Costing Interventions for Developing an Essential Package of Health Services: Application of a Rapid Method and Results From Pakistan

BACKGROUND

The Federal Ministry of National Health Services, Regulations and Coordination (MNHSR&C) in Pakistan has committed to progress towards universal health coverage (UHC) by 2030 by providing an Essential Package of Health Services (EPHS). Starting in 2019, the Disease Control Priorities 3rd edition (DCP3) evidence framework was used to guide the development of Pakistan's EPHS. In this paper, we describe the methods and results of a rapid costing approach used to inform the EPHS design process.

METHODS

A total of 167 unit costs were calculated through a context-specific, normative, ingredients-based, and bottom-up economic costing approach. Costs were constructed by determining resource use from descriptions provided by MNHSR&C and validated by technical experts. Price data from publicly available sources were used. Deterministic univariate sensitivity analyses were carried out.

RESULTS

Unit costs ranged from 2019 US$ 0.27 to 2019 US$ 1478. Interventions in the cancer package of services had the highest average cost (2019 US$ 837) while interventions in the environmental package of services had the lowest (2019 US$ 0.68). Cost drivers varied by platform; the two largest drivers were drug regimens and surgery-related costs. Sensitivity analyses suggest our results are not sensitive to changes in staff salary but are sensitive to changes in medicine pricing.

CONCLUSION

We estimated a large number of context-specific unit costs, over a six-month period, demonstrating a rapid costing method suitable for EPHS design.

Much room for change: access to surgical care for stateless individuals in Pakistan

BACKGROUND

As developing countries take steps towards providing universal essential surgery, ensuring the equitable distribution of such care for underrepresented populations is a vital function of the global surgery community. Unfortunately, in the context of the global "stateless", there remains much room for improvement.

KEY ISSUES

Inherent structural deficiencies, such as lack of adequate population data on stateless communities, absent health coverage policies for stateless individuals, and minimal patient-reported qualitative data on barriers to surgical service delivery prevent stateless individuals from receiving the care they require - even when healthcare infrastructure to provide such care exists. The authors therefore propose more research and targeted interventions to address the systemic issues that prevent stateless individuals from accessing surgical care.

CONCLUSION

It is essential to address the aforementioned barriers in order to improve stateless populations' access to surgical care. Rigorous empirical and qualitative research provides an important avenue through which these structural issues may be addressed.

Craniopharyngioma: A lower-middle-income-country epidemiology

OBJECTIVE

To quantify the frequency of craniopharyngiomas presenting to tertiary care neurosurgical centres, the demographics and mortality rate, and commonly presenting to neurosurgical practice.

Method

Our study was a retrospective cross-sectional analysis of patients admitted at 32 neurosurgical centres between January 1, 2019, and December 31, 2019, with brain tumour. Kruskal Wallis analysis was used to determine normality; normally distributed variables were reported as means with standard deviation, while median with interquartile range was used for non-normally distributed variables.

RESULTS

Of 2750 patients with brain tumours, 114 patients presented with craniopharyngioma. The median age at diagnosis was 18 years, with 42 (42.8%) patients below the age of 15, 40 (40.9%) patients aged 15-39, and 16 (16.3%) patients aged 40 and above. There were 70 (61.4%) males and 44 (38.6%) females in our cohort. Gross total resection was performed in 42(36.8%), 45 (39.5%) underwent subtotal resection, 9 (7.9%) underwent CSF diversion only, and 2 (1.8%) had a biopsy. Most of our patients 94(82.5%) presented to public hospitals, with 20 (17.5%) patients presenting to private hospitals (p=0.002). The overall survival at two years was 86.8% in patients with known outcomes, and only 10% of patients died within 30 days of surgery.

CONCLUSIONS

Craniopharyngiomas comprised a small portion of all brain tumours in our region. They are more common in males and in patients from the lower socioeconomic class. These patients mainly presented to public sector hospitals, and the three highest volume centres were all public sector institutions. The overall survival rate at two years in our region is lower than in other regions.

Private vs public care for intracranial tumours: Findings from Pakistan

OBJECTIVE

To observe the patient characteristics and centres providing neuro-oncological care in public and private health hospitals in Pakistan.

Method

The Pakistan Association of Neuro-oncology carried out a retrospective, cross-sectional study in 2019 on patients admitted to 32 hospitals in Pakistan, with dedicated neurosurgical facilities. Patients with a histopathological diagnosis of an intracranial tumour were included.

RESULTS

Public health care facilities catered for 84% patients with ages between 20 and 60 years and children having intracranial tumours. Private centres were utilised by 66.7% patients from the upper socioeconomic sector. More patients were lost to follow-up in the public sector (n = 784) versus in the private sector (n = 356). Mortality was also higher in the public sector hospitals, (13.9%) as compared to 9.6% in the private sector.

CONCLUSIONS

Public and private sector health services for neuro-oncological care in Pakistan still have a long way to go to cover the gaps for unmet needs. Strengthening health systems for brain tumour care is imperative to increase both the access to care and the quality of care to fulfil this need.

Factors associated with lost to follow up in patients with brain tumours: A multi-centre study in Pakistan

OBJECTIVE

To identify populations at risk for lost to follow-up while undergoing management of brain tumours in a low-resource setting.

Methods

A retrospective study was conducted at the neurosurgical centre on patients presenting with a brain tumour from January 1, 2019, to December 31, 2019. Data on demographic characteristics, surgical characteristics, treatment, and outcomes such as mortality status, were collected by manual chart review. LTFU was defined as patients discontinuing clinical follow-up at the institute of surgical consultation within two years from the initial visit. Univariate (odds ratio) and multivariate (b-coefficient) logistic regression were used to determine factors' significance for LTFU.

RESULTS

From a total of 2750 patients from 32 centres, 1140 (41.4%) were LTFU during the study period. Of these 1140 LTFU patients, 156 (13.7%) were LTFU without any intervention, 984 (86.3%) were LTFU after the primary surgery, and 872 (76.5%) patients were LTFU without any adjuvant treatment. On univariate analysis annual hospital case volume (p< 0.001), older age group (15-39 years (p=0.037) and ?40 years (p= 0.016)), and non-surgical treatment (p<=0.026) correlated with a higher risk of LTFU. Belonging to the middle-class cohort was correlated with a better chance of follow up (p=0.001). Multivariate analysis demonstrated that larger centres had the largest b-coefficient of 1.53 (95% CI= 1.3-1.8, p< 0.001).

CONCLUSIONS

Our study demonstrated that almost half of patients diagnosed with brain tumours were LTFU within two years of diagnosis. Larger centres, non-surgical treatment, and older age seem to be associated with higher LTFU. Identifying vulnerable populations will allow the need-based provision of care and follow-up to improve health outcomes.

Time to surgery after radiological diagnosis of brain tumours in Pakistan: A nationwide cross-sectional study

OBJECTIVE

To investigate waiting times for brain tumour surgery in Pakistan from a nationwide sample and highlight specific affected patient populations.

Method

A nationwide study was conducted as part of the Pakistan Brain Tumour Epidemiology Study; data from 32 high-volume neurosurgical centres were collected. The national sample included 2,750 patients. Time to surgery was calculated by the difference in dates recorded for radiological diagnosis and the date of the first surgery. This was further stratified according to demographic factors, histopathological diagnosis, type of surgical procedure performed and survival outcomes.

RESULTS

The data of 1,474 patients for time to surgery was available. Patients travelling to public hospitals had significantly longer mean wait times (94.07 (CI: 85.29, 102.84) vs 75.14 (CI: 54.72, 95.56) days, p<0.001). Significant differences were seen between patients of various age groups, as adolescents (116.63 (CI: 65.27, 167.98) days) and young adults (103.34 (CI: 85.96, 120.72) days) had higher waiting times compared to middle-aged (72.44 (CI: 61.26, 83.61) days) and older (48.58 (CI: 31.17, 65.98) days) adults. No difference was seen between the genders. A significantly longer time to surgery was observed for middle- and lower-socioeconomic class patients. Those undergoing gross total resection of the tumour had significantly (p<0.001) longer waiting times for surgery when compared to STR (sub-total resection), biopsy, and CSF-diversion procedures, for all tumour types. Patients diagnosed with meningioma had the most prolonged waiting periods (106 (CI: 76, 95) days). Gliomas had a mean waiting period of 88 (CI: 73, 103) days across the country. Low-grade gliomas had significantly (p=0.031) longer mean waiting times (99.73 (CI: 61.91, 127.36) days) in comparison to high-grade gliomas (70.13 (CI: 43.39, 89.69 ) days). A significant difference was seen between waiting times for patients who survived surgical procedures for a brain tumour on the most recent follow-up and those who had expired (91.87 (CI: 79, 107.74) vs 77.41 (CI: 59.90, 94.91) days, p<0.001).

CONCLUSIONS

Prolonged delays to surgery are a significant barrier within low-and-middle-income countries, leading to adverse outcomes for patients. Patients undergoing brain tumour surgery at public hospitals from lower or middle SES and electing for gross resections were more likely to have longer delays.

Pakistan Brain Tumour Epidemiology Study (PBTES): Uncovering the Hidden Burden of Brain Tumours in the Country

Epidemiological studies have significantly helped determine the burden, types, and geographical distribution of brain tumours in HICs (highincome countries). However, brain tumour data from low-and-middle-income countries is often sparse, focusing on a few centres1. The situation in Pakistan is no different. Few oncological registries exist in our region that focus on common tumours. Collecting data regarding brain tumours has been challenging, as evidenced by the underreported incidence of brain tumours by centers such as the Karachi Cancer Registry (KCR), Pakistan Atomic Energy Commission (PAEC) report, and GLOBOCAN. Brain tumours are distinct from other cancer types by having more than 200 subtypes, requiring complex analysis, grading, and personalized therapeutic strategies. Moreover, there is no current standardized system to record brain tumour patient data, making it difficult to collate data from various centers. Continue.

Conducting the Pakistan brain tumour epidemiology study - report on the methodology

Objectives

To combat the lack of brain tumour registries, the Pakistan Brain Tumour Epidemiology Study (PBTES) was conducted without any funding from an external source.

METHODS

A retrospective analysis of patient data, including patients of all age groups diagnosed with all histopathological types of brain tumours from all over Pakistan, was performed. For this, Pakistan Brain Tumour Consortium (PBTC) was established, including 32 neurosurgical centres from around the country. Data was collected online through a proforma that included variables such as patient demographics, clinical characteristics, operative details, postoperative complications, survival indices, and current functional status. The data collection and analysis team included principal investigators, core leads, regional leads, regional associates, and student facilitators. Despite logistical concerns and lack of resources, the PBTES was conducted successfully, and a formal brain tumour surveillance database was formed without any external funding, which remains unheard of.

CONCLUSIONS

The methods applied in this study are reproducible and can be employed not just to develop more robust brain tumour and other cancer registries but also to study the epidemiology of communicable and non-communicable diseases in resource-limited settings, both locally and globally.

Prioritizing Pituitary Adenoma Care in Pakistan: Analysis from an Epidemiological Study

OBJECTIVE

To identify symptoms and risk factors and promptly diagnose, treat, and manage pituitary adenomas. Prioritizing care for pituitary adenomas will reduce the prolonged disability.

Method

Patients with a histopathological diagnosis of a pituitary adenoma that presented at 32 tertiary care neurosurgical centres were included. The information recorded included demographics, treatment methods, adjuvant chemoradiotherapy and loss to follow-up. Data on tumour size, functionality, and laterality were collected.

RESULTS

Of the 32 hospitals surveyed, 24 operated on pituitary adenomas, and treated 277 patients. The mean age at diagnosis was 39.8 ± 13 years, with a majority of males (63.5%) being diagnosed than females. Paediatric cases constituted only 4.7% of the total pituitary adenomas operated upon. Gross total resection was reported for 155 (56%) of all pituitary adenoma patients. Majority of the patients affected by pituitary adenomas (80.1%) were from the working class.

CONCLUSIONS

Highlighting care for non-malignant brain tumours is important for Pakistan's health system. Evidence pertaining to gender and age disparities indicates that males in the younger age groups are predominantly affected, which takes a large socio-economic toll on patients and their households. This study also highlights the need to incorporate digital health technologies for postoperative follow-up and adjuvant treatment.

Distance travelled for brain tumour surgery: An Low and Middle Income Country's perspective

OBJECTIVE

To examine the effect of distance travelled for brain tumour surgery on patient outcomes in an LMIC.

METHODS

Data were collected as part of the Pakistan Brain Tumour Epidemiology Study (PBTES) for brain tumour patients who underwent surgery in 2019. Mapping software was used to calculate the distance travelled by each patient from their primary address to the hospital. This was analysed in correlation with outcomes (change in KPS score, current status) and demographic variables.

RESULTS

Of 2366 patients, the median distance travelled across the country was 104 km (IQR: 9.07 - 304). Only 970 (41%) patients had access to brain tumour surgical care within 50 km of their primary address. A total of 372 (15.7%) patients requiring brain tumour surgery had to travel more than 500 km to reach their primary care hospital. Patients travelling more than 50 km for brain tumour surgery had better pre- and post-surgery Karnofsky performance scores (p<0.001) than those travelling less than 50 km. The overall survival for these patients was also better (82.4% vs 75.7%, p= 0.002) compared to patients travelling less than 50 km.

CONCLUSIONS

The distance to a hospital dictates a patient's access to continuity of care through adjuvant chemoradiotherapy and regular follow-ups. Less than half of brain tumour patients in Pakistan had access to brain tumour surgery care within 50 km of their homes. Overall outcomes were significantly better in patients travelling more than 50km for neurosurgical care - suggesting a distance bias effect.

Metastatic brain tumours in Pakistan: An epidemiological overview

OBJECTIVE

To quantify the metastatic brain tumour burden presenting to tertiary care neurosurgical centres, the demographics and mortality rate, and the type of metastatic tumours commonly presenting to neurosurgical practice.

Method

A cross-section retrospective study was conducted on patients diagnosed with brain tumours from 32 neurosurgical centres across Pakistan between January 1, 2019, to December 31, 2019. At least one neurosurgical resident and one neurosurgical faculty member were recruited from each centre as members of the Pakistan Brain tumour consortium. Mean with standard deviation or median with interquartile range was reported as variables.

RESULTS

Of 2750 patients in this cohort, 77 (2.8%) were diagnosed with metastatic brain tumours. The median age of these patients was 52 (IQR= 43-60) years; 9 (14%) adults were aged 20-39 years, 37 (57%) were aged 40-59, and 19 (29%) were aged 60 and above. There were 62 (82.7%) married patients with 4% unmarried. The median KPS score both pre and post-surgery was 80 (IQR= 60-90, 70-90 respectively), and 43 (55.8%) patients were lost to follow-up. The mortality rate for patients that followed up was 50%, 17 patients were alive, and 17 were deceased at the end of the study period. The 30-day mortality rate amongst our patients was 11.8% (n=4).

CONCLUSIONS

The number of patients presenting to neurosurgical care with brain metastases is much lower than the expected incidence of metastatic brain lesions. Multidisciplinary integration and the establishment of a registry to track patients diagnosed with brain tumours is the first step in ensuring better care for these patients.

Ependymoma: an epidemiological perspective from a low- and middle-income country

OBJECTIVE

To enumerate the burden of ependymoma in our region and identify the demographic, tumoural, surgical, clinical characteristics, and outcomes of patients diagnosed with ependymoma.

METHODS

This retrospective cross-sectional study included patients admitted under neurosurgical service between January 1 and December 31, 2019. The inclusion criterion for the study was a histopathological diagnosis of the brain lesion. The experience of the ependymal brain tumours observed at the 32 participating sites in Pakistan is presented.

RESULTS

A total of 2750 patients with brain tumours were seen in 2019 at our centres of whom 58(2.1%) had a histopathological diagnosis of ependymoma. The median age at diagnosis was nine (IQR= 4.5-24.5) years. The median time to surgery from date of radiological diagnosis was 38.5 (IQR= 4-93.8) days. The median KPS score at presentation was 70 (IQR= 60-80), and post-surgery was 90 (IQR= 70-100), showing an average increase of 20. Our population's overall mortality rate for ependymoma was 31.1%, with the 30-day mortality rate being 2.2% (lower than the 4.5% on average for all brain tumours in our cohort).

CONCLUSIONS

Ependymomas were predominantly found in the paediatric population in the presented cohort. While gender distribution and histopathological grading seemed to follow international trends, this study had a much higher mortality rate and a much lower gross total resection rate than centres in high-income countries.

The Pakistan Brain Tumour Epidemiology Study

Objectives

To provide information about brain tumour epidemiology in Pakistan and potential associated risk factors due to family, medical and social characteristics.

METHODS

A retrospective cross-sectional nationwide study was designed by the Pakistan Society of Neuro-oncology, to include patients diagnosed with brain tumours in Pakistan retrospectively, from January 1, 2019- December 31, 2019. The study intended to involve data from all age groups for all brain tumour cases, irrespective of histopathology which would determine the national prevalence and incidence of these tumours.

RESULTS

A total of 2750 brain tumour cases were recorded, of which 1897 (69%) were diagnosed in the public sector. MRIs were a more common radiological study compared to CT scans. Gliomas were the most common tumours 778 (28.29%), while pineal tumours were the least common 19 (0.69%). The median age at diagnosis for males was 36 (24-49), while the median age at diagnosis for females was 37 (24-48). Hypertension was the most common co-morbidity in patients diagnosed with a brain tumour, 524 (51.89%), and smoking was the most frequent social behaviour, 355 (62.02%). Findings indicate a low metastasis frequency and few females seeking care.

CONCLUSIONS

The PBTES and the PBTC have presented an opportunity and platform for hospitals and health professionals to work together to strengthen cancer care health systems, ensure implementation of treatment guidelines and conduct regular cancer registration.

Meningioma - defining characteristics of the affected Pakistani population

OBJECTIVE

To ascertain the age and gender differences, treatment, and management of meningiomas across Pakistan..

METHODS

Data were collected as part of the PBTES, and patients with a histopathological diagnosis of an intracranial meningioma in 2019 that presented at these centres were included in this cohort study sub-analysis. Thirty-two centres participated in the study. Medical students, residents, and faculty collated data from medical records.

RESULTS

Our data indicate that meningiomas constitute 15.6% of all intracranial tumours in Pakistan and occur more often in females (236, 55%) than in males. The mean age at diagnosis was 43.7 ± 19.9 years. Meningiomas had a slightly higher preponderance in the right hemisphere of the brain at 203 (47.32%) tumours and 267 (62.2%) of the tumours in the frontal and parietal lobes. We found that 174 (61.3%) of all meningiomas diagnosed in Pakistan in 2019 were grade I tumours, which was also the most commonly occurring tumour grade. Adjuvant chemoradiotherapy for meningiomas was rarely observed in Pakistan.

CONCLUSIONS

The PBTES reveals a low hospital-based incidence of meningiomas in 2019 when compared to the incidence in high-income countries but found evidence similar to those of other LMICs. Tumour characteristics, such as location, grading and surgical procedures, were similar to global literature.

Schwannoma: A surgical epidemiology

OBJECTIVE

To identify the surgical incidence and prevalence of schwannoma in our region and quantify the demographic, surgical, neoplastic, and outcome characteristics of the patients diagnosed with schwannoma..

METHODS

A retrospective cross-sectional study was conducted from January 1 to December 31, 2019. Enrolled were 32 of the highest volume neurosurgical centres in Pakistan. Patients with a histopathological diagnosis of schwannoma and radiological imaging were included in the study. Medical records were reviewed for data, and SPSS version 25 was used for statistical analysis. Patients were followed up for one year, which was the duration of the study.

RESULTS

From 2750 patients diagnosed with brain tumours, 148 patients had schwannomas. Out of these, 84 (56.8%) patients were male, and 64 (43.2%) patients were female. The mean age of the patients was 39 ± 14 years. The socioeconomic statuses of the enrolled patients were lower in 72 (53.3%) patients, middle in 57 (42.2%) patients, and upper middle to upper in 6 (4.4%) patients. All patients underwent surgery, 14 patients received radiotherapy, and two patients received chemotherapy. In our cohort, 115 (77.7%) patients presented to public sector hospitals, with only 33 (22.3%) patients presenting to private hospitals. At the end of the study period, 60 (40.5%) patients had been lost to follow-up. Of the remaining 88 patients, 75 (85.2%) were alive. The mortality rate on a one-year follow-up was 14.8%.

CONCLUSIONS

Schwannoma comprises a larger percentage of the brain tumours in our regions than reported in the literature. The high mortality rate is of particular concern and warrants further investigation to improve patient care and outcomes.

Treatment patterns of glioma in Pakistan: An epidemiological perspective

Objective

To define the landscape of treatment patterns and current epidemiological data regarding gliomas in Pakistan.

METHODS

As part of the Pakistan Brain Tumour Epidemiology Study (PBTES), data were collected from 32 neurosurgical centres across the country. Our retrospective study looked at patients who underwent surgical procedures for gliomas in 2019 in neurosurgical centres. The data was collated and analysed using STATA version 15.

RESULTS

A total of 781 patients with gliomas were identified 479(61.8%) in public sector hospitals, 302(39.1%) in the private sector). The most common histopathological subtypes were glioblastoma 262 (33.5%), followed by astrocytoma 147(18.8%) and oligodendroglioma 93(11.9%). Gender distribution was skewed towards men 508(65%). Private institution hospitals performed surgical biopsies as the first surgical procedure 75(23%) more often than public hospitals 38(9%). Chemotherapy was given to 115(29.8%) patients, and there was no data regarding 467(53%) of patients. Similarly, only 202(43.9%) patients received radiation therapy, and there was no data for 469(60%) of patients. For high-grade gliomas specifically, only 95(31.8%) patients with HGG have a record of receiving radiation therapy, and only 57(18.9%) had a record of being started on chemotherapy.

Conclusion

Our study highlighted gaps in glioma management within Pakistan, with only around half of our patients receiving chemotherapy and radiotherapy, despite it being indicated. In our experience, high-grade tumours were diagnosed at a younger age than in high-income countries, but overall, glioblastoma was a smaller constituent of our tumour sample than expected.

Gender disparities in brain tumours: A Pakistan brain tumour epidemiology study analysis

OBJECTIVE

To explore the differences in demographic, surgical, and prognostic characteristics between the two genders in patients with brain tumours in Pakistan.

Method

This study was a retrospective cross-sectional analysis of patients with a histopathological brain tumour diagnosis across 32 high-volume hospitals in Pakistan. The study period was from January 1, 2019, to December 31, 2019. There were no restrictions on inclusion apart from time..

RESULTS

From 2750 patients enrolled in the study, 1605 (58.4%) were male, and 1142 (41.6%) were female . The median age amongst males was 36 (24-49), while the median age amongst females was 37 (24-48). The ratio of married to unmarried patients was 2.7:1 for females and 1.3:1 for males. Surgical treatment was carried out for 1430 (58.1%) males and 1013 (41.9%) females. The median time to surgery was 25 (4-107) days for males and 31 (5-98) days for females. The greatest disparity in tumour malignancy was in grade IV gliomas.

CONCLUSIONS

Males generally have a higher incidence of brain tumours in our experience, apart from meningiomas, which favour females. The mortality rate and glioblastoma incidence rate are both higher amongst males. However, post-treatment cure is also witnessed. Sociocultural norms play a prominent role in accessing healthcare. Women are generally at a disadvantage compared to their male counterparts, which may impact reporting of brain tumour cases and treatment outcomes.

A national overview of paediatric and adolescent and young adult surgical neuro-oncology in Pakistan

OBJECTIVE

To build a comprehensive brain tumour database that will allow us to analyse in detail the prevalence, demographics, and outcomes of the disease in paediatric, adolescent, and young adult age groups.

Method

A national cross-sectional study was conducted at 32 centres, and data regarding patient demographics and brain tumours were collected. This data was then stratified based on age groups, healthcare sectors, socioeconomic status, tumour types, and surgical outcomes.

RESULTS

Most of the patients who were diagnosed with brain tumours belonged to a lower socioeconomic background and went to public sector hospitals. More males were diagnosed with and treated for brain tumours in the paediatric, adolescent, and young adult populations. The most common tumour in the paediatric population was medulloblastoma (23.7%) and the most common tumour in the adolescent (27.8%) and young adult population (34.7%) was glioma. Significant improvement in KPS scores were seen for: craniopharyngioma (p = 0.001), meningioma (p < 0.0005) and pituitary adenoma (p < 0.0005).

CONCLUSIONS

This study shows that in all three age groups, there was a greater prevalence in males. Most of the patients belonged to a lower-middle-income class background and most patients presented to public sector hospitals. Greater knowledge of these parameters unique to each age group is the key to understanding and alleviating the burden of disease. Cancer registries, specifically brain tumour registries that keep up-to-date records of these patients, are essential to identify and keep track of these unique parameters to advance medical research and treatment strategies, ultimately lowering the disease burden.

Perceptions and experiences of healthcare providers during COVID-19 pandemic in Karachi, Pakistan: an exploratory qualitative study

OBJECTIVE

To explore healthcare provider's perspectives and experiences of the barriers and facilitators to treat and manage COVID-19 cases.

DESIGN AND SETTING

We conducted an exploratory qualitative study using a purposive sampling approach, at a private tertiary care teaching hospital in Karachi, Pakistan. Study data were analysed manually using the conventional content analysis technique.

PARTICIPANTS

Key-informant interviews (KIIs) were conducted with senior management and hospital leadership and in-depth interviews (IDIs) were conducted with front-line healthcare providers.

RESULTS

A total of 31 interviews (KIIs=19; IDIs=12) were conducted, between April and May 2020. Three overarching themes emerged. The first was 'challenges faced by front-line healthcare providers working in COVID-19 wards. Healthcare workers experienced increased anxiety due to the fear of acquiring infection and transmitting it to their family members. They felt overwhelmed due to the exhaustive donning and doffing process, intense work and stigmatisation. The second theme was 'enablers supporting healthcare providers to deal with the COVID-19 pandemic'. Front liners pointed out several enabling factors that supported hospital staff including a safe hospital environment, adequate training, a strong system of information sharing and supportive management. The third theme was 'recommendations to support the healthcare workforce during the COVID-19 crisis'. Healthcare workers recommended measures to mitigate current challenges including providing risk allowance to front-line healthcare providers, preparing a backup health workforce, and establishing a platform to address the mental health needs of the healthcare providers.

CONCLUSION

This study provides an initial evidence base of healthcare providers' experiences of managing patients with COVID-19 in the early stage of the pandemic and highlights measures needed to address the encountered challenges. It offers lessons for hospitals in low-income and middle-income countries to ensure a safe working environment for front-line workers in their fight against COVID-19.

Pakistan’s Community-based Lady Health Workers (LHWs): Change Agents for Child Health?

BACKGROUND: In Pakistan&rsquo;s high child mortality context, a large-scale Lady Health Worker (LHW) Program raises the need to look at whether LHWs are delivering their key mandate as agents of change for child health. This study examines the quantity and quality of LHW interactions with mothers for child health and their impact on mothers&#39; knowledge and child health practices. METHODS: 1,968 mothers of children &lt;2 years (n=1,968) were interviewed through a cross-sectional survey in two rural districts of Pakistan focusing on immunization, nutrition, and early child illness. Data on frequency of LHW&rsquo;s visits; services provided, specific services related to routine immunization (RI), nutrition and child illness, and maternal knowledge and practices were analyzed using median values for continuous variables and counts and percentages for categorical data. RESULTS: Monthly visits by LHW were reported by only 63% of LHW covered households. During LHW monthly encounters, Oral Polio drops administration was most frequently reported (77%), followed by RI (59%), breastfeeding counseling (20%), child illness management advice (18%), growth monitoring (9.5%), while none reported receiving hygiene counseling. Although LHWs were reported to be the main information source for child health; limited impact of LHW-mother interaction was seen on maternal knowledge and practices: 76% mothers reported receiving ORS packets from LHWs but only 27% knew of correct usage, only 34% washed hands before feeding children, less than a third could correctly recall early signs of pneumonia and awareness of Vaccine Preventable Diseases other than Polio ranged from 42%-9% only. CONCLUSION: Although LHWs are main information source for child health services but infrequent, poor quality household encounters indicate ineffective delivery on the key mandate of community-based child health. Policy debate instead of focusing on scaling up or downsizing the program, should prioritize quality and supervision to improve value for money of a critical community resource.

Global strategies and local implementation of health and health-related SDGs: lessons from consultation in countries across five regions

Evidence on early achievements, challenges and opportunities would help low-income and middle-income countries (LMICs) accelerate implementation of health and health-related sustainable development goals (HHSDGs). A series of country-specific and multicountry consultative meetings were conducted during 2018-2019 that involved 15 countries across five regions to determine the status of implementation of HHSDGs. Almost 120 representatives from health and non-health sectors participated. The assessment relied on a multidomain analytical framework drawing on existing public health policy frameworks. During the first 5 years of the sustainable development goals (SDGs) era, participating LMICs from South and Central Asia, East Africa and Latin America demonstrated growing political commitment to HHSDGs, with augmentation of multisectoral institutional arrangements, strengthening of monitoring systems and engagement of development partners. On the other hand, there has been limited involvement of civic society representatives and academia, relatively few capacity development initiatives were in place, a well-crafted communication strategy was missing, and there is limited evidence of additional domestic financing for implementing HHSDGs. While the momentum towards universal health coverage is notable, explicit linkages with non-health SDGs and integrated multisectoral implementation strategies are lacking. The study offers messages to LMICs that would allow for a full decade of accelerated implementation of HHSDGs, and points to the need for more implementation research in each domain and for testing interventions that are likely to work before scale-up.

Food supplements to reduce stunting in Pakistan: a process evaluation of community dynamics shaping uptake

Background

There is an increasing interest in use of food supplements to prevent childhood stunting, however the evidence on the process indicators is scarce. We in this study explore the barriers to the effective implementation of food supplementation programs and the possible mitigation strategies which can guide the design of future programs.

Methods

We undertook a process evaluation of a stunting prevention food supplementation pilot program in rural Pakistan that distributed Wheat Soy Blend (WSB) to pregnant & lactating women, and Lipid-based Nutrient Supplement (LNS) and micronutrient powder (MNP) to < 5 years children. We used a mixed methods approach through a quantitative survey of 800 households and conducted 18 focused group discussion (FGDs) (with male and female caregivers), 4 FGDs (with Community Health Workers (CHWs)) and 22 key informant interviews (with district stakeholders) to evaluate the community side factors affecting uptake through five parameters: value, acceptability, receipt of supplement, usage and correct dosage.

Results

The findings show that proportionately few beneficiaries consumed the full dose of supplements, despite reasonable knowledge amongst caregivers. Sharing of supplements with other household member was common, and the full monthly stock was usually not received. Qualitative findings suggest that caregivers did not associate food supplements with stunting prevention. WSB was well accepted as an extra ration, LNS was popular due its chocolaty taste and texture, whereas MNP sprinkles were perceived to be of little value. The cultural food practices led to common sharing, whereas interaction with CHWs was minimal for nutrition counselling. Qualitative findings also indicate CHWs related programmatic constraints of low motivation, multi-tasking, inadequate counselling skills and weak supervision.

Conclusion

We conclude that the community acceptability of food supplements does not translate into optimal consumption. Hence a greater emphasis is needed on context specific demand creation and focusing on the supply side constraints with improved logistical planning, enhanced motivation and supervision of community workers with involvement of multiple stakeholders. While, similar studies are needed in varying contexts to help frame universal guidelines.

Trial registration

ClinicalTrials.gov Identifier: NCT02422953. Registered on April 22, 2015.

Mobilising Expertise and Resources to Close the Radiotherapy Gap in Cancer Care

Closing the gap in cancer care within low- and middle-income countries and in indigenous and geographically isolated populations in high-income countries requires investment and innovation. This is particularly true for radiotherapy, for which the global disparity is one of the largest in healthcare today. New models and paradigms and non-traditional collaborations have been proposed to improve global equity in cancer control. We describe recent initiatives from within the radiation oncology community to increase access to treatment, build the low- and middle-income countries' radiation oncology workforce, mobilise more professionals from within high-income countries and raise awareness of the global need for equitable cancer care.

Integrated parasite management with special reference to gastro-intestinal nematodes

Domestic animals are susceptible to a large number of parasitic diseases, which lead to severe economic losses to livestock industry. So, it is necessary to control parasitic infections in these animals. Control of these helminths is undertaken mostly by anthelmintics, but because of their widespread use there is development of resistance across the globe. However, total dependence on a single method of control has proved to be non-sustainable and cost ineffective in the long term. A combination of treatment and management is necessary to control parasitism so that it will not cause further economic losses to producer as well as to livestock industry. To become practically and ecologically sustainable, parasitic control schemes need to be based on integrated parasite management.

Associations between presence of handwashing stations and soap in the home and diarrhoea and respiratory illness, in children less than five years old in rural western Kenya

OBJECTIVE

We tested whether soap presence in the home or a designated handwashing station was associated with diarrhoea and respiratory illness in Kenya.

METHODS

In April 2009, we observed presence of a handwashing station and soap in households participating in a longitudinal health surveillance system in rural Kenya. Diarrhoea and acute respiratory illness (ARI) in children < 5 years old were identified using parent-reported syndromic surveillance collected January-April 2009. We used multivariate generalised linear regression to estimate differences in prevalence of illness between households with and without the presence of soap in the home and a handwashing station.

RESULTS

Among 2547 children, prevalence of diarrhoea and ARI was 2.3 and 11.4 days per 100 child-days, respectively. Soap was observed in 97% of households. Children in households with soap had 1.3 fewer days of diarrhoea/100 child-days (95% CI -2.6, -0.1) than children in households without soap. ARI prevalence was not associated with presence of soap. A handwashing station was identified in 1.4% of households and was not associated with a difference in diarrhoea or ARI prevalence.

CONCLUSIONS

Soap presence in the home was significantly associated with reduced diarrhoea, but not ARI, in children in rural western Kenya. Whereas most households had soap in the home, almost none had a designated handwashing station, which may prevent handwashing at key times of hand contamination.

A phytotoxin Solanapyrone-A downregulates calcium-dependent protein kinase activity in potato

We previously demonstrated that alternaric acid, a host-specific toxin produced by the plant pathogenic fungus Alternaria solani, in the presence of Ca(2+) and Mg(2+), stimulated in vitro phosphorylation of His-tagged calcium-dependent protein kinase 2 from potato cultivar Rishiri (RiCDPK2). Herein, we report that Solanapyrone-A (SpA), a non-host-specific toxin produced by A. solani, inhibited the phosphorylation of RiCDPK2 in the presence of Ca(2+) and Mg(2+). However, SpA stimulated RiCDPK2 phosphorylation in the absence of these cations. Based on the current findings, we suggest that RiCDPK2 may mediate SpA-induced signaling independent of Ca(2+) and Mg(2+), leading to a compatible interaction between potato and A. solani.

Alternaric acid stimulates phosphorylation of His-tagged RiCDPK2, a calcium-dependent protein kinase in potato plants

Calcium-dependent protein kinases (CDPK) are an essential component of plant defense mechanisms against pathogens. We investigated the effect of alternaric acid, a host-specific toxin produced by the plant fungal pathogen Alternaria solani (Pleosporaceae), on a putative plasma membrane and cytosolic kinase RiCDPK2 of potato (Solanum tuberosum) and on hypersensitive cell death of host potato cells. Alternaric acid, in the presence of Ca²⁺ and Mg²⁺, stimulated in vitro phosphorylation of His-tagged RiCDPK2, a Ca²⁺-dependent protein kinase found in potato plants. We concluded that Ca²⁺ and Mg²⁺ play an important role in the interaction between alternaric acid and RiCDPK2. Based on our observations, alternaric acid regulates RiCDPK2 kinase during the infection process in an interaction between host and A. solani, leading to the inhibition of hypersensitive cell death in the host. We suggest that alternaric acid is a primary determinant by which A. solani stimulates CDPK activity in the host, suppressing hypersensitive cell death.

Comparisons of DNA marker-based genetic diversity with phenotypic estimates in maize grown in Pakistan

We compared DNA-based genetic diversity estimates with conventional estimates by investigating agronomically important traits in maize grown in the northwestern region of Pakistan. RAPD markers were used to characterize 10 commonly cultivated maize genotypes. The same material was tested for phenotypic variation of quantitative traits using replicated field trials. The genetic distances between pairs of genotypes using RAPD data were used to generate a similarity matrix and to construct a phenogram. Statistical analyses were carried out on the data obtained from field trials of all maize genotypes for days to 50% tasseling, days to 50% silking, plant height, ear height, grain yield, grain weight per cob, and ear length. Analysis of variance and single degree of freedom contrasts were performed on morphological data to examine the relationship between molecular-based clusters and agronomic traits. A molecular marker-based phenogram led to the grouping of all genotypes into four major clusters, some of which were distantly related. These clusters contained one to four genotypes. Analysis of variance showed significant variations among all genotypes for agronomic traits. The single degree of freedom contrasts between groups of genotypes indicated significant differences for most traits. Pair-wise comparisons between clusters were also significant. The two types of data correlated well, providing an opportunity for better choices for selection.

Designer orthopaedic surgery in a patient with anti-Vel antibodies

The authors present a rare case of anti-Vel antibodies in a patient who underwent a shoulder replacement with a custom designed procedure which involved combination of autologous blood pre-deposit, pre-operative haemodilution and resurfacing arthroplasty.

Successful desensitization with cetuximab after an infusion reaction to panitumumab in patients with metastatic colorectal cancer

BACKGROUND

Cetuximab and panitumumab are chimeric and fully human monoclonal antibodies, respectively, against epidermal growth factor receptor used in the treatment of metastatic colorectal cancer (mCRC). Incidence of documented infusion reaction (IR) is more common with cetuximab (all grades [g]: 15-21%, g 3/4: 2-5%) than panitumumab (all g: 4%, g 3/4: 1%). Anecdotal reports suggest successful challenge with panitumumab following IR with cetuximab (Saif et al. in Cancer Chemother Pharmacol 63(6):1017-1022, 2009). However, safety of cetuximab after IR with panitumumab is not known. We report two patients successfully desensitized with cetuximab after IR with panitumumab.

PATIENTS AND METHODS

A 42-year-old female with mCRC received panitumumab as a third-line agent. She developed severe chest tightness, pain, and shortness of breath (SOB), 5 min after first panitumumab infusion. A second 70-year-old male with mCRC developed severe facial flushing, back pain, SOB, tachycardia and hypotension, 5 min after second dose of panitumumab plus irinotecan as a second-line therapy. These two patients received desensitization protocol for cetuximab after a test dose of 20 mg IV over 10 min followed by a slow infusion 10% of original rate in 0-2 h, 25% of original rate in 2-2.5 h, 50% reduced rate in 2.5-3 h, and then 100% infusion rate after 3 h. Patients were observed 4 h after completion of infusion.

RESULTS

First patient received a total of 12 cycles of cetuximab with stable disease, no recurrence of IR, and grade 1-2 acniform rash that first developed after third cycle. Second patient received a total of eight cycles uneventfully without IR.

CONCLUSIONS

To our knowledge, this is the first report of two patients with documented IR with panitumumab being desensitized successfully with cetuximab. Though anecdotal reports suggest safety of panitumumab in patients following IR with cetuximab, panitumumab can also cause severe IR. Our experience suggests that in case of limited options, such patients can be successfully challenged with cetuximab in a hospital after appropriate desensitization and premedication. Further studies focusing on desensitization and identifying hypersensitivity profile of different anti-epidermal growth factor receptor antibodies are warranted.

Outcomes of triple negative breast cancer in African-Americans vs. Caucasians: a community-based study

Abstract #3043

Background: Breast cancers with a triple negative tumor (TNT) subtype are associated with inferior outcomes and more recently racial disparities in patients with TNT have been demonstrated with African American women experiencing worse outcomes compared to Caucasians. This study examines association of race (AA vs. Caucasians) and breast cancer outcomes in a large community hospital TNT population.&#x2028; Methods: Breast cancers of the TNT subtype were reviewed from a hospital-based tumor registry. Cases diagnosed from 1999 to 2006 were included in the study. Multivariate regression analyses were conducted including socio-demographic, and treatment factors. Endpoints were local/systemic recurrence and death.&#x2028; Results: Of 1827 newly diagnosed cases of breast cancer from 1999- 2006, 93 were of the TNT subtype. A higher number of AA (17.58%) had TNT compared to Caucasians (3.7%). In patients with TNT, AA presented at a younger age (mean age 51.78 years vs. 58.52 years, (&lt;50 years) (p value=0.07), had more advanced disease at diagnosis (stage 3) (5.38% vs. 1.08%; p value 0.001) and had a poor insurance status (uninsured and Medicaid) (9.68% vs. 4.30%; p value 0.004). There was no difference in the histologic grade of the tumors. AA had a higher rate of local recurrence (4.30% vs. 2.15%; p value 0.029), systemic recurrence (19% vs. 10%; p value 0.02) [Figure 2] and death (17.20% vs. 13.98%; p value 0.005) [Figure 1] compared to Caucasians.&#x2028; &#x2028; &#x2028; &#x2028; Even after adjusting for insurance status and treatment modalities, AA had a higher mortality rate compared to Caucasians (p value 0.014).&#x2028; Conclusions: The high prevalence of TNTs among AA women and poorer survival in spite of adjusting for insurance and treatment modalities, suggests an underlying biologic variation with respect to race/ ethnicity.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3043.

Rapid detection of Brucella spp. by the loop-mediated isothermal amplification method

AIMS

To develop a rapid and sensitive method for detecting Brucella spp.

METHODS AND RESULTS

Two sets of six Brucella-specific primers for loop-mediated isothermal amplification (LAMP) were designed from the sequence of the Brucella abortus BCSP31 gene. The specificity and sensitivity were examined for six Brucella species (22 strains) and 18 non-Brucella species (28 strains). The LAMP assay was specific to Brucella spp. in 35 min at 63 degrees C and sensitive (detected 10 fg of genomic DNA). The assay was also applied for the detection of Brucella DNA in contaminated milk and infected mouse organs.

CONCLUSIONS

We developed a sensitive and specific LAMP assay for Brucella spp., with the test appearing to be useful for the detection of the pathogen from clinical and food samples.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first report of the development of LAMP for the detection of Brucella spp. As the LAMP assay can be performed at a constant temperature and its reactivity is directly observed with the naked eye without electrophoresis, our assay should be useful for the diagnosis of brucellosis as well as the detection of the bacteria in environmental or food samples.

Molecular characterization of Ephedra species found in Pakistan

Ephedra, also known as "ma huang", is a dioecious, drought- and frost-resistant, perennial, evergreen shrub with compelling medicinal value. The genus is represented by 42 species around the world, 9 of which were provisionally reported from Pakistan. Species of the genus have a controversial taxonomy due to their overlapping morphological features. Conventional tools alone are not sufficient for characterizing the species. The objective of present study was to assess the genetic variability present in different biotypes of Ephedra growing in Pakistan using molecular markers. A total of six genotypes collected from diverse geographic zones of Pakistan were used. The DNA of all genotypes was amplified using nine randomly amplified polymorphic DNA (RAPD) primers to study genetic variability at the molecular level. The dissimilarity coefficient matrix based on the data of 9 RAPD primers was used to construct a dendrogram which was then used to group the genotypes in clusters. Based on the dendrogram and dissimilarity coefficient matrix, the RAPD markers used here revealed a moderate to high level of genetic polymorphism (6 to 49%) among the genotypes. It was found that the collection of genotype accessions from Swat Valley in northwestern Pakistan was most distantly related to the other five collections. More molecular markers including functional genes and ribosomal spacer regions are suggested to find a better estimate of the genetic diversity present in Ephedra growing in Pakistan. The information provided here is useful for identifying valuable Ephedra variants which will be used for medicinal purposes and earning foreign currency.

Construction and evaluation of cDNA libraries for large-scale expressed sequence tag sequencing in wheat (Triticum aestivum L.)

A total of 37 original cDNA libraries and 9 derivative libraries enriched for rare sequences were produced from Chinese Spring wheat (Triticum aestivum L.), five other hexaploid wheat genotypes (Cheyenne, Brevor, TAM W101, BH1146, Butte 86), tetraploid durum wheat (T. turgidum L.), diploid wheat (T. monococcum L.), and two other diploid members of the grass tribe Triticeae (Aegilops speltoides Tausch and Secale cereale L.). The emphasis in the choice of plant materials for library construction was reproductive development subjected to environmental factors that ultimately affect grain quality and yield, but roots and other tissues were also included. Partial cDNA expressed sequence tags (ESTs) were examined by various measures to assess the quality of these libraries. All ESTs were processed to remove cloning system sequences and contaminants and then assembled using CAP3. Following these processing steps, this assembly yielded 101,107 sequences derived from 89,043 clones, which defined 16,740 contigs and 33,213 singletons, a total of 49,953 "unigenes." Analysis of the distribution of these unigenes among the libraries led to the conclusion that the enrichment methods were effective in reducing the most abundant unigenes and to the observation that the most diverse libraries were from tissues exposed to environmental stresses including heat, drought, salinity, or low temperature.

Extensive subcutaneous emphysema following arthroscopy: a case report

We report an unusual presentation of delayed subcutaneous emphysema of the thigh following arthroscopy with a fluid medium, which was managed conservatively. This rare presentation must be recognised by all orthopaedic surgeons practising arthroscopic surgery.

A spontaneously arising mutation in connexin32 with repeated passage of FRTL-5 cells coincides with increased growth rate and reduced thyroxine release

In this study we examine changes in the cellular properties of FRTL-5 cells as a function of passage number, with particular emphasis on gap junction expression, karyotype, morphology, growth rate and thyroxine (T(4)) release. Early passage FRTL-5 follicular cells transfer dye through gap junctions from injected cell(s) to third-order neighboring cells and beyond within their respective follicles and have immuno-detectable connexin32 (Cx32) type gap junctional plaques in their lateral contacting plasma membranes. By contrast, FRTL-5 cells established as monolayers, or as follicles from cultures passed more than 15 times, did not transfer microinjected Lucifer Yellow dye to contiguous neighboring cells and did not express any immuno-detectable rat thyroid specific connexins (Cx43, Cx32 or Cx26). Western blots confirmed that total, membrane and cytosolic Cx32 protein was present only in early pass follicular cultures. To better understand the passage-dependent loss of Cx32 expression, RT-PCR primers were made to the most unique sequences of the rat Cx32 molecule, the cytoplasmic and carboxyl-terminal regions. These primers were used to screen FRTL-5 RNA from cultures of various passage numbers. The results revealed that later passage cultures had a single base deletion in the middle of the Cx32 cytoplasmic loop region at nucleotide position 378. This base deletion was in the middle position of the codon for amino acid 116, which is normally a CAC (histidine) but read with the frame shift was a CCC (proline). The four amino acids that followed this deletion were also altered with the fourth one becoming UAA, the ochre translation stop codon. This premature stopping of translation resulted in a truncation of 60% of the protein, which included the remaining cytoplasmic loop, third and fourth transmembrane regions and the carboxyl-terminus. The later passage cultures did not produce a carboxyl-terminal RT-PCR product, indicating that the mRNA was also truncated. These regions of the Cx32 molecule contain the sequences and epitopes to which probes and antibodies are directed, and as such alterations of these regions with repeated passage explains reports by others that FRTL-5 cells do not express Cx32, and implies that cultures used for these assessments were passed more than 15 times. To determine if genetic or epigenetic abnormalities existed in FRTL-5 cells we performed chromosome spreads from various passage cultures. FRTL-5 cells have been reported to be diploid and more recently non-diploid; however, we found them to be fully tetraploid. This tetraploidy appears to be unstable in that later passes are tetraploid plus two or three extra chromosomes. There were no obvious translocations, breaks or large-scale interstitial deletions of any chromosomes in the FRTL-5 cultures tested. As FRTL-5 cells were repeatedly passed their morphology changed. Monolayer areas spread from beneath the follicles, and the follicles became flattened in appearance. These physical changes were coincident with dramatically increased growth rates. Early cultures (passed 3-12 times) divided on average every 49+/-1 h, whereas later passes (passes 20-25) divided every 28+/-3 h. To correlate these changes with a measure of thyroid function we assayed T(4) output. Early passage follicular cultures incubated for 6 h with sodium iodide, released on average 5.27+/- 0.33 ng/ml of T(4)/100 follicles. Later passes, or early passes treated with heptanol to down-regulate Cx32, released an average of 3.84+/-0.50 ng/ml of T(4)/100 follicles. There was a 27% difference in T(4) release between early follicular cultures, that were coupled by Cx32, and late or down-regulated early follicular cultures, that were uncoupled (P<0.0001). Collectively, the physical changes documented in this study were coincident with the loss of functional Cx32. This implies a relationship between the loss of intercellular communication and changes in morphogenic appearance, growth rate and reduced thyroid function and supports the previously postulated, tumor-suppressor role for Cx32. FRTL-5 cultures from low passage numbers are an excellent model of primary thyroid cells. However, many reports in the literature ascribe features to FRTL-5 cells that are mutually inconsistent. These differences may be resolved in the future by addressing the passage number and the conditional differences of the cultures being studied.

Identification of connexin43 (alpha1) gap junction gene mutations in patients with hypoplastic left heart syndrome by denaturing gradient gel electrophoresis (DGGE)

Gap junction channels formed by the connexin43 protein are considered to play crucial roles in development and function because they allow the direct cell-to-cell exchange of molecules that mediate multiple signaling events. Previous results have shown that connexin43 channels are intricately gated by phosphorylation and that disruption of this regulation gives rise to severe heart malformations and defects of laterality in human, chick and frog. Here we report the identification of connexin43 gene mutations that represent a minor population of connexin43 alleles, which could be reliably detected by using denaturing gradient gel electrophoresis (DGGE) to visualize normal and mutant DNAs that were separately sequenced. In contrast, sequencing of total PCR products without DGGE-pre-selection failed to consistently identify these mutations. Forty-six controls and 20 heart transplant recipients were examined in this study. In the latter group, 14 children had hypoplastic left heart syndrome (HLHS) in which connexin43 gene defects were detected in eight. The remaining six transplant patients with HLHS and all controls showed no defects. All eight HLHS children with gene defects had the same four substitutions: two that were silent polymorphisms, and two that were missense, replacing arginine codons at positions 362 and 376 with codons for glutamines. All four of these substitutions are identical to the nucleotide sequence of the connexin43 pseudogene, suggesting the possibility of an illicit recombination. A breakpoint region was identified 5' to the mutation site in a 63bp domain that is 100% identical in the gene and pseudogene. Results from in vitro phosphorylation indicate that the absence of arginines 362 and 376 completely abolishes phosphorylation in the connexin43 channel regulation domain suggesting a possible mechanism for the pathologies associated with HLHS.

Clotrimazole analogues: effective blockers of the slow afterhyperpolarization in cultured rat hippocampal pyramidal neurones

1. The pharmacology of the slow afterhyperpolarization (sAHP) was studied in cultured rat hippocampal pyramidal neurones. 2. Clotrimazole, its in vivo metabolite, 2-chlorophenyl-bisphenyl-methanol (CBM) and the novel analogues, UCL 1880 and UCL 2027, inhibited the sI(AHP) with similar IC50s (1-2 microM). 3. Clotrimazole and CBM also inhibited the high voltage-activated (HVA) Ca2+ current in pyramidal neurones with IC50s of 4.7 microM and 2.2 microM respectively. UCL 1880 was a less effective Ca2+ channel blocker, reducing the HVA Ca2+ current by 50% at 10 microM. At concentrations up to 10 microM, UCL 2027 had no effect on the Ca2+ current, indicating that its effects on the sI(AHP) were independent of Ca2+ channel block. 4. Clotrimazole also inhibited both the outward holding current (IC50=2.8 microM) present at a potential of -50 mV and the apamin-sensitive medium AHP (mAHP; IC50 approximately amp;10 microM). The other clotrimazole analogues tested had smaller effects on these two currents. The present work also shows that 100 nM UCL 1848, an inhibitor of apamin-sensitive conductances, abolishes the mAHP. 5. Currents were recorded from HEK293 cells transfected with hSK1 and rSK2. The SK currents were very sensitive to inhibition by UCL 1848 but were not significantly reduced by the sI(AHP) inhibitor, UCL 2027 (10 microM). 10 microM UCL 1880 reduced the hSK1 current by 40%. 6. UCL 2027 appears to be the first relatively selective blocker of the sAHP to be described. Furthermore, the ability of UCL 2027 to block the sAHP with minimal effect on SK1 channel activity questions the role of this channel in the sAHP.

Further studies on periodic limb movement disorder and restless legs syndrome in children with attention-deficit hyperactivity disorder

Fourteen consecutive children who were newly diagnosed with attention-deficit hyperactivity disorder (ADHD) and who had never been exposed to stimulants and 10 control children without ADHD underwent polysomnographic studies to quantify Periodic Limb Movements in Sleep (PLMS) and arousals. Parents commonly gave both false-negative and false-positive reports of PLMS in their children, and a sleep study was necessary to confirm their presence or absence. The prevalence of PLMS on polysomnography was higher in the children with ADHD than in the control subjects. Nine of 14 (64%) children with ADHD had PLMS at a rate of >5 per hour of sleep compared with none of the control children (p <0.0015). Three of 14 children with ADHD (21%) had PLMS at a rate of >20 per hour of sleep. Many of the PLMS in the children with ADHD were associated with arousals. Historical sleep times were less for children with ADHD. The children with ADHD who had PLMS chronically got 43 minutes less sleep at home than the control subjects (p = 0.0091). All nine children with ADHD who had a PLMS index of >5 per hour of sleep had a long-standing clinical history of sleep onset problems (>30 minutes) and/or maintenance problems (more than two full awakenings nightly) thus meeting the criteria for Periodic Limb Movement Disorder (PLMD). None of the control children had a clinical history of sleep onset or maintenance problems. The parents of the children with ADHD were more likely to have restless legs syndrome (RLS) than the parents of the control children. Twenty-five of 28 biologic parents of the children with ADHD and all of the biologic parents of the control children were reached for interview. Eight of twenty-five parents of the children with ADHD (32%) had symptoms of RLS as opposed to none of the control parents (p = 0.011). PLMS may directly lead to symptoms of ADHD through the mechanism of sleep disruption. Alternative explanations for the association between ADHD and RLS/PLMS are that they are genetically linked, they share a common dopaminergic deficit, or both.

Transformation of nitrobenzene by ferredoxin NADP oxidoreductase from spinach leaves

Nitrobenzene was reduced in a solution containing ferredoxin NADP oxidoreductase (FNR) from spinach leaves and NADPH generating system. The product of nitrobenzene was identified as phenylhydroxylamine (PHA) on 1:1 basis.

Effects of perinatal zidovudine on hematopoiesis: a comparison of effects on progenitors from human fetuses versus mothers

OBJECTIVE

To compare the effects of zidovudine (ZDV) on clonal maturation of hematopoietic progenitors obtained from the bone marrow of women of child-bearing age with its effects on progenitors obtained from the marrow, liver and blood of fetuses. We also sought to determine whether the adverse effects of ZDV on fetal hematopoiesis resulted exclusively from an action on progenitors, or also involved the inhibition of the production of hematopoietic growth factors.

PARTICIPANTS

Hematopoietic progenitors were obtained from bone-marrow aspirates of seven women of child-bearing age, from the bone marrow and liver of seven mid-trimester abortuses, and from the umbilical cord blood of seven term infants.

METHODS

We added increasing concentrations of ZDV to clonal assays of hematopoietic progenitors, after which we assayed clonal maturation of progenitors, and counted the number of erythrocytes per erythroid clone and the number of neutrophils per granulocytic clone. Light-density cell fractions and enriched CD34+ progenitor fractions were studied. In other studies we determined the effect of increasing concentrations of ZDV on production of granulocyte colony-stimulating factor (G-CSF) protein [enzyme-linked immunosorbent assay (ELISA)] and mRNA by fetal and maternal monocytes, and on production of erythropoietin protein (ELISA) and mRNA by Hep3B cells.

RESULTS

Mature erythroid progenitors were the most sensitive to the adverse effects of ZDV on clonal maturation, and multipotent progenitors were the most resistant. Erythroid progenitors from all fetal and neonatal sources were more sensitive to the effect of ZDV than those from the bone marrow of adult women. The inhibitory effects were explained by an action on CD34+ cells; no effect was observed on production of G-CSF or erythropoietin.

CONCLUSIONS

We speculate that the low hematocrits of neonates delivered after antenatal ZDV treatment are due to reduced clonal maturation of erythroid progenitors, and that fetal erythroid progenitors are inhibited to a greater extent than maternal progenitors.

Elimination of nitrite from the explosive 2,4,6-trinitrophenylmethylnitramine (tetryl) catalyzed by ferredoxin NADP oxidoreductase from spinach

Nitroreductase enzymes generally catalyze the reduction of nitroaromatic compounds to the corresponding amines. In contrast, ferredoxin NADP oxidoreductase (FNR), glutathione reductase, xanthine oxidase, and cytochrome c reductase catalyze the NADPH dependent elimination of the nitramine nitro group from 2,4,6-trinitrophenylmethylnitramine to form N-methylpicramide (NMP). Nitrite elimination was inhibited under aerobic conditions. Our results suggest that under aerobic conditions, tetryl is enzymatically reduced to the nitroanion radical which is then involved in the reduction of molecular oxygen. Under anaerobic conditions, the radical is reduced to NMP and nitrite is eliminated.

Reduced cell-cell communication in a spontaneous murine model of autoimmune thyroid disease

MRL-lpr/lpr mice manifest a systemic lupus-like autoimmune disease. As part of this syndrome, the mice spontaneously develop autoimmune thyroiditis, which is morphologically and biochemically similar to human autoimmune thyroiditis. In this study we investigated whether thyroid tissue obtained from sites of chronic inflammation had altered gap junctional communication. Fresh tissue sections revealed that thyroid from the nondiseased mice (MRL-(+)/+) had connexins (Cx) localized to the plasma membrane at points of thyroid cell-cell contact. In contrast, the Cx in diseased mouse (MRL-lpr/lpr) thyroid tissue were not localized to the plasma membrane, and the fluorescent intensity was reduced for Cx43 and Cx26. Northern analysis confirmed that murine thyroid tissue expressed messenger RNA for these Cx. However, the diseased tissue expressed lower levels of Cx32 and Cx26 messenger RNA. The infiltrating cells and their biologically active products present in the diseased thyroid tissue may mediate the reduced Cx expression and aberrant gap junctional assembly. We established primary thyrocyte cultures to determine whether these differences persisted when the inflammatory factors were removed. The nondiseased thyroid cells were communication competent, with fluorescent dye transfer proceeding from the injected cell to primary contacts (95%) and to second and third order neighboring cells in 75% of the trials. Thyroid cells from the diseased mice were communication incompetent, in that 80% of microinjections failed to result in dye transfer to cells in direct contact. Immunocytochemistry indicated that the functional coupling in the normal mouse thyroid cells was associated with Cx43 located in the plasma membrane as assembled gap junctional plaques. The communication-deficient diseased thyroid cells had internalized Cx43 predominantly localized to perinuclear regions of the cells. Collectively, these data document altered Cx-protein distribution in the autoimmune diseased thyroid. The diseased thyroid tissue was devoid of plasma membrane identifiable gap junctions and deficient in intercellular communication. Culturing removed the inflammatory mediators; however, the disease cells retained their communication incompetence. These results suggest that if this deficiency was initiated by components of the inflammation process, then protracted changes must have occurred so that the continued presence of these factors was no longer required to sustain this difference.