidylate synthase and dihydrofolate reductase inhibitors and as potential antitumor agents

N-{4-[(2-Amino-6-ethyl-4-oxo-3,4-dihydrothieno[2,3-d]pyrimidin-5-yl)thio]benzoyl}-L-glutamic acid 2 and 13 nonclassical analogues 2a-2m were synthesized as potential dual thymidylate synthase (TS) and dihydrofolate reductase (DHFR) inhibitors and as antitumor agents. The key intermediate in the synthesis was 2-amino-6-ethyl-5-iodothieno[2,3-d]pyrimidin-4(3H)-one, 7, to which various arylthiols were attached at the 5-position. Coupling 8 with L-glutamic acid diethyl ester and saponification afforded 2. X-ray crystal structures of 2 and 1 (the 6-methyl analogue of 2), DHFR, and NADPH showed for the first time that the thieno[2,3-d]pyrimidine ring binds in a "folate" mode. Compound 2 was an excellent dual inhibitor of human TS (IC50 = 54 nM) and human DHFR (IC50 = 19 nM) and afforded nanomolar GI50 values against tumor cells in culture. The 6-ethyl substitution in 2 increases both the potency (by 2-3 orders of magnitude) as well as the spectrum of tumor inhibition in vitro compared to the 6-methyl analogue 1. Some of the nonclassical analogues were potent and selective inhibitors of DHFR from Toxoplasma gondii.

Ability of SPI2 mutant of S. typhi to effectively induce antibody responses to the mucosal antigen enterotoxigenic E. coli heat labile toxin B subunit after oral delivery to humans

We have evaluated an oral vaccine based on an Salmonella enteric serovar typhi (S. typhi) Ty2 derivative TSB7 harboring deletion mutations in ssaV (SPI-2) and aroC together with a chromosomally integrated copy of eltB encoding the B subunit of enterotoxigenic Escherichia coli heat labile toxin (LT-B) in volunteers. Two oral doses of 10(8) or 10(9)CFU were administered to two groups of volunteers and both doses were well tolerated, with no vaccinemia, and only transient stool shedding. Immune responses to LT-B and S. typhi lipopolysaccharide were demonstrated in 67 and 97% of subjects, respectively, without evidence of anti-carrier immunity preventing boosting of LT-B responses in many cases. Further development of this salmonella-based (spi-VEC) system for oral delivery of heterologous antigens appears warranted.

The effect of Pretoria Pasteurization on bacterial contamination of hand-expressed human breastmilk

One of the challenges facing the development of programs to reduce mother to child transmission of HIV in developing countries remains the problem of infant feeding. One of the alternative feeding methods under investigation for infants of HIV-infected mothers is heat treatment of expressed breastmilk by Pretoria Pasteurization. The objective of this study was to determine the effect of Pretoria Pasteurization on commensal and pathogenic bacteria in hand-expressed human breastmilk, and to determine the duration of time for which milk can be kept safely without refrigeration after Pretoria Pasteurization. Samples of milk were hand expressed by lactating women in the postnatal ward. The samples were split into control and pasteurized specimens. The pasteurized specimens underwent Pretoria Pasteurization. All samples were stored at room temperature and were sampled for bacterial culture every 4 h, up to 12 h. Clinically significant levels of bacterial contamination occurred in 59 per cent of control and 7.8 per cent of pasteurized samples. Four pasteurized samples showed significant contamination. There is strong evidence that the contaminating organisms in these samples were introduced by handling after pasteurization. The 53 (91 per cent) pasteurized samples that had no contamination at 4 h remained sterile for the remainder of the standing period of 12 h. Forty-one per cent of control samples already had significant growth after standing at room temperature for 4 h. In conclusion, Pretoria Pasteurization kills pathogenic and commensal bacteria in hand-expressed breastmilk. Expressed breastmilk that has undergone Pretoria Pasteurization can be kept without refrigeration for up to 12 h with minimal probability of bacterial contamination provided that it is kept in the pasteurization container and is not handled.

Uterine sarcomas in South African black women: a clinicopathologic study with ethnic considerations

BACKGROUND

There is considerable evidence for a higher incidence of uterine sarcomas in blacks when compared to whites. However, whether this higher incidence is related to differences in clinicopathologic presentation is not known.

PATIENTS AND METHODS

We reviewed slides and clinical charts of 81 patients with a primary diagnosis of uterine sarcoma referred between 1991 and 1999 to Kalafong Academic and Pretoria Academic Hospital. After review, 49 cases remained for study.

RESULTS

Uterine sarcomas were distributed between leiomyosarcoma (LMS) (39%), carcinosarcoma (CS) (49%) and endometrial stromal sarcoma (ESS) (12%). LMS and ESS tend to present at an earlier age when compared to CS (respectively p < 0.008 and 0.02). Of women with LMS more women are premenopausal when compared to CS (p < 0.009). Lower abdominal pain is more common in LMS (p < 0.009), whereas bleeding is more common in women suffering from CS (p < 0.01). Lymphovascular space involvement and cervical involvement are more common in CS when compared to LMS. In CS, the carcinoma component has most of the metastatic potential.

CONCLUSION

Among black South African women different clinicopathologic features for uterine LMS, CS and ESS are observed. We also present genetic and/or hormonal factors possibly contributing to the pathophysiology of uterine sarcomas in blacks.

Symphysis-fundal measurement as a predictor of low birthweight

OBJECTIVE

To prospectively test the value of a symphysis-fundal measurement in labor of less than or equal to 29 cm as a predictor of birth mass below 2000 g.

METHOD

Women admitted to Kalafong Hospital in labor with a singleton pregnancy were included in the study. Symphysis-fundal measurement according to the method of Westin was performed on two separate occasions and recorded together with other pertinent details. A receiver-operator curve was constructed to test various cut-off measurements.

RESULTS

A total of 1216 women were included in the study. One hundred twenty-one fetuses had a birth mass less than 2000 g (10%). A measurement of less than or equal to 29 cm had a sensitivity of 69% and a specificity of 98% with a positive predictive value of 81% and a negative predictive value of 97%. On the receiver-operator curve a cutoff of 30 cm showed a better sensitivity with little loss of specificity.

CONCLUSION

A symphysis-fundal measurement of less than or equal to 29 cm is a good predictor of birth mass less than 2000 g and can be used as an indication for referral to centres with neonatal facilities.

Carbohydrate biopolymers enhance antibody responses to mucosally delivered vaccine antigens

We have evaluated the ability of two carbohydrate biopolymers, chitosan and gellan, to enhance antibody responses to subunit influenza virus vaccines delivered to the respiratory tracts of mice. Groups of mice were vaccinated three times intranasally (i.n.) with 10 microg of purified influenza B/Panama virus surface antigens (PSAs), which consist of hemagglutinin (HA) and neuraminidase (NA), either alone or admixed with chitosan or gellan solutions. Separate groups were vaccinated subcutaneously (s.c.) with PSAs adsorbed to Alhydrogel or chitosan or gellan alone i.n. Serum antibody responses were determined by enzyme-linked immunosorbent assay (ELISA) for influenza virus-specific immunoglobulin G (IgG) and by HA inhibition (HAI) and NA inhibition (NAI) assays. The local respiratory immune response was measured by assaying for influenza virus-specific IgA antibody in nasal secretions and by enumerating nasal and pulmonary lymphocytes secreting IgA, IgG, and IgM anti-influenza virus-specific antibodies by enzyme-linked immunospotting (ELISPOT). When administered alone i.n., B/Panama PSA was poorly immunogenic. Parenteral immunization with B/Panama PSA with Alhydrogel elicited high titers of anti-B/Panama antibodies in serum but a very poor respiratory anti-B/Panama IgA response. In contrast, i.n. immunization with PSA plus chitosan stimulated very strong local and systemic anti-B/Panama responses. Gellan also enhanced the local and serum antibody responses to i.n. PSA but not to the same extent as chitosan. The ability of chitosan to augment the immunogenicity of influenza vaccines given i.n. was confirmed using PSA prepared from an influenza A virus (A/Texas H1N1).

The impact of a pregnancy confirmation clinic on the commencement of antenatal care

OBJECTIVE

To introduce a pregnancy confirmation clinic as part of antenatal care and to determine whether this would alter the gestational age at which patients commence antenatal care.

SETTING

Three municipal antenatal clinics in Atteridgeville and Central Pretoria.

METHOD

A pregnancy confirmation clinic was set up at three sites. At the clinic any woman wishing to confirm whether she was pregnant was offered a urine beta-HCG test. If this test was positive, on-site testing for syphilis, anaemia and rhesus status, dipstick testing of the urine, clinical examination and ultrasound examination were performed. Women with abnormal test results were commenced on appropriate treatment immediately and women requiring further medical care or investigation were referred appropriately.

RESULTS

The study recruited 382 women, 145 of whom were defaulters from contraception. Half of the women (191) had a positive pregnancy test. The mean presenting gestational age was 12 weeks 4 days (standard deviation 5 weeks, range 5 weeks-25 weeks 2 days). Treatable conditions with the potential to influence pregnancy outcome were identified in 37 of the pregnant women (19.4%) Forty-three of the pregnant women intended to terminate the pregnancy.

CONCLUSION

It is possible to shift the commencement of antenatal care to an earlier gestational age.

A comparison of active and passive smoking during pregnancy: long-term effects

Previous research has determined that maternal smoking during pregnancy is associated with negative effects for the child at birth and throughout childhood. Much less is known about the consequences of exposure to secondary smoke during fetal development. The present study investigates and compares the long-term consequences of active and passive smoking during pregnancy. Ninety-one children between the ages of six and nine years were tested using a comprehensive neuropsychological test battery. After considering potential confounds, children of nonsmoking mothers generally were found to perform better than the two smoking groups on tests of speech and language skills, intelligence, visual/spatial abilities and on the mother's rating of behavior. The performance of children of passive smokers was found, in most areas, to be between that of the active smoking and nonsmoking groups. It was concluded that there is a continuum of long-term smoking effects and that, although active maternal smoking is associated with effects of greater breadth and magnitude than passive maternal smoking, children of passive smokers are also at risk for a pattern of negative developmental outcomes.

Beta- and pre-beta-lipoproteins in coronary disease and hyperlipoproteinaemia

A very high percentage of male patients with proven coronary disease and/or raised lipid levels had a pre-beta-hyperlipoproteinaemia (class P [6] or Fredrickson [3] type IV) and relatively few had a beta-hyperlipoproteinaemia (class B or Fredrickson type IIA). Mixed hyperlipoproteinaemia was found in a large number of male patients but these again had predominantly raised triglyceride. More female patients over 40 years had beta-hyperlipoproteinaemia. Our retrospective study shows that raised triglyceride levels are more often found in patients with coronary disease than raised cholesterol levels.

Mithramycin treatment of hypercalcaemia and renal failure in a patient with paratesticular embryonic sarcoma

A 17-year-old patient with a small paratesticular embryonic sarcoma presented with symptoms of renal failure, polyuria and widespread bone metastases. Investigation revealed hypercalcaemia and uraemia without any evidence of hyperparathyroidism. The hypercalcaemia responded over a period of weeks to administration of mithramycin with initial improvement in the symptoms and metabolic derangements. Control was lost with the necrosis of intra-abdominal tumour deposits and haemorrhagic polypoid deposits in the alimentary tract. The value and hazards of mithramycin are well demonstrated by these rare complications of this type of tumour.