A Quality Improvement Initiative to Enhance the Treatment of Children With Severe Acute Malnutrition in Nepal

Objectives

Despite being implemented for decades, Nepal's Integrated Management of Acute Malnutrition program has experienced several implementation challenges such as low coverage, stock outs of ready-to-use therapeutic food supplies, poor reporting, loss to follow up and sub-optimal counselling. To address these and build a culture of continuous service delivery improvement, the Suaahara-II program adopted and assessed a quality improvement (QI) approach.

Methods

Change ideas, including increasing case identification through various platforms, developing QA standards to measure service quality, and providing incentives for female community health volunteers, were implemented as part of the QI initiative in four pilot municipalities. To assess changes in outcomes such as cure rate and number of cases identified and lost to follow-up, baseline information was collected over six months pre-implementation and performance was monitored throughout the QI implementation cycle of 17 months (February 2019—June 2021). We also analyzed secondary data from the government health management information system and established a monitoring mechanism to ensure data quality for outcome measures. For the outcome measure of service quality score, we developed a quality assurance (QA) checklist to score services while treating children with severe acute malnutrition (SAM).

Results

Our findings suggest that the QI effort was effective. The SAM cure rate increased from 67.4% pre-implementation to 80% post-implementation and the loss-to-follow-up rate declined from 26% to 8%. The number of new SAM cases fluctuated between 0–20 cases per month likely due to restrictions to mobility caused by the COVID-19 pandemic. Although there is no comparison to facilities that did not participate in the QI pilot, those that did had an average quality assurance score of 82.4%–above the 80% benchmark.

Conclusions

We found that the QI approach helped improve SAM cure rate, limited loss-to-follow-up and improved quality of case management for children with SAM. To successfully and sustainably implement QI to improve service delivery, leadership and local government accountability, regular coaching support and collaborative team efforts are key.

Funding Sources

United States Agency for International Development (USAID).

Experience in Growth Monitoring and Promotion Integrated With Immunization Services in a City Corporation of Bangladesh

Objectives

We aim to share the experience of the USAID's Strengthening Multi-sectoral Nutrition Programming through Implementation Science Activity (MSNP), which has been integrating Growth Monitoring (GMP) and Expanded Program of Immunization (EPI) for children under two years in Khulna City Corporation (KCC), Ministry of Local Government Rural Development and Cooperatives (LGRD), Bangladesh.

Methods

The team analyzed the GMP and EPI service data, observed client-provider interactions (service delivery) (n = 3 nutrition counselors), conducted semi-structured interview with health assistants (n = 6) and informal discussion with mothers (n = 10) who visited the GMP/EPI service facilities from October 2021 to January 2022.

Results

Both health assistants and nutrition counselors delivered GMP and EPI services, serving as key enablers of EPI-GMP integration. Reminder text messages were sent by MSNP project to mothers of children lost-for-follow-up to encourage their service return. From October 2021 to January 2022 GMP-EPI integrated services were provided to 1518 children (October: 32; November: 281; December: 583; January: 622).

Major challenges included coordination gaps between service activities; space constraints to conduct GMP; overburdening of health assistants to fulfil EPI lost-to-follow-up targets during COVID-19 pandemic and priority for vaccination of COVID-19 to EPI; lack of awareness among caregivers of the importance of appropriate nutrition during the child's first 1000 days for healthy physical and mental development.

Conclusions

Although this experience suggests integration of GMP into EPI can work, improvements are needed. The MSNP project will increase coordination among donors, Ministry of Health and LGRD, KCC and partner NGOs, service providers and mothers to ensure sustained and effective GMP-EPI integration; provide need-based infant and young child feeding counseling and train caregivers on community-based management of acute malnutrition, and strengthen service provision by providing supportive supervision to them.

Funding Sources

United States Agency for International Development (USAID).

Malnutrition Matters: Impact of Nutritional Status on Early Childhood Development in Nepal

Objectives

Malnutrition is associated with sub-optimal brain development, which adversely affects cognitive development in children. However, limited information exists in Nepal on the effects of various types of malnutrition on early childhood development (ECD). We assessed the association of stunting, wasting and underweight (three prominent forms of malnutrition) with the four domains of the ECD index (literacy-numeracy, physical, social-emotional and learning development) among children 36 to 59 months of age.

Methods

This study used a recently published national household survey from Nepal, the Multiple Indicator Cluster Survey (MICS) 2019 dataset. Unadjusted and adjusted logistic regression was used to identify the association between ECD indicators and stunting, wasting and underweight. The study sample consisted of children aged 3–4 years (n = 2870). Children were considered developmentally on track if they met specific criteria in each of the four ECD domains.

Results

Results indicated that 43.9% of stunted, 8.2% wasted and 29.6% underweight children did not sufficiently meet ECD index criteria to be considered developmentally on track. Adjusted odds ratios (OR) indicated that children with literacy-numeracy skills (stunting OR 0.53, p < 0.01, CI 0.42 – 0.67; underweight OR 0.61, p < 0.01, CI 0.47 – 0.79) were adequately nourished (stunting OR 0.47, p < 0.01, CI 0.29 – 0.75; underweight OR 0.55, p < 0.01, CI 0.34 – 0.88), and children with adequate learning development were less likely to be stunted or underweight (stunting OR 0.54, p < 0.01, CI 0.40 – 0.74; underweight OR 0.54, p < 0.01, CI 0.39 – 0.75). However, the study demonstrated no significant association between malnutrition and social-emotional development after adjusting for confounding variables. Likewise, no association between the four ECD domains and child wasting was observed after adjusting for socio-economic confounders.

Conclusions

Children's nutrition status impacts ECD outcomes. For better development outcomes among children, ECD components should be integrated into nutrition programming through capacity building activities of mothers, coupling nutrition messaging with ECD and providing books and tools for early learning.

Funding Sources

Family Health International (FHI 360).

Bridging the Knowledge Gap in Bangladesh for Effective Locally Driven Conditional Cash Transfer in Multisectoral Nutrition Programming

Objectives

The USAID's Strengthening Multisectoral Nutrition Programming through Implementation Science Activity (MSNP) in Bangladesh gathered local knowledge to augment national data to ensure nutrition programming delivery was appropriately targeted. Such knowledge allowed MSNP's social protection conditional cash transfer (CCT) activity to reach most at-risk individuals.

Methods

Using structured field observation forms, six trained staff documented nutrition programming decision-making processes and MSNP project activities regarding appropriate beneficiary targeting in six districts. Numerous project documents were reviewed and site visits conducted to evaluate CCT implementation in action. Data were coded into three aspects of learning (challenges and methods to alleviate them, successes, and recommendations for future programming) and analyzed according to themes identified in research utilization literature.

Results

CCT, an incentive-based delivery mechanism targeting women based on locally collected data, positively influenced household decision-makers, including women, to provide effective health and nutrition care for themselves and their children. CCT, received upon completion of antenatal care visits and participation in nutrition education sessions, effectively supported the uptake of MSNP community workers’ nutrition advice led to improve water, sanitation, and hygiene practices in remote areas. Requiring CCT beneficiaries to open bKash accounts to ensure financial transparency and that funds reached the intended participants helped establish women as nutrition decision makers, improving financial inclusion for extreme-poor women.

Conclusions

CCT stimulates use of nutrition and health services, increasing household resources for nutrition-related behaviors and allowing women to exercise financial freedom. To improve evidence utilization in nutrition programming, national indicators must be complemented with local knowledge gathering processes, with local stakeholders and beneficiaries involved to ensure appropriate targeting and to transform knowledge into practice.

Funding Sources

United States Agency for International Development (USAID).

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

The Dose Response: Perceptions of People Living with HIV in the United States on Alternatives to Oral Daily Antiretroviral Therapy

There are two concurrent and novel major research pathways toward strategies for HIV control: (1) long-acting antiretroviral therapy (ART) formulations and (2) research aimed at conferring sustained ART-free HIV remission, considered a step toward an HIV cure. The importance of perspectives from people living with HIV on the development of new modalities is high, but data are lacking. We administered an online survey in which respondents selected their likelihood of participation or nonparticipation in HIV cure/remission research based on potential risks and perceived benefits of these new modalities. We also tested the correlation between perceptions of potential risks and benefits with preferences of virologic control strategies and/or responses to scenario choices, while controlling for respondent characteristics. Of the 282 eligible respondents, 42% would be willing to switch from oral daily ART to long-acting ART injectables or implantables taken at 6-month intervals, and 24% to a hypothetical ART-free remission strategy. We found statistically significant gender differences in perceptions of risk and preferences of HIV control strategies, and possible psychosocial factors that could mediate willingness to switch to novel HIV treatment or remission options. Our study yielded data on possible desirable product characteristics for future HIV treatment and remission options. Findings also revealed differences in motivations and preferences across gender and other sociodemographic characteristics that may be actionable as part of research recruitment efforts. The diversity of participant perspectives reveals the need to provide a variety of therapeutic options to people living with HIV and to acknowledge their diverse experiential expertise when developing novel HIV therapies.

A systematic review and network meta-analysis of adjuvant therapy for curatively resected biliary tract cancers

Background

Recent randomized controlled trials (rcts) have contributed high-quality data about adjuvant therapy in curatively resected biliary tract cancer (btc); however, a standard approach to treating those patients still has not been developed.

Methods

We conducted a systematic review of published studies and abstracts up to and including June 2018, choosing rcts involving patients with btc receiving adjuvant chemotherapy after complete surgical resection. Network meta-analysis methods were used for indirect comparisons of overall survival (os) and relapse-free survival (rfs) for various adjuvant therapies.

Results

Five rcts were included in qualitative synthesis, and three rcts (bilcap, prodige 12-accord 18, and bcat) had data sufficient for inclusion in the meta-analysis. Results from the indirect comparison demonstrated no significant improvement in os for capecitabine compared with gemcitabine or with gemcitabine-oxaliplatin (gemox), the hazard ratios (hrs) being 0.82 [95% confidence interval (ci): 0.53 to 1.27] and 0.86 (95% ci: 0.56 to 1.34) respectively. Similarly, no significant improvement in rfs was observed for capecitabine compared with gemcitabine or gemox.

Conclusions

Although in the present analysis, we found no statistically significant improvements in os or rfs for capecitabine compared with gemox or gemcitabine, capecitabine can-until further prospective trials are completed-be considered the standard of care in the adjuvant setting based on a single randomized phase iii study.

Adherence to clinic recommendations among patients with phenylketonuria in the United States

OBJECTIVE

Assess current management practices of phenylketonuria (PKU) clinics across the United States (US) based on the key treatment metrics of blood phenylalanine (Phe) concentrations and blood Phe testing frequency, as well as patient adherence to their clinic's management practice recommendations.

METHODS

An online survey was conducted with medical professionals from PKU clinics across the US from July to September 2015. Forty-four clinics participated in the survey and account for approximately half of PKU patients currently followed in clinics in the US (Berry et al., 2013).

RESULTS

The majority of PKU clinics recommended target blood Phe concentrations to be between 120 and 360μM for all patients; the upper threshold was relaxed by some clinics for adult patients (from 360 to 600μM) and tightened for patients who are pregnant/planning to become pregnant (to 240μM). Patient adherence to these recommendations (percentage of patients with blood Phe below the upper recommended threshold) was age-dependent, decreasing from 88% in the 0-4years age group to 33% in adults 30+ years. Patient adherence to recommendations for blood testing frequency followed a similar trend. Higher staffing intensity (specialists per 100 PKU patients) was associated with better patient adherence to clinics' blood Phe concentrations recommendations.

CONCLUSION

Clinic recommendations of target blood Phe concentrations in the US are now stricter compared to prior years, and largely reflect recent guidelines by the American College of Medical Genetics and Genomics (Vockley et al., 2014). Adherence to recommended Phe concentrations remains suboptimal, especially in older patients. However, despite remaining above the guidelines, actual blood Phe concentrations in adolescents and adults are lower than those reported in the past (Walter et al., 2002; Freehauf et al., 2013). Continued education and support for PKU patients by healthcare professionals, including adequate clinic staffing, are needed to improve adherence. Future research is needed to understand how to improve adherence to reduce the number of patients lost to follow-up, as the findings of this and similar surveys do not address how to keep patients in clinic.

Assessment of myocardial metabolic flexibility and work efficiency in human type 2 diabetes using 16-[18F]fluoro-4-thiapalmitate, a novel PET fatty acid tracer

Altered myocardial fuel selection likely underlies cardiac disease risk in diabetes, affecting oxygen demand and myocardial metabolic flexibility. We investigated myocardial fuel selection and metabolic flexibility in human type 2 diabetes mellitus (T2DM), using positron emission tomography to measure rates of myocardial fatty acid oxidation {16-[(18)F]fluoro-4-thia-palmitate (FTP)} and myocardial perfusion and total oxidation ([(11)C]acetate). Participants underwent paired studies under fasting conditions, comparing 3-h insulin + glucose euglycemic clamp conditions (120 mU·m(-2)·min(-1)) to 3-h saline infusion. Lean controls (n = 10) were compared with glycemically controlled volunteers with T2DM (n = 8). Insulin augmented heart rate, blood pressure, and stroke index in both groups (all P < 0.01) and significantly increased myocardial oxygen consumption (P = 0.04) and perfusion (P = 0.01) in both groups. Insulin suppressed available nonesterified fatty acids (P < 0.0001), but fatty acid concentrations were higher in T2DM under both conditions (P < 0.001). Insulin-induced suppression of fatty acid oxidation was seen in both groups (P < 0.0001). However, fatty acid oxidation rates were higher under both conditions in T2DM (P = 0.003). Myocardial work efficiency was lower in T2DM (P = 0.006) and decreased in both groups with the insulin-induced increase in work and shift in fuel utilization (P = 0.01). Augmented fatty acid oxidation is present under baseline and insulin-treated conditions in T2DM, with impaired insulin-induced shifts away from fatty acid oxidation. This is accompanied by reduced work efficiency, possibly due to greater oxygen consumption with fatty acid metabolism. These observations suggest that improved fatty acid suppression, or reductions in myocardial fatty acid uptake and retention, could be therapeutic targets to improve myocardial ischemia tolerance in T2DM.

In vivo occupancy of dopamine D3 receptors by antagonists produces neurochemical and behavioral effects of potential relevance to attention-deficit-hyperactivity disorder

Dopamine D(3) receptors have eluded definitive linkage to neurologic and psychiatric disorders since their cloning over 20 years ago. We report a new method that does not employ a radiolabel for simultaneously defining in vivo receptor occupancy of D(3) and D(2) receptors in rat brain after systemic dosing using the tracer epidepride (N-[[(2S)-1-ethylpyrrolidin-2-yl]methyl]-5-iodo-2,3-dimethoxybenzamide). Decreases in epidepride binding in lobule 9 of cerebellum (rich in D(3) receptors) were compared with nonspecific binding in the lateral cerebellum. The in vivo occupancy of the dopamine D(3) receptors was dose dependently increased by SB-277011A (trans-N-[4-[2-(6-cyano-1,2,3,4-tetrahydroisoquinolin-2-yl)ethyl]cyclohexyl]-4-quinolinecarboxamide) and U99194 (2,3-dihydro-5,6-dimethoxy- N,N-dipropyl-1H-inden-2-amine). Both antagonists increased extracellular levels of acetylcholine (ACh) in the medial prefrontal cortex of rats and modified brain-tissue levels of ACh and choline. Consistent with these findings, the D(3) receptor antagonists enhanced the acquisition of learning of rats either alone or in the presence of the norepinephrine uptake blocker reboxetine as with the attention-deficit-hyperactivity disorder (ADHD) drug methylphenidate. Like reboxetine, the D(3) receptor antagonists also prevented deficits induced by scopolamine in object recognition memory of rats. Mice in which the dopamine transporter (DAT) has been deleted exhibit hyperactivity that is normalized by compounds that are effective in the treatment of ADHD. Both D(3) receptor antagonists decreased the hyperactivity of DAT(-/-) mice without affecting the activity of wild type controls. The present findings indicate that dopamine D(3) receptor antagonists engender cognition-enhancing and hyperactivity-dampening effects. Thus, D(3) receptor blockade could be considered as a novel treatment approach for cognitive deficits and hyperactivity syndromes, including those observed in ADHD.

Achieving Diameter-Selective Separation of Single-Walled Carbon Nanotubes by Using Polymer Conformation-Confined Helical Cavity

A water-soluble poly[(m-phenylenevinylene)-alt-(p-phenylenevinylene)] (PmPV) 2 has been synthesized, which exhibits an unsymmetrical substitution pattern on the para-phenylene unit. With one substituent being hydrophilic while the other being hydrophobic, the polymer chain has a higher tendency to fold in aqueous solution, thereby promoting helical conformation. The polymer is found to selectively disperse the single-walled nanotubes (SWNTs) of small diameters (d = 0.75-0.84 nm), in sharp contrast to PmPV 1 with a symmetrical substitution pattern. The intriguing diameter-based selectivity is believed to be associated with the confined helical conformation, which provides a suitable cavity to host the SWNT of proper sizes. The study thus provides a useful demonstration that the polymer conformation can have a profound impact on the SWNT sorting.

Selection of Single-Walled Carbon Nanotube with Narrow Diameter Distribution by Using a PPE-PPV Copolymer

Electronic and mechanic properties of single-walled carbon nanotubes (SWNTs) are uniquely dependent on the tube's chiralities and diameters. Isolation of different type SWNTs remains one of the fundamental and challenging issues in nanotube science. Herein, we demonstrate that SWNTs can be effectively enriched to a narrow diameter range by sequential treatment of the HiPco sample with nitric acid and a π-conjugated copolymer poly(phenyleneethynylene) (PPE)-co-poly(phenylenevinylene) (PPV). On the basis of Raman, fluorescence, and microscopic evidence, the nitric acid is found to selectively remove the SWNTs of small diameter. The polymer not only effectively dispersed carbon nanotubes but also exhibited a good selectivity toward a few SWNTs. The reported approach thus offers a new methodology to isolate SWNTs, which has the potential to operate in a relatively large scale.

First Report of Tomato chlorosis virus Infecting Tomato in Georgia

Tomato yellow leaf curl virus (TYLCV) and Tomato spotted wilt virus (TSWV) are prevalent in field-grown tomato (Solanum lycopersicum) production in Georgia. Typical TYLCV symptoms were observed during varietal trials in fall 2009 and 2010 to screen genotypes against TYLCV at the Coastal Plain Experiment Station, Tifton, GA. However, foliar symptoms atypical of TYLCV including interveinal chlorosis, purpling, brittleness, and mottling on upper and middle leaves and bronzing and intense interveinal chlorosis on lower leaves were also observed. Heavy whitefly (Bemisia tabaci (Gennadius), B biotype) infestation was also observed on all tomato genotypes. Preliminary tests (PCR and nucleic acid hybridization) in fall 2009 indicated the presence of TYLCV, TSWV, Cucumber mosaic virus, and Tomato chlorosis virus (ToCV); all with the exception of ToCV have been reported in Georgia. Sixteen additional symptomatic leaf samples were randomly collected in fall 2010 and the preliminary results from 2009 were used to guide testing. DNA and RNA were individually extracted using commercially available kits and used for PCR testing for ToCV, TYLCV, and TSWV. Reverse transcription (RT)-PCR with ToCV CP gene specific primers (4) produced approximately 750-bp amplicons from nine of the 16 leaf samples. Four of the nine CP gene amplicons were purified and directly sequenced in both directions. The sequences were 99.4 to 100.0% identical with each other (GenBank Accession Nos. HQ879840 to HQ879843). They were 99.3 to 99.5%, 97.2 to 97.5%, and 98.6 to 98.9% identical to ToCV CP sequences from Florida (Accession No. AY903448), Spain (Accession No. DQ136146), and Greece (Accession No. EU284744), respectively. The presence of ToCV was confirmed by amplifying a portion of the HSP70h gene using the primers HSP-1F and HSP-1R (1). RT-PCR produced approximately 900-bp amplicons in the same nine samples. Four HSP70h gene amplicons were purified and directly sequenced in both directions. The sequences were 99.4 to 99.7% identical to each other (Accession Nos. HQ879844 to HQ879847). They were 99.2 to 99.5%, 98.0 to 98.4%, and 98.9 to 99.3% identical to HSP70h sequences from Florida (Accession No. AY903448), Spain (Accession No. DQ136146), and Greece (Accession No. EU284744), respectively. TYLCV was also detected in all 16 samples by PCR using degenerate begomovirus primers PAL1v 1978 and PARIc 496 (3) followed by sequencing. TSWV was also detected in two of the ToCVinfected samples by RT-PCR with TSWV N gene specific primers (2) followed by sequencing. To our knowledge, this is the first report of the natural occurrence of ToCV in Georgia. Further studies are required to quantify the yield losses from ToCV alone and synergistic interactions between ToCV in combination with TSWV and/or TYLCV in tomato production in Georgia. References: (1) T. Hirota et al. J. Gen. Plant Pathol. 76:168, 2010. (2) R. K. Jain et al. Plant Dis. 82:900, 1998. (3) M. R. Rojas et al. Plant Dis. 77:340, 1993. (4) L. Segev et al. Plant Dis. 88:1160, 2004.

Hyaluronan (HA) content, the ratio of HA fragments and the expression of CD44 in the ovine cervix vary with the stage of the oestrous cycle

The complex anatomy of the ovine cervix limits the success of trans-cervical artificial insemination in sheep. However, there is a degree of natural relaxation of cervix at oestrus that is accompanied by an increase in the water content. As hyaluronan (HA) has a high affinity for water molecules, in this study, we tested the hypothesis that the HA content of the cervix, the proportion of different size fragments of HA and expression of its receptor CD44 vary with the stage of the oestrous cycle. Oestrous was synchronized in 25 Welsh mountain ewes, and their cervices were collected either during luteal phase (n=8) or pre-LH (n=8) or post-LH (n=9) surge stage of the oestrous cycle. The pre-LH surge group had the highest HA content (2.96 ng/mg of cervical tissue), which was significantly (P≤0.05) higher than that observed for the post-LH surge (2.04 ng/mg) group. The luteal phase group had a mean HA content intermediate between the pre- and post-LH surge groups, and was significantly different from either. The frequency of cervical samples containing both sizes of HA fragments (small and large) was significantly higher (P≤0.05) in the pre-LH surge group compared with the luteal and the post-LH surge groups, whereas that in post-LH surge group was significantly (P≤0.05) higher than that in the luteal group. The number of cervical samples that contained only small HA fragments was significantly (P≤0.05) higher in the luteal group compared with both the pre- and post-LH surge groups, whereas the number of samples containing only large HA fragments was significantly (P≤0.05) higher in the post-LH surge group compared with the luteal or pre-LH surge groups. Overall mean expression of CD44 in the vaginal and mid regions was significantly (P≤0.001) higher than that in the uterine region, with no difference between the vaginal and mid regions of the cervix. Pattern of CD44 expression depended on the stage of the oestrous cycle. At the luteal stage, CD44 expression did not vary among epithelial, sub-epithelial, circular and longitudinal smooth muscle layers, whereas at the pre- and post-LH surge stages, the expression in the epithelial layer was significantly (P≤0.001) higher than that in the other three layers. In general, CD44 expression in the transverse smooth muscle layer was significantly (P≤0.05) lower than the expression in all the other layers at all the stages of the oestrous cycle. The results indicated that the HA varied with the steroid status. Higher HA values at a time when cervical relaxation is naturally higher may indicate its involvement in remodelling of the cervix at oestrus.

326 MICROINJECTIONS OF SMALL INTERFERING RNA AND COMPLEMENTARY RNA TO ELUCIDATE THE INVOLVEMENT OF ENDOGENOUS PHOSPHOLIPASE C ISOFORMS IN BOVINE OOCYTE ACTIVATION DURING FERTILIZATION

Phospholipase C (PLC) isoforms stimulate the hydrolysis of phosphatidyl inositol (4,5)-bisphosphate (PIP2) to produce diacylglycerol (DAG) and 1,4,5 inositol trisphosphate (IP3), with IP3 regulating the release of calcium (Ca2+) from the endoplasmic reticulum. This release of calcium is essential for oocyte activation, and a sperm-specific PLC isoform, PLCγ;, has been proposed as the primary agent that initiates the activation process. However, the oocyte contains many endogenous PLC isoforms (PLC β, γ, and δ) that could also be involved in regulating or initiating these calcium oscillations downstream of other initiating events. In order to better elucidate the involvement of endogenous PLC isoforms as well as the specific role of the sperm-specific form, small interfering RNA (siRNA) directed against the specific bovine PLC isoforms (PLCζ;, PLCγ1, PLCγ2, PLCδ1, PLCδ3, PLCδ4, PLCβ1, PLCβ3) were microinjected into bovine oocytes, and the subsequent effects on PLC mRNA levels and bovine fertilization were evaluated. Real-time PCR (qPCR) was used to quantify the levels of PLC message present in bovine oocytes at the time of injection (15 h post-maturation) and 6, 10, and 14 h post-injection. The qPCR results indicated a near-complete knockdown of mRNA levels in bovine oocytes 10 h post-injection for the isotypes PLCγ1, PLCγ2, PLCδ3, PLCδ4, PLCβ1, PLCβ3, but only partial knockdown of PLCS 1 mRNA. Oocytes microinjected with PLC siRNA were also fertilized and cultured in vitro according to our standard laboratory procedures (Reed et al. 1996 Theriogenology 45, 439-449). The oocytes microinjected with PLCζ;, PLCδ1, PLCδ3, PLCδ4, PLCβ1, PLCβ3 siRNA resulted in cleavage rates similar to the negative control siRNA, non-injected, and sham-injected treatment groups, whereas bovine oocytes microinjected with PLCγ1 and PLCγ2 siRNA had significantly lower cleavage rates compared with the controls. Additionally, complementary cRNA for each specific PLC isoform was microinjected into bovine oocytes to ascertain each isoform’s ability to induce parthenogenetic activation. Development was observed in oocytes microinjected with a variety of cRNAs, and the activating effects of the cRNA were negligible if the oocytes were microinjected with the corresponding siRNA before microinjection with cRNA. Interestingly, siRNA specific for PLCζ; failed to reduce cleavage when treated bovine oocytes were fertilized. These data illustrate the potential involvement of multiple endogenous PLC isoforms and not just the sperm-specific PLCζ; isoform in bovine oocyte activation during fertilization.

Abstract IA-22: Cellular responses to telomerase perturbations

Telomerase is a ribonucleoprotein that replenishes the DNA at telomeres, thereby counteracting telomere shortening. Telomerase is highly active in many human malignancies. Telomerase functions in cancer maintenance include replenishing telomeric DNA and maintaining cell immortality. The telomerase RNA component provides a short template that is copied to make telomeric DNA. We found that mutating the template to cause various aberrant telomeric sequences to be added in human cancer cells rapidly caused massive ATM-dependent and ATM-independent chromosome fusions and cell death.

We also showed previously that human cancer cells responded rapidly to abrupt depletion of telomerase RNA by rapid and distinctive cellular/transcriptional responses, despite no obvious bulk telomere shortening or loss of telomere integrity. This and evidence from others indicates that, in addition to its telomere-elongating role, telomerase may play other roles in cells: cells lacking or overexpressing telomerase show a variety of responses even in the absence of detectable effects on telomere integrity or functionality. We are performing ChIP—SEQ experiments to identify genomic sites of telomerase interaction. New results of experiments exploring these roles of telomerase in cancer will be presented. Together, these and other findings indicate that telomerase, both via its roles in telomere maintenance and other roles, provides potential new inroads into cancer therapies.

Citation Information: Cancer Res 2009;69(23 Suppl):IA-22.

Positive margins in laparoscopic partial nephrectomy in 855 cases: a multi-institutional survey from the United States and Europe

PURPOSE

Open partial nephrectomy has emerged as the standard of care in the management of renal tumors smaller than 4 cm. While laparoscopic radical nephrectomy has been shown to be comparable to open radical nephrectomy with respect to long-term outcomes, important questions remain unanswered regarding the oncological efficacy of laparoscopic partial nephrectomy. We examined the practice patterns and pathological outcomes following laparoscopic partial nephrectomy.

MATERIALS AND METHODS

A survey was sent to academic medical centers in the United States and in Europe performing laparoscopic partial nephrectomy. The total number of laparoscopic partial nephrectomies, positive margins, indications for intraoperative frozen biopsy as well as tumor size and position were queried.

RESULTS

Surveys suitable for analysis were received from 17 centers with a total of 855 laparoscopic partial nephrectomy cases. Mean tumor size was 2.7 cm (+/-0.6). There were 21 cases with positive margins on final pathology, giving an overall positive margin rate of 2.4%. Intraoperative frozen sections were performed selectively at 10 centers based on clinical suspicion of positive margins on excised tumor. Random biopsies were routinely performed on the resection bed at 5 centers. Frozen sections were never performed at 2 centers. Of the 21 cases with positive margins 14 underwent immediate radical nephrectomy based on the frozen section and 7 were followed expectantly.

CONCLUSIONS

Early experience with laparoscopic partial nephrectomy in this multicenter study demonstrates oncological efficacy comparable to that of open partial nephrectomy with respect to the incidence of positive margins. The practice of intraoperative frozen sections varied among centers and is not definitive in guiding the optimal surgical treatment.

Quality-control ranges for antimicrobial susceptibility testing by broth dilution of the Brachyspira hyodysenteriae type strain (ATCC 27164T)

There are no approved standards for antimicrobial susceptibility testing of the fastidious spirochete Brachyspira hyodysenteriae. An interlaboratory study was performed to establish MIC quality control ranges for six antimicrobial agents for the type strain of B. hyodysenteriae using broth dilution. The results showed that B. hyodysenteriae B78T ATCC 27164T is a suitable quality control strain. This is a first step toward standardization of methods regarding this anaerobe.

Validation of a monoclonal antibody-based capture enzyme-linked immunosorbent assay for detection of Campylobacter fetus

A monoclonal antibody (MAb)-based antigen capture enzyme-linked immunosorbent assay (ELISA) was compared with the routine culture methodology for the detection of Campylobacter fetus subspecies from bovine and ovine field samples inoculated into Clark's transport enrichment medium (TEM). The work was a collaboration between two different diagnostic laboratories, one in Canada and the other in England. In both labs, TEM samples were incubated for 4 days at 35 degrees C and then tested by culture and ELISA. The ELISA consisted of initial screening with MAb M1825 against C. fetus subspecies core lipopolysaccharide (LPS). All samples positive on ELISA screening were then retested by ELISA with MAb M1825 and MAbs M1177, M1183, and M1194, which recognize serotype A- and/or serotype B-specific C. fetus subspecies LPS epitopes. The Canadian samples consisted of 1,060 preputial washings from 529 bulls, of which 18 were positive by both culture and ELISA and 1,042 were negative by both methods. The English samples consisted of 321 tissue specimens, mostly stomach contents and placentas, from 190 aborted ovine and bovine fetuses. A total of 262 samples were negative by culture and ELISA, 52 samples were positive by culture and ELISA, and 7 samples were culture negative but ELISA positive. The results for all 70 culture-positive isolates were confirmed by conventional biochemical methods as C. fetus subsp. fetus, with 39 presumptively identified by the ELISA as serotype A and 30 presumptively identified as serotype B and with one sample containing isolates presumptively identified as serotype A and serotype B. A receiver operating characteristic analysis of the combined ELISA data from both countries resulted in an area under the curve of 0.997, with a sensitivity of 100% and a specificity of 99.5% relative to the results of culture. The data confirm that this ELISA method can be used as an excellent test for the screening of field samples in TEM for the presence of C. fetus subspecies.

An evaluation of near patient tests for detecting herpes simplex virus type-2 antibody

OBJECTIVES

To examine the "in use" test characteristics of the POCkit "near patient" HSV-2 rapid test for the detection of HSV-2 IgG antibodies for use in the clinic. This test relies on a visual interpretation of the result.

METHODS

2093 serum samples, 229 from UK and 919 from Italian genitourinary medicine clinic patients and 945 from obstetric and gynaecology clinic patients in Italy were tested. Tests were carried out according to manufacturers' protocol in the United Kingdom and Italy. Three readers independently recorded a score for each test carried out and the results were compared.

RESULTS

In the UK study, the three readers disagreed on the result on 5.2% of tests. In the Italian study, there was disagreement in 10.2% of tests.

CONCLUSIONS

This study has demonstrated a problem in the subjective nature of the interpretation of the POCkit HSV-2 test. It highlights the need for adequate training of clinic staff and the need for clinics to adopt policies of quality assurance and ongoing monitoring which will ensure the validity and accuracy of this clinic based test.

Automated purification and quantification of oligonucleotides

We have developed automated methods for the trityl-on purification and quantification of synthetic oligonucleotides. Oligonucleotide purification is by solid-phase extraction cartridges using Amberchrom CG-50 resin on an XYZ-axis robotic system. Quantification is by OD260nm using an online UV-visible spectrophotometer with sipper. The purification of 20 oligonucleotides requires 5 min of user set-up time, plus 20 min per sample of robot time. For a 15-25-mer at the 40 nmol scale of synthesis, the method gives a yield of 2.8 ODs from a load of 10.1 OD, i.e., a 28% average yield. Oligonucleotides purified by this method have proven to be successful for primers for automated DNA sequencing.

A randomized, placebo-controlled study of rifabutin added to a regimen of clarithromycin and ethambutol for treatment of disseminated infection with Mycobacterium avium complex

Current guidelines suggest that disseminated Mycobacterium avium complex (MAC) infection be treated with a macrolide plus ethambutol or rifabutin or both. From 1993 to 1996, 198 AIDS patients with MAC bacteremia participated in a prospective, placebo-controlled trial of clarithromycin (500 mg b.i.d.) plus ethambutol (1,200 mg/d), with or without rifabutin (300 mg/d). At 16 weeks, 63% of patients in the rifabutin group and 61% in the placebo group (P = .81) had responded bacteriologically. Changes in clinical symptoms and time to survival were similar in both groups. Development of clarithromycin resistance during therapy was similar in the two groups; of patients who had a bacteriologic response, however, only 1 of 44 (2%) receiving rifabutin developed clarithromycin resistance, vs. 6 of 42 (14%) in the placebo group (P = .055). Thus, rifabutin had no impact on bacteriologic response or survival but may protect against development of clarithromycin resistance in those who respond to therapy.

Acute fatigue in chronic fatigue syndrome patients

BACKGROUND

Chronic fatigue syndrome (CFS) patients often complain that they are more susceptible to acute mental fatigue. It is important to determine whether this is observed using objective tests of sustained attention and responding.

METHODS

Sixty-seven patients who fulfilled the criteria for CFS proposed by Sharpe et al. (1991) were compared with 126 matched healthy controls. Acute fatigue was assessed by comparing performance at the start and end of a lengthy test session and by examining changes over the course of individual tasks.

RESULTS

CFS patients showed impaired performance compared to the controls and these differences increased as the volunteers developed acute fatigue. In addition, differences between the two groups were larger at the end of the test session.

CONCLUSIONS

The present results show that CFS patients are more susceptible to acute fatigue than healthy controls. This could reflect motor fatigue or an inability to compensate for fatigue with increased effort. This profile is consistent with previous research on fatigue and suggests that interpretation of certain aspects of CFS may be helped by considering it as the end point of a continuum of fatigue rather than a distinct disease.

Risk of hepatitis A infection in sewage workers

OBJECTIVE

To evaluate the risk of hepatitis A virus (HAV) infection among sewage workers from occupational exposure to raw sewage.

METHODS

An analytical cross sectional study of 241 company employees with possible occupational exposure to sewage in a large water and sewerage company was carried out. Previous exposure to hepatitis A virus infection was assessed, as were its associations with possible risk factors.

RESULTS

Frequent occupational exposure to raw sewage was a significant risk factor for HAV infection, independently of other known risk factors (odds ratio 3.73, 95% confidence interval 1.48 to 9.37). Of 50 employees who reported occupational exposure to raw sewage most of the time, 30 (60%) had had HAV infection.

CONCLUSION

Employees who are likely to be at risk of frequent exposure should have their immunity ensured. The salivary assay for IgG anti-HAV used in the study was highly specific and would be suitable for prevaccination testing of older employees, who are more likely to be immune.

Caffeine and the common cold

An experiment was carried out to determine whether caffeinated and decaffeinated coffee removed the malaise (reduced alertness, slower psychomotor performance) associated with having a common cold. One hundred volunteers were tested when healthy and 46 returned to the laboratory when they developed colds. Those subjects who remained healthy were then recalled as a control group. On the second visit subjects carried out two sessions, one pre-drink and another an hour after the drink. Subjects were randomly assigned to one of the following three conditions, caffeinated coffee (1.5 mg/kg caffeine/body weight), decaffeinated coffee or fruit juice. Subjects with colds reported decreased alertness and were slower at performing psychomotor tasks. Caffeine increased the alertness and performance of the colds subjects to the same level as the healthy group and decaffeinated coffee also led to an improvement. These results suggest that drugs which increase alertness can remove the malaise associated with the common cold, and that increased stimulation of the sensory afferent nerves may also be beneficial.

Integration of laptop computer technology into an undergraduate nursing course

An evaluative study was done to determine the effects of laptop computer use on baccalaureate nursing students' attitudes toward computers, computer knowledge, and computer skills. Students in the experimental group (n = 20) received laptop computers and 9 hours of computer instruction. They were encouraged to use the laptop computers for e-mail, library searches, and word processing. The comparison group (n = 18) completed the same assignments in the usual manner. Students had positive attitudes toward computers both pretest and posttest with no significant increase or difference between the two groups. There was no significant difference between the two groups in computer knowledge outcomes; however, the experimental group had statistically significant gains in computer skills. Results of this study suggest that the integration of laptop computer technology into the undergraduate nursing curriculum can be an effective way to increase students' computer skills while maintaining positive attitudes toward computers in nursing.

A comparison of the acute effects of a low dose of alcohol on mood and performance of healthy volunteers and subjects with upper respiratory tract illnesses

An experiment was carried out to determine whether a low dose of alcohol produced different behavioural effects in healthy volunteers to those suffering from an upper respiratory tract illness. Ninety-nine subjects were tested, with 48 subjects being assigned to the alcohol condition and 51 to the juice only condition. A dose of 1.5 ml of vodka per kg body weight was used and the alcohol manipulation was double-blind. Approximately half of the subjects in each condition were healthy and the others had upper respiratory tract illnesses, probably colds. Subjects with colds reported an increase in negative affect and were slower at performing psychomotor tasks. Few main effects of alcohol were obtained. Of major interest were the interactions between health status and alcohol conditions. The alcohol improved the mood of healthy subjects but produced greater negative moods in subjects with colds. Similarly, performance of selective and sustained attention tasks showed different effects of alcohol in healthy and ill subjects.