An uncommon, unilateral motor variation of the intercostobrachial nerve

The intercostobrachial nerve (ICBN) is commonly defined as a purely sensory nerve supplying the skin of the lateral chest wall, axilla, and medial arm. However, numerous branching patterns and distributions, including motor, have been reported. This report describes an uncommon variant of the right ICBN observed in both an 86-year-old white female cadaver and a 77-year-old white male cadaver. In both cases the ICBN presented with an additional muscular branch, termed the "medial pectoral branch", piercing and therefore innervating the pectoralis major and minor muscles. Clinically, the ICBN is relevant during surgical access to the axilla and can result in sensory deficits (persistent pain/loss of sensory function) to this region following injury. However, damage to the variation observed in these cadavers may result in additional partial motor loss to pectoralis major and minor.

Tackling tuberculosis in sub-Saharan Africa: EDCTP achievements and the road ahead

The European and Developing Countries Clinical Trials Partnership (EDCTP) was established in 2003 to accelerate the development of medical interventions for tuberculosis (TB), human immunodeficiency virus (HIV) and malaria, with a particular focus on Phase II and III clinical trials. Between 2003 and 2015, the first EDCTP programme committed €65.6 million to research on TB and TB-HIV co-infection. The programme made a significant contribution to the first three elements of the DOTS TB control strategy, which mobilised European and African funding for TB-related research and generated important evidence on TB diagnostics and treatment regimens. As well as informing the development of international policy on TB diagnosis and treatment, the programme also significantly enhanced the capacity of countries in sub-Saharan Africa to undertake clinical trials and associated clinical research. The lessons learned from the first EDCTP programme have informed the development of a second, expanded EDCTP programme, EDCTP2, which was launched in 2014, and is due to run until 2024. One key lesson is the need for continued partnerships to fight the global threat of TB.

P4-09-15: Clinical and Pathological Predictors of Outcome among Patients with Triple Negative Breast Cancer

Background

Triple negative (TN) breast cancer portends a poor prognosis, yet outcomes remain heterogeneous. Specific characteristics of individual TN patients that can predict outcome compared to non-triple negative (NTN) patients have yet to be well defined.

Methods: A prospective oncology database at Hackensack University Medical Center was queried for all patients with invasive breast cancer between 2000 and 2005. Patients with triple negative breast cancer were identified and compared to non-triple negative patients. Numerical values were compared by Mann-Whitney test; categorical values by Chi square/Fisher exact test. Log-rank test was used to compare outcome statistics, univariate and multivariate analyses were used to identify factors affecting relapse-free survival and overall survival.

Results: A total of 2,216 patients were identified (TN: n=260; NTN: n=1956). There was no difference in race (white vs non-white; TN: 82.3% vs NTN: 87.3%) or family history of breast cancer (TN: 19.2% vs NTN: 16.8%). TN patients were significantly younger (median age; TN: 55.5 vs NTN 57.7; p< .05), had larger tumors (mean cm; TN: 3.1 vs NTN: 2.4; p<.05), had higher grade tumors (% grade 3; TN:74.6 vs NTN: 26.1; p<.0001), had higher proliferation index (>20% nuclei stained for Ki-67; TN: 30.8% vs NTN: 6.7%; p<.0001), but were less likely to have lymph node metastases at presentation (TN: 35.7% vs NTN: 48.0%; p < .0001). Among node negative patients, overall survival (OS) and disease free survival (DFS) were not significantly different between TN and NTN. Among node positive patients, both OS and DFS were worse for TN patients compared to NTN patients (p < .0008). By univariate analysis, age, nodal status, tumor size and tumor grade were all independent predictors of DFS, but proliferation rate and TN status were not. In a multivariate analysis, however, age, TN status, nodal status and tumor size were all significantly associated with DFS.

Conclusion: Although TN patients have poor outcomes overall, among node negative patients, TN status does not affect overall nor disease free survival. Among node positive patients, however, TN status has a significant impact on outcome. In this analysis, well established predictors of outcome, including age, tumor size, tumor stage and nodal status were all independent predictors of outcome, but TN status and Ki-67 level were not.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-09-15.

Strengthening capacity, collaboration and quality of clinical research in Africa: EDCTP Networks of Excellence

Developing countries bear 90% of the global disease burden, but only access about 10% of globally available health research funding. Weak south-south networking hampers effective use of limited resources, production of critical mass of quality scientists, career opportunities and incentives to retain the few available scientists. The south must urgently act strategically to accelerate generation of talented scientists, create enabling environment and incentives to retain scientists and attract back those in diaspora. The creation of strong networks of excellence for clinical research among southern academic and research institutions is a novel strategic approach championed by European and Developing Countries Clinical Trials Partnership to achieve the aforementioned goals and mitigate the high disease burden. It will promote strong collaboration, resource sharing and cross-mentorship allowing each partner to grow with complementary capacities that support each other rather than compete negatively. It will enable the south and Africa in particular to participate actively and own the means for solving its own health problems and raise the professional quality and capacity of southern institutions to forge better and equal partnership with northern institutions.

Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Lilongwe District, Malawi

SETTING

Lilongwe District, Malawi.

OBJECTIVE

To assess the cost and cost-effectiveness of new treatment strategies for new pulmonary tuberculosis patients, introduced in 1997.

METHODS

For new smear-positive pulmonary patients, two strategies were compared: 1) the strategy used until the end of October 1997, involving 2 months of hospitalisation at the beginning of treatment, and 2) a new decentralised strategy introduced in November 1997, in which patients were given the choice of in- or outpatient care during the first 2 months of treatment. For new smear-negative pulmonary patients, the two strategies compared were 1) the strategy used until the end of October 1997, which did not require any direct observation of treatment (DOT) and 2) a new community-based strategy introduced in November 1997, which required DOT by a community member 'guardian' or a health worker for the first 2 months of treatment. Costs were analysed from the perspective of health services, patients, and the community in 1998 US dollars, using standard methods. Cost-effectiveness was calculated as the cost per patient cured (smear-positive cases) and as the cost per patient completing treatment (new smear-negative cases).

FINDINGS

For new smear-positive patients, the cost per patient treated was dollars 456 with the conventional hospital-based strategy, and dollars 106 with the new decentralised strategy. Costs fell by 54% for health services and 58% for patients. The cost per patient cured was dollars 787 for the conventional hospital-based strategy, and dollars 296 for decentralised treatment. For smear-negative patients, the cost per patient treated was dollars 67 with the conventional unsupervised strategy, and dollars 101 with the community-based DOT strategy. Costs increased for health services, patients and guardians. Cost-effectiveness was similar with both strategies, at around dollars 200 per patient completing treatment. When new smear-positive and new smear-negative patients were considered together, the new strategies were associated with a 50% reduction in total annual costs.

CONCLUSION

There is a strong economic case for expansion of decentralisation and community-based DOT in Malawi. Further investment in training and programme supervision may help to increase effectiveness.

TNF-alpha promoter single nucleotide polymorphisms are markers of human ancestry

We present a map of single nucleotide polymorphisms (SNPs) in the human tumor necrosis factor (TNF)-alpha promoter based upon exploratory sequencing of 333 human TNF-alpha gene promoters from individuals of distinct ancestral backgrounds. We detect 10 TNF-alpha promoter SNPs that occur with distinct frequencies in populations of different ancestry. Consistent with these findings, we show that two TNF-alpha SNPs, the -243 SNP and the -856 SNP, are the first SNP markers of a sub-Saharan African-derived extended haplotype and an Amerindian HLA haplotype, respectively. Comparisons of TNF-alpha promoter SNP allele frequencies can thus help elucidate variation of HLA haplotypes and their distribution among existing ethnic groups and shed light into the history of human populations.

Local perceptions of tuberculosis in a rural district in Malawi

SETTING

Ntcheu district, Malawi.

OBJECTIVE

To determine 1) the number of patients treated by traditional healers, 2) the type of diseases managed by them, 3) the perceived causes of these disease, and 4) how both patients and healers looked at tuberculosis (TB).

DESIGN

In-depth interviews and structured questionnaires with traditional healers, and focus group discussions with TB patients and their guardians.

RESULTS

Traditional healers recognized four main causes of disease, related to why the patient is sick rather than what the patient is suffering from. Two hundred and seventy-six traditional healers saw approximately 4600 patients a week, managing a variety of diseases, mainly of a chronic nature. Twenty-four per cent of patients seen by traditional healers had a cough, including patients with TB. Traditional healers believe they can cure TB, and have therefore been briefed on the infectious form of TB (smear-positive cases). The possibility of including traditional healers in early diagnosis has been explored.

CONCLUSION

There is a need to address local beliefs in health education and possibly find ways of involving healers in supervision of treatment.

Placental haemozoin and malaria in pregnancy

Malaria infections in pregnant women cause poor birth outcomes. Malaria pigment (haemozoin) accumulates in the placenta within macrophages and extracellularly, but its pathological significance is not understood. In order to study the potential role of haemozoin in malaria pathogenesis, we enrolled primigravid women at a Malawian government antenatal clinic and followed them through delivery. One hundred and thirteen women (71 per cent) out of 159 women followed through delivery were parasitaemic at least once. Mean placental haemozoin concentrations were significantly higher in women with delivery parasitaemias (223 ng/mg protein) than in women who never had a detectable parasitaemia (43 ng/mg protein; P<0.05), but were not significantly higher in women who were parasitaemic only during the antenatal period (67 ng/mg protein). Haemozoin was not associated with preterm delivery (PTD) or intrauterine growth retardation (IUGR) (P -values, 0.307-0.787). Thus, placental haemozoin is associated with malaria infection at the time of delivery and does not seem to be associated with poor birth outcome.

Malaria and pregnancy: placental cytokine expression and its relationship to intrauterine growth retardation

Malaria infections during pregnancy can lead to the delivery of low-birth-weight infants. In this study, cytokine mRNA was measured in placentas from 23 malaria-infected and 21 uninfected primigravid women who had delivered in Mangochi, Malawi, a region with a high rate of transmission of falciparum malaria. Significantly increased expression of interleukin (IL)-1beta, IL-8, and tumor necrosis factor (TNF)-alpha and decreased expression of IL-6 and transforming growth factor-beta1 were found in malaria-infected compared with uninfected placentas. TNF-alpha and IL-8 were produced by maternally derived hemozoin-laden placental macrophages. Increased TNF-alpha expression was associated with increased placental hemozoin concentrations. Increased TNF-alpha or IL-8 expression in the placenta was associated with intrauterine growth retardation but not with preterm delivery. The results suggest that malaria infections induce a potentially harmful proinflammatory response in the placenta.

Malaria infection during pregnancy: intrauterine growth retardation and preterm delivery in Malawi

In sub-Saharan Africa, malaria infection in pregnancy contributes to low birth weight through intrauterine growth retardation (IUGR) and preterm delivery (PTD). It was hypothesized that malaria-associated PTD and IUGR have differing etiologies due to timing of infection. In a prospective cohort of primigravid women enrolled at the antenatal clinic of Mangochi District Hospital in Malawi, the associations were investigated between antenatal or delivery parasitemias and IUGR or PTD. Among 178 singleton deliveries, 35% of infants were preterm or had IUGR. Cord blood parasitemia (odds ratio [OR]=3.34; 95% confidence interval [CI], 1.3-8.8], placental parasitemia (OR=2.43; 95% CI, 1.2-5.1), and postdelivery maternal peripheral parasitemia (OR=2.78; 95% CI, 1.3-6.1) were associated with PTD. Parasitemia and/or clinically diagnosed malaria in the antenatal period was associated with IUGR (OR=5.13; 95% CI, 1.4-19.4). Delivery parasitemias had borderline associations with IUGR. The risk patterns observed suggest that the timing and severity of infection influences the occurrence of IUGR or PTD.

Patients' perceptions of chamba (marijuana) use in Malawi

This study examines the perceptions of the social aspects, triggers, and effects of chamba (marijuana) use among psychiatric patients at Zomba Mental Hospital in Malawi. Focus groups were used to elicit responses from 44 male and 10 female psychiatric patients about their perceptions of chamba use in Malawi. This study provides insight into these patients' perceptions of the triggers and effects of their chamba use, and it has implications for the development of treatment and prevention programs for chamba users in Malawi.

Attributions for admission to Zomba Mental Hospital: implications for the development of mental health services in Malawi

Within Malawi, as in many other African countries, a variety of traditional and modern attributions exist regarding the cause of a person's mental disturbance, or their admission to a 'mental' hospital. It is argued that a good mental health service should consider the beliefs of the patients it seeks to serve. Consequently we studied 103 consecutive admissions to Zomba Mental Hospital in order to find out how patients explained their own admission to the hospital. Traditional attributions were the most common, followed by medical and then psychological attributions. Some patients explained their admission to the hospital by combining traditional, medical or psychological ideas. Content analysis of traditional attributions identified examples of "Tropical Tolerance" and the "Pull Down" phenomenon. The possible interactive nature of traditional, medical and psychological processes is discussed and it is suggested that traditional healers should be incorporated into 'modern' Malawian mental health services.