Spinal Muscular Atrophy Type 1 Survival Without New Pharmacotherapies: Two Treatment Paradigms

OBJECTIVES

The aims of the study are to present noninvasive respiratory management outcomes using continuous noninvasive ventilatory support and mechanical in-exsufflation from infancy for spinal muscular atrophy type 1 and to consider bearing on new medical therapies.

DESIGN

Noninvasive ventilatory support was begun for consecutively referred symptomatic infants with spinal muscular atrophy type 1 from 1 to 10 mos of age. Intercurrent episodes of respiratory failure were managed by intubation then extubation to continuous noninvasive ventilatory support and mechanical in-exsufflation despite failing ventilator weaning and extubation attempts. Intubations, tracheotomies, and survival were monitored.

RESULTS

Of 153 patients with spinal muscular atrophy 1 consecutively referred since 1995, 37 became continuous noninvasive ventilatory support dependent, almost half before 10 yrs of age. Of the 37, 18 required continuous noninvasive ventilatory support for a mean 18.6 ± 3.3 yrs to a mean 25.3 (range, 18-30) yrs of age, dependent from as young as 4 mos of age with 0 to 40 ml of vital capacity. One of the 18 died from COVID-19 acute respiratory distress syndrome at age 24 after 23 yrs of continuous noninvasive ventilatory support. Extubation success rate of 85% per attempt (150/176) resulted in only one undergoing tracheotomy.

CONCLUSIONS

Medical treatments begun during the first 6 wks of age convert spinal muscular atrophy 1 into spinal muscular atrophy 2 or 3 but cough flows remain inadequate to avoid many pneumonias that, once resolved by a treatment paradigm of extubation to continuous noninvasive ventilatory support and mechanical in-exsufflation, eliminates need to resort to tracheotomies.

HeartWare Left Ventricular Assist Device Exercise Hemodynamics With Speed Adjustment Based on Left Ventricular Filling Pressures

Functional capacity remains limited in heart failure patients with left ventricular assist devices (LVADs) due to fixed pump speed and inability to offload the left ventricle adequately. We hypothesized that manually adjusting LVAD speed during exercise based on pulmonary capillary wedge pressures would increase total cardiac output and maximal oxygen consumption. Two participants with a HeartWare LVAD underwent an invasive ramp study at rest followed by an invasive cardiopulmonary stress test exercising in two randomized phases: fixed speed and adjusted speed. In the latter phase, speed was adjusted every 1 minute during exercise at ±20 rpm/1 mm Hg change from baseline pulmonary capillary wedge pressure. There was no difference in maximal oxygen consumption between the two phases, with a modest increase in total cardiac output during speed adjustment. Filling pressures were initially controlled during speed adjustment until speed was capped at 4,000 rpm, at which point filling pressures increased. Blood pressure was variable. The pressure across the head of the pump (ΔP) was higher with speed adjustment. Contrary to our hypothesis, LVAD speed adjustment during exercise did not improve total cardiac output and functional capacity. This variable response may be attributed to the native cardiac reserve and baroreceptor response; however, additional studies are needed.

Identifying Gene-Treatment Interactions and Targetable Radiation Vulnerabilities in Glioblastoma through Coupling of In Vivo CRISPR Perturbation and Single Cell Transcriptomics

PURPOSE/OBJECTIVE(S)

Glioblastoma (GBM) is an incurable brain tumor comprised of dynamic malignant cell states and microenvironment components that underlie treatment resistance. Here we use genome-wide CRISPR/Cas9 functional genomics to define biological drivers and therapeutic vulnerabilities across human and mouse GBM models. To interrogate these mechanisms in the context of the tumor microenvironment and in vivo physiology, we established in vivo Perturb-seq intracranially, a technique coupling functional genomics with single cell transcriptomics, where each cell is an individual experiment.

MATERIALS/METHODS

Orthotopic intracranial tumor models were established using human (GBM6, GBM43) or mouse (GL261, SB28) GBM cells stably expressing CRISPR interference (CRISPRi) machinery. Perturb-seq target selection for phenotyping of gene-treatment interactions was performed using genome-wide CRISPRi screens ± radiotherapy in cell cultures. Dual sgRNA lentivirus libraries were transduced either ex vivo prior to intracranial GBM cell transplantation or in vivo using intratumor convection enhanced delivery (CED). Transcriptional phenotyping was performed using single-cell RNA-seq with CRISPR direct capture following focal brain radiotherapy (2 Gy x 5) or mock treatment. GBM cell states were validated using single-nucleus RNA-seq data from 86 primary-recurrent patient-matched GBMs. Mechanistic and functional validation was performed using small molecule inhibitors, immunohistochemistry, clonogenic assays, and in vivo survival experiments.

RESULTS

In vivo Perturb-seq ± radiotherapy of 48 genes underlying GBM radiotherapy responses, which were enriched for DNA damage response and metabolic pathways, was performed in > 425,000 single cells. Radiotherapy induced 16 distinct GBM cell states, and genetic perturbations reprogrammed these cell states in a treatment-dependent fashion. Quantitative modeling of gene/radiotherapy interactions using high dimensional manifolds revealed in vivo-specific genetic dependencies. We revealed a critical role for Prkdc, the catalytic subunit of DNA-dependent protein kinase (DNA-PK), as a radiotherapy sensitizer through regulation of cell intrinsic growth and oxidative stress pathways, and cell extrinsic interferon and signaling pathways that altered cell-cell interactions in vivo. These pathways were also disrupted in single-nucleus RNA-seq analysis of post-radiotherapy human GBM tumors. Inhibition of Prkdc using a Food and Drug Administration approved small molecule sensitized GBM cells to radiotherapy and extended survival in mice harboring human intracranial xenografts.

CONCLUSION

We establish in vivo Perturb-seq in orthotopic GBM models as a platform for simultaneous functional genomic discovery and characterization of therapeutic targets, revealing an underappreciated role for Prkdc in GBM tumors in vivo that is targetable using small molecules. These tools are adaptable for a wide range of disease models and treatment modalities.

Cadaveric Prehospital Amputation: Which Reciprocating Saw Blade Offers the Most Efficient Amputation

OBJECTIVE

Field amputations are a low-frequency, high-risk procedure. Many prehospital personnel utilize the reciprocating saw. This study compares the efficiency, speed, and degree of tissue damage of different reciprocating saw blades found commercially.

METHODS

Amputations were performed on two human cadavers at different levels of the upper and lower extremities. Four different blades were used, each with a different teeth-per-inch (TPI) design. The amputations were timed, blade temperature was recorded, subjective operator effort was obtained, amount of splatter was evaluated, and an orthopedic physician evaluated the extent of tissue damage and operating room repair difficulty.

RESULTS

The blade with fourteen TPI was superior in overall speed to complete the amputations at 1.07 seconds per one centimeter of tissue (SD = 0.49 seconds) and had the lowest fail rate (0/8 amputations). The three TPI, six TPI, and ten TPI blades all required a "rescue" technique and were slower. The blade with fourteen TPI caused the least amount of tissue damage and was deemed the easiest to repair. Secondary outcomes demonstrated the fourteen TPI blade had generated the least amount of heat and produced the least amount of splatter. All blades had a perceived effort of "easy" to complete the amputation.

CONCLUSION

While all blades were able to achieve an amputation, the overall recommendation is use of a fourteen TPI blade. It did not require any rescue techniques, provided the most straightforward amputation to repair, had the least amount of biohazard splatter and temperature increase, and was the fastest blade overall.

Estimating the effects of COVID-19 on essential health services utilization in Uganda and Bangladesh using data from routine health information systems

Background

Since March 2020, the coronavirus disease 2019 (COVID-19) pandemic has been a major shock to health systems across the world. We examined national usage patterns for selected basic, essential health services, before and during the COVID-19 pandemic in Uganda and Bangladesh, to determine whether COVID-19 affected reporting of service utilization and the use of health services in each country.

Methods

We used routine health information system data since January 2017 to analyze reporting and service utilization patterns for a variety of health services. Using time series models to replicate pre-COVID-19 trajectories over time we estimated what levels would have been observed if COVID-19 had not occurred during the pandemic months, starting in March 2020. The difference between the observed and predicted levels is the COVID-19 effect on health services.

Results

The time trend models for Uganda and Bangladesh closely replicated the levels and trajectories of service utilization during the 38 months prior to the COVID-19 pandemic. Our results indicate that COVID-19 had severe effects across all services, particularly during the first months of the pandemic, but COVID-19 impacts on health services and subsequent recovery varied by service type. In general, recovery to expected levels was slow and incomplete across the most affected services.

Conclusion

Our analytical approach based on national information system data could be very useful as a form of surveillance for health services disruptions from any cause leading to rapid responses from health service managers and policymakers.

Hedgehog target genes regulate lipid metabolism to drive basal cell carcinoma and medulloblastoma

Hedgehog (Hh) signaling is essential for development, homeostasis, and regeneration1. Misactivation of the Hh pathway underlies medulloblastoma, the most common malignant brain tumor in children, and basal cell carcinoma (BCC), the most common cancer in the United States2. Primary cilia regulate Hh signal transduction3, but target genes that drive cell fate decisions in response to ciliary ligands or oncogenic Hh signaling are incompletely understood. Here we define the Hh gene expression program using RNA sequencing of cultured cells treated with ciliary ligands, BCCs from humans, and Hh-associated medulloblastomas from humans and mice (Fig. 1a). To validate our results, we integrate lipidomic mass spectrometry and bacterial metabolite labeling of free sterols with genetic and pharmacologic approaches in cells and mice. Our results reveal novel Hh target genes such as the oxysterol synthase Hsd11β1 and the adipokine Retnla that regulate lipid metabolism to drive cell fate decisions in response to Hh pathway activation. These data provide insights into cellular mechanisms underlying ciliary and oncogenic Hh signaling and elucidate targets to treat Hh-associated cancers.

Area-specific covid-19 effects on health services utilization in the Democratic Republic of the Congo using routine health information system data

BACKGROUND

Since March 2020, the COVID-19 pandemic has shocked health systems worldwide. This analysis investigated the effects of the pandemic on basic health services utilization in the Democratic Republic of the Congo (DRC) and examined the variability of COVID effects in the capital city Kinshasa, in other urban areas, and in rural areas.

METHODS

We estimated time trends models using national health information system data to replicate pre-COVID-19 (i.e., January 2017-February 2020) trajectories of health service utilization, and then used those models to estimate what the levels would have been in the absence of COVID-19 during the pandemic period, starting in March 2020 through March 2021. We classified the difference between the observed and predicted levels as the effect of COVID-19 on health services. We estimated 95% confidence intervals and p-values to examine if the effect of the pandemic, nationally and within specific geographies, was statistically significant.

RESULTS

Our results indicate that COVID-19 negatively impacted health services and subsequent recovery varied by service type and by geographical area. COVID-19 had a lasting impact on overall service utilization as well as on malaria and pneumonia-related visits among young children in the DRC. We also found that the effects of COVID-19 were even more immediate and stronger in the capital city of Kinshasa compared with the national effect. Both nationally and in Kinshasa, most affected services had slow and incomplete recovery to expected levels. Therefore, our analysis indicates that COVID-19 continued to affect health services in the DRC throughout the first year of the pandemic.

CONCLUSIONS

The methodology used in this article allows for examining the variability in magnitude, timing, and duration of the COVID effects within geographical areas of the DRC and nationally. This analytical procedure based on national health information system data could be applied to surveil health service disruptions and better inform rapid responses from health service managers and policymakers.

Simultaneous Bilateral Anterior Cruciate Ligament Revision Reconstruction

There are limited studies in the literature regarding the reconstruction of bilateral anterior cruciate ligament (ACL) injuries in a single-stage setting. However, there have been no published studies describing simultaneous revision reconstructions of previously reconstructed bilateral ACLs. We present the case of a 37-year-old male who underwent previous reconstruction of both ACLs at an outside hospital and presented to our outpatient clinic with instability and pain. Simultaneous bilateral ACL revision reconstruction was performed with the use of tibialis anterior allografts. This case report suggests that single-stage bilateral ACL revision reconstruction is a safe procedure that can provide good results for the patient.

Diagnostic yield of pediatric and prenatal exome sequencing in a diverse population

The diagnostic yield of exome sequencing (ES) has primarily been evaluated in individuals of European ancestry, with less focus on underrepresented minority (URM) and underserved (US) patients. We evaluated the diagnostic yield of ES in a cohort of predominantly US and URM pediatric and prenatal patients suspected to have a genetic disorder. Eligible pediatric patients had multiple congenital anomalies and/or neurocognitive disabilities and prenatal patients had one or more structural anomalies, disorders of fetal growth, or fetal effusions. URM and US patients were prioritized for enrollment and underwent ES at a single academic center. We identified definitive positive or probable positive results in 201/845 (23.8%) patients, with a significantly higher diagnostic rate in pediatric (26.7%) compared to prenatal patients (19.0%) (P = 0.01). For both pediatric and prenatal patients, the diagnostic yield and frequency of inconclusive findings did not differ significantly between URM and non-URM patients or between patients with US status and those without US status. Our results demonstrate a similar diagnostic yield of ES between prenatal and pediatric URM/US patients and non-URM/US patients for positive and inconclusive results. These data support the use of ES to identify clinically relevant variants in patients from diverse populations.

DDDR-33. TARGETING TGFΒ PATHWAY DEPENDENCIES IN GROUP 3 MEDULLOBLASTOMA

Medulloblastoma (MB) is one of the most prevalent malignant brain tumors in children, with tremendous cognitive and neuroendocrine disability among survivors. Group 3 (G3) MBs have poor overall survival at < 50%, few recurrent mutations, higher frequency of metastasis, and no targeted therapies. Amplification of MYC (c-myc) and activation of TGFβ signaling are frequent in G3 MB. We hypothesize that the TGFβ pathway and MYC contribute to the intrinsic resistance of G3 MB through deregulation of key genes and pathways. We previously established humanized models for SHH MB by introducing MYCN or PTCH1 deletions into neuroepithelial stem (NES) cells derived from normal human induced pluripotent stem cells (hIPSCs). In this study, we transduced NES cells with TGFb effectors activated in G3 MB (ACVR2A, TGFbR1, TGFb1, TGFb3, and SMAD5) alone and/or in combination with MYC, prioritizing combinations observed in patients. Excitingly, both MYC and TGFβ effectors drove tumor formation in vivo with the combination of TGFβ effectors with MYC leading to more aggressive tumors. We thus describe six new humanized isogenic models for both non-MYC and MYC driven G3 MB. We next found that NES cells expressing MYC with either TGFβR1 or TGFβ1 showed resistance to clinical TGFβR1 inhibitors, compared to cells driven by either TGFβR1 or TGFβ1 alone. To decipher mechanisms of resistance, we integrated CUT & RUN to probe for MYC genomic localization and relevant histone PTMs with RNA-seq analysis of MYC and TGFβ pathway driven NES cells. We discovered a subset of genes upregulated in MYC and TGFb-driven lines that are targets of the histone demethylase KDM2B. We postulate that epigenetic remodeling via MYC and recruitment of other MYC-interacting cofactors culminates in transcriptional changes that lead to aggressive disease. Overall, our studies provide insights on identifying new therapeutic avenues for patients with MYC and TGFβ driven G3 MB.

MODL-32. IMPACT OF PRDM6 ON CHROMATIN ACCESSIBILITY, GENE EXPRESSION, AND MEDULLOBLASTOMA FORMATION

Group 4 medulloblastoma (MB) is the most common medulloblastoma subgroup and shows high incidence of metastasis and late-onset relapse. Group 4 MBs lack a unifying oncogenic driver and treatment targets, despite extensive genomic characterization. Group 4 MBs are characterized by recurrent genetic alterations in chromatin modifiers, amplification of stemness genes, and putative enhancer "hijacking" events. A substantial fraction of Group 4 MBs are characterized by enhancer hijacking through tandem duplication of SNCAIP, resulting in high expression of PRDM6, a putative transcriptional repressor and histone methyltransferase. Some PRDM6-overexpressing MBs show additional mutations in chromatin regulators and high MYCN expression. We set out to elucidate the impact and oncogenic potential of sustained PRDM6 expression in early neural stem cell populations and patient-derived medulloblastoma cells. We find that PRDM6 expression in human iPSC-derived neuroepithelial stem cells (NESCs) results in tumor growth in mice, albeit at low penetrance. Moreover, we find that PRDM6 expression in MYCN-overexpressing NESCs does not further alter tumor aggressiveness or survival in vivo. Notably, PRDM6 overexpression in the patient-derived Group 3 MYC-amplified D283-Med cell line causes significantly increased aggressiveness of tumor growth and shorter survival in mice. At the cellular level, PRDM6 localizes to the nucleus, suggesting a role in gene expression regulation. Consistent with this notion, ATAC-seq and RNA-seq analysis of PRDM6-NESCs and PRDM6-D283-Med cells reveals major changes in chromatin accessibility and gene expression, including upregulation of integrin family members and genes related to focal adhesion and extracellular matrix-receptor interaction pathways. We conclude that PRDM6 promotes tumor growth in NESCs and may play a role in tumor maintenance through interactions with the extracellular matrix and tumor microenvironment.

Measuring results of humanitarian action: adapting public health indicators to different contexts

Humanitarian crises represent a significant public health risk factor for affected populations exacerbating mortality, morbidity, disabilities, and reducing access to and quality of health care. Reliable and timely information on the health status of and services provided to crisis-affected populations is crucial to establish public health priorities, mobilize funds, and monitor the performance of humanitarian action. Numerous efforts have contributed to standardizing and presenting timely public health information in humanitarian settings over the last two decades. While the prominence of process and output (rather than outcome and impact) indicators in monitoring frameworks leads to adequate information on resources and activities, health outcomes are rarely measured due to the challenges of measuring them using gold-standard methods that are difficult to implement in humanitarian settings.

We argue that challenges in collecting the gold-standard performance measures should not be a rationale for neglecting outcome measures for critical health and nutrition programs in humanitarian emergencies. Alternative indicators or measurement methods that are robust, practical, and feasible in varying contexts should be used in the interim while acknowledging limitations or interpretation constraints. In this paper, we draw from existing literature, expert judgment, and operational experience to propose an approach to adapt public health indicators for measuring performance of the humanitarian response across varied contexts.

Contexts were defined in terms of parameters that capture two of the main constraints affecting the capacity to obtain performance information in humanitarian settings: (i) access to population or health facilities; and (ii) availability of resources for measurement. Consequently, 2 × 2 tables depict four possible scenarios: (A) a situation with accessible populations and with available resources; (B) a situation with available resources but limited access to affected populations; (C) a situation with accessible populations and limited resources; and (D) a situation with both limited access and limited resources.

Methods and data sources can vary from large population-based surveys, rapid assessments of populations or health facilities, routine health management information systems, or data from sentinel sites in the community or among facilities. Adapting indicators and methods to specific contexts of humanitarian settings increases the potential for measuring the performance of humanitarian programs beyond inputs and outputs by assessing health outcomes, and consequently improving program impact, reducing morbidity and mortality, and improving the quality of lives amongst persons affected by humanitarian emergencies.

Social autopsy analysis of the determinants of neonatal and under-five mortalities in Nigeria, 2013-2018

Background

Nigeria suffers from one of the world’s highest child mortality rates, with about 900,000 deaths in a single year, despite being classified as a middle-income country. Over the past few years, substantial efforts have been made to reduce child mortality, with under-five mortality declining by 31.6% between 1990 and 2018. However, this decline is slower than needed to reduce child mortality significantly. This study presents the social autopsy component of the 2019 verbal and social autopsy (VASA) survey to provide an in-depth understanding of the social determinants of under-five mortality in Nigeria.

Methods

The study was a cross-sectional inquiry into the social determinants of neonatal and 1-59 months child deaths from the 2018 Nigeria Demographic and Health Survey (NDHS) weighted to represent the Nigerian population. The social autopsy survey asked about maternal care for neonates and 1-59 months children during the final illness.

Results

Child mortality in Nigeria in children aged 1-59 months is strongly associated with levels of wealth, place of residence, and maternal education. The association of these same socio-economic factors with neonatal mortality is weaker. While there were significant associations with wealth quintiles and geopolitical zones, higher maternal education was not significantly associated with lower neonatal death rates. Maternal complications in pregnancy and/or labour and delivery were common and strongly associated with stillbirths and deaths in the first two days. Severity scores at the inception of the illnesses did not show differences between children who only received informal care versus those who went to formal care providers. The main barriers to care were distance, cost, transport, and the need to travel at night, and these barriers were interlinked. More distant facilities usually required vehicle transport, which was expensive for low-income families. Travelling for an emergency at night was even more difficult in terms of finding and paying for transport and involving problems with insecurity and bad roads.

Conclusions

The family, community, and health system factors related to neonatal and 1-59 months child deaths in Nigeria were highlighted in this study. Deaths were commonly associated with numerous factors, each of which could contribute to the sequence of events resulting in a preventable death.

Causes of deaths in neonates and children aged 1-59 months in Nigeria: verbal autopsy findings of 2019 Verbal and Social Autopsy study

Background

Nigeria has one of the highest under-five mortality rates in the world. Identifying the causes of these deaths is crucial to inform changes in policy documents, design and implementation of appropriate interventions to reduce these deaths. This study aimed to provide national and zonal-level estimates of the causes of under-five death in Nigeria in the 2013–2018 periods.

Methods

We conducted retrospective inquiries into the cause of deaths of 948 neonates and 2,127 children aged 1–59 months as identified in the 2018 Nigeria Demographic and Health Survey (NDHS). The verbal autopsy asked about signs and symptoms during the final illness. The Physician Coded Verbal Autopsy (PCVA) and Expert Algorithm Verbal Autopsy (EAVA) methods were employed to assign the immediate and underlying cause of deaths to all cases.

Result

For the analysis, sampling weights were applied to accommodate non-proportional allocation. Boys accounted for 56 percent of neonatal deaths and 51.5 percent of the 1–59-months old deaths. About one-quarter of under-5 mortality was attributed to neonatal deaths, and 50 percent of these neonatal deaths were recorded within 48 h of delivery. Overall, 84 percent of the under-5 deaths were in the northern geopolitical zones. Based on the two methods for case analysis, neonatal infections (sepsis, pneumonia, and meningitis) were responsible for 44 percent of the neonatal deaths, followed by intrapartum injury (PCVA: 21 percent vs. EAVA: 29 percent). The three main causes of death in children aged 1–59 months were malaria (PCVA: 23 percent vs. EAVA: 35 percent), diarrhoea (PCVA: 17 percent vs. EAVA: 23 percent), and pneumonia (PCVA: 10 percent vs. EAVA: 12 percent). In the North West, where the majority of under-5 (1–59 months) deaths were recorded, diarrhoea was the main cause of death (PCVA: 24.3 percent vs. EAVA: 30 percent).

Conclusion

The causes of neonatal and children aged 1–59 months deaths vary across the northern and southern regions. By homing on the specific causes of mortality by region, the study provides crucial information that may be useful in planning appropriately tailored interventions to significantly reduce under-five deaths in Nigeria.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13507-z.

In Vivo Evaluation of a Physiologic Control System for Rotary Blood Pumps Based on the Left Ventricular Pressure-Volume Loop

Current generation continuous flow assist devices to operate at a fixed speed, which limits preload response and exercise capacity in left ventricular assist device (LVAD) patients. A feedback control system was developed to automatically adjust pump speed based on direct measurements of ventricular loading using a custom cannula tip with an integrated pressure sensor and volume-sensing conductance electrodes. The input to the control system is the integral of the left ventricular (LV) pressure versus conductance loop (PGA) over each cardiac cycle. The feedback control system adjusts pump speed based on the difference between the measured PGA and the desired PGA. The control system and cannula tip were tested in acute ovine studies (n = 5) using the HeartMate II LVAD. The preload response of the control system was evaluated by partially occluding and releasing the inferior vena cava using a vessel loop snare. The cannula tip was integrated onto a custom centrifugal flow LVAD and tested in a 14-day bovine study. The control system adjusted pump support to maintain constant ventricular loading: pump speed increased (decreased) following an increase (decrease) in preload. This study demonstrated in vivo the Starling-like response of an automatic pump control system based on direct measurements of LV loading.

Health beliefs and (timely) use of facility-based care for under-five children: lessons from the qualitative component of Nigeria's 2019 VASA

Background

Nigeria’s under-five health outcomes have improved over the years, but the mortality rates remain unacceptably high. The qualitative component of Nigeria’s 2019 verbal and social autopsy (VASA) showed that caregivers’ health beliefs about causes of illnesses and efficacious treatment options contribute to non-use/delay in use of facility-based healthcare for under-five children. This study explored how these health beliefs vary across zones and how they shape how caregivers seek healthcare for their under-five children.

Methods

Data for this study come from the qualitative component of the 2019 Nigeria VASA, comprising 69 interviews with caregivers of under-five children who died in the five-year period preceding the 2018 Nigeria Demographic and Health Survey (NDHS); and 24 key informants and 48 focus group discussions (FGDs) in 12 states, two from each of the six geo-political zones. The transcripts were coded using predetermined themes on health beliefs from the 2019 VASA (qualitative component) using NVivo.

Results

The study documented zonal variation in belief in traditional medicine, biomedicine, spiritual causation of illnesses, syncretism, and fatalism, with greater prevalence of beliefs discouraging use of facility-based healthcare in the southern zones. Driven by these beliefs and factors such as availability, affordability, and access to and perceived quality of care in health facilities, caregivers often choose one or a combination of traditional medicines, care from medicine vendors, and faith healing. Most use facility-based care as the last option when other methods fail.

Conclusion

Caregivers’ health beliefs vary by zones, and these beliefs influence when and whether they will use facility-based healthcare services for their under-five children. In Nigeria’s northern zones, health beliefs are less likely to deter caregivers from using facility-based healthcare services, but they face other barriers to accessing facility-based care. Interventions seeking to reduce under-five deaths in Nigeria need to consider subnational differences in caregivers’ health beliefs and the healthcare options they choose based on those beliefs.

A comparison of approaches to measuring maternal mortality in Bangladesh, Mozambique, and Bolivia

Background

Many low- and middle-income countries cannot measure maternal mortality to monitor progress against global and country-specific targets. While the ultimate goal for these countries is to have complete civil registrations systems, other interim strategies are needed to provide timely estimates of maternal mortality.

Objective

The objective is to inform on potential options for measuring maternal mortality.

Methods

This paper uses a case study approach to compare methodologies and estimates of pregnancy-related mortality ratio (PRMR)/maternal mortality ratio (MMR) obtained from four different data sources from similar time periods in Bangladesh, Mozambique, and Bolivia—national population census; post-census mortality survey; household sample survey; and sample vital registration system (SVRS).

Results

For Bangladesh, PRMR from the 2011 census falls closely in line with the 2010 household survey and SVRS estimates, while SVRS’ MMR estimates are closer to the PRMR estimates obtained from the household survey. Mozambique's PRMR from household survey method is comparable and shows an upward trend between 1994 and 2011, whereas the post-census mortality survey estimated a higher MMR for 2007. Bolivia's DHS and post-census mortality survey also estimated comparable MMR during 1998–2003.

Conclusions

Overall all these data sources presented in this paper have provided valuable information on maternal mortality in Bangladesh, Mozambique, and Bolivia. It also outlines recommendations to estimate maternal mortality based on the advantages and disadvantages of several approaches.

Contribution

Recommendations in this paper can help health administrators and policy planners in prioritizing investment for collecting reliable and contemporaneous estimates of maternal mortality while progressing toward a complete civil registration system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-022-00281-8.

Estimating the impact of donor programs on child mortality in low- and middle-income countries: a synthetic control analysis of child health programs funded by the United States Agency for International Development

Background

Significant levels of funding have been provided to low- and middle-income countries for development assistance for health, with most funds coming through direct bilateral investment led by the USA and the UK. Direct attribution of impact to large-scale programs funded by donors remains elusive due the difficulty of knowing what would have happened without those programs, and the lack of detailed contextual information to support causal interpretation of changes.

Methods

This study uses the synthetic control analysis method to estimate the impact of one donor’s funding (United States Agency for International Development, USAID) on under-five mortality across several low- and middle-income countries that received above average levels of USAID funding for maternal and child health programs between 2000 and 2016.

Results

In the study period (2000–16), countries with above average USAID funding had an under-five mortality rate lower than the synthetic control by an average of 29 deaths per 1000 live births (year-to-year range of − 2 to − 38). This finding was consistent with several sensitivity analyses.

Conclusions

The synthetic control method is a valuable addition to the range of approaches for quantifying the impact of large-scale health programs in low- and middle-income countries. The findings suggest that adequately funded donor programs (in this case USAID) help countries to reduce child mortality to significantly lower rates than would have occurred without those investments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-021-00278-9.

Miniaturized Fontan Circulation Assist Device: Chronic In Vivo Evaluation

We have miniaturized and optimized our implantable rotary blood pump developed to provide long-term mechanical right heart support for patients who have failing Fontan circulation. The objective of this study was to evaluate the miniaturized Fontan circulation assist device (mini-FCAD) during 30-day sheep studies (n = 5). A complete right heart bypass was performed and all return flow was supported by the pump. Postoperatively, unfractionated heparin was given to maintain thromboelastography R times of 2× normal. The first two studies were terminated on day 0 and day 4 due to complications. In the final three studies, the animals remained healthy and were electively terminated at 30 ± 2 days. Pump flow was between 5 and 7 lpm, left atrial pressure remained normal, and inlet pressures were between 3 and 18 mm Hg with no incidents of suction. There was no evidence of hemolysis, end organ or pulmonary dysfunction, thromboembolic events, nor thermal damage to the surrounding tissue. Explanted devices from two studies were free of thrombi and in the third study there were unattached thrombi on the SVC inlet of the rotor. The mini-FCAD was successfully tested in vivo as a right heart replacement device demonstrating adequate circulatory support and normal physiologic pulmonary and venous pressures.

Oral Immunotherapy With Human Secretory Immunoglobulin A Improves Survival in the Hamster Model of Clostridioides difficile Infection

Coadministration of human secretory IgA (sIgA) together with subtherapeutic vancomycin enhanced survival in the Clostridioides difficile infection (CDI) hamster model. Vancomycin (5 or 10 mg/kg × 5 days) plus healthy donor plasma sIgA/monomeric IgA (TID × 21 days) or hyperimmune sIgA/monomeric IgA (BID × 13 days) enhanced survival. Survival was improved compared to vancomycin alone, P = .018 and .039 by log-rank Mantel-Cox, for healthy and hyperimmune sIgA, respectively. Passive immunization with sIgA (recombinant human secretory component plus IgA dimer/polymer from pooled human plasma) can be administered orally and prevents death in a partially treated CDI hamster model.

Effectiveness of a community-level social mobilization intervention in achieving the outcomes of polio vaccination campaigns during the post-polio-endemic period: Evidence from CORE Group polio project in Uttar Pradesh, India

BACKGROUND

A social mobilization (SM) initiative contributed to India's success in polio elimination. This was the CORE Group Polio Project (CGPP) India, a partner of the Uttar Pradesh (UP) SM Network and which continued its SM activities, even during the polio-free period through a network of multi-level social mobilizers. This paper assesses the effects of this community-level SM (CLSM) intervention on the extent of community engagement and performance of polio Supplementary Immunization Activity campaigns (SIAs) during the post-polio-endemic period (i.e., from March 2012 to September 2017).

METHODS

This study followed a quasi-experimental design. We used secondary, cluster-level data from CGPP India's Management Information System, including 52 SIAs held from January 2008 to September 2017, covering 56 blocks from 12 districts of UP. We computed various indicators and performed Generalized Estimating Equations based analysis to assess the statistical significance of differences between the outcomes of intervention and non-intervention areas. We then estimated the effects of the SM intervention using Interrupted time-series, Difference-in-Differences and Synthetic Control Methods. Finally, we estimated the population influenced by the intervention.

RESULTS

The performance of polio SIAs changed over time, with the intervention areas having better outcomes than non-intervention areas. The absence of CLSM intervention during the post-polio-endemic period would have negatively impacted the outcomes of polio SIAs. The percentage of children vaccinated at polio SIA booths, percentage of 'X' houses (i.e., households with unvaccinated children or households with out-of-home/out-of-village children or locked households) converted to 'P' (i.e., households with all vaccinated children or households without children eligible for vaccination), and percentage of resistant houses converted to polio acceptors would have gone down by 14.1 (Range: 12.7 to 15.5), 6.3 (Range: 5.2 to 7.3) and 7.4 percentage points, respectively. Community engagement would have reduced by 7.2 (Range: 6.6 to 7.7) percentage points.

CONCLUSIONS

The absence of CLSM intervention would have significantly decreased the level of community engagement and negatively impacted the performance of polio SIAs of the post-polio-endemic period. The study provides evidence of an added value of deploying additional human resource dedicated to social mobilization to achieve desired vaccination outcomes in hard-to-reach or programmatically challenging areas.

LGG-06. COMPREHENSIVE GENOMIC CHARACTERIZATION AND INTEGRATED CLINICAL ANALYSIS OF LOW-GRADE GLIOMAS IN CHILDREN WITH NEUROFIBROMATOSIS TYPE 1

Background

Low-grade gliomas (LGGs) arising in children with neurofibromatosis type 1 (NF1) are usually not biopsied. To identify secondary genetic alterations or molecular features that may contribute to pathogenesis and correlate with clinical behavior, we initiated a comprehensive molecular and clinical analysis of pediatric NF1-LGGs.

Methods

NF1-LGGs were analysed by whole-genome sequencing (31), targeted gene panel sequencing (9), RNAseq transcriptomal profiling (33) and genome-wide DNA methylation analysis (67). Clinical annotation was available for 48 subjects.

Results

Most LGGs harbored bi-allelic NF1 inactivation as the sole genetic abnormality, but 11% had additional alterations (FGFR1 mutation, n=3; PIK3CA mutation, n=2; homozygous 9p21 deletion, n=2; MYB:QKI fusion, n=1; SETD2 mutation, n=1; EGFR amplification, n=1). FGFR1 mutation conferred additional growth advantage in multiple complementary murine Nf1 models. 88% of NF1-LGGs resembled sporadic pilocytic astrocytoma (PA) by methylation, higher than that based on histology. Non-PA methylation patterns included low-grade glial/glioneuronal tumors, rosette-forming glioneuronal tumors, MYB/MYBL1-altered glioma, and high-grade astrocytoma with piloid features (2 tumors histologically diagnosed as LGG). In total, 18% of samples were classified as non-PA and/or harbored an additional non-NF1 mutation. Non-PA methylation class tumors were more likely to harbor an additional non-NF1 mutation (p=0.005). 7.7% of optic pathway hypothalamic gliomas (OPHGs) had other mutations or were not classified by methylation as PA, compared with 20.6% of NF1-LGGs arising elsewhere. There was no difference based on age for the presence of an additional non-NF1 mutation or non-PA methylation class.

Conclusions

Given the overall low occurrence of non-NF1 mutations or non-PA methylation class tumors in this series, routine clinical biopsy of typically-appearing NF1-LGG may not be indicated, particularly for children with OPHG. Biopsy should be considered for non-OPHG tumors refractory to conventional treatment. As additional agents are developed and treatment strategies evolve, the rationale for biopsy of NF1-LGG may become stronger.

BIOL-11. THE ROLE OF ABERRANT EXPRESSION OF PRDM6 IN THE DEVELOPING CEREBELLUM AND IN GROUP 4 MEDULLOBLASTOMA

Group 4 medulloblastoma is the most common medulloblastoma subgroup with an intermediate prognosis and a high incidence of metastasis and late-onset relapse cases. Despite several comprehensive genomic studies in medulloblastoma, Group 4 medulloblastomas lack a unifying oncogenic driver and treatment targets. This subgroup is characterized by recurrent genetic alterations in chromatin modifiers, amplification of stemness genes, and enhancer hijacking events. 17% of Group 4 medulloblastoma cases are characterized by enhancer hijacking through tandem duplication of SNCAIP, resulting in high expression of PRDM6, a putative transcriptional repressor and histone methyltransferase. PRDM6 amplified medulloblastoma cases show additional mutations in other chromatin regulators, such as KDM6A, KMT2C and KMT2D, ZMYM3, and high MYCN expression. In this project, we investigate the impact and oncogenic potential of sustained PRDM6 expression in early neural stem cell populations and the developing mouse cerebellum. We drive expression of PRDM6 in human iPSC-derived neuroepithelial stem cells (NESCs) with and without high MYCN expression to study its implications in tumorigenesis. To test for tumor growth in vivo and changes in tumor progression as a function of PRDM6 activity, NESCs are injected into the cerebellum of adult mice. In order to elucidate impact of PRDM6 activity during embryonic cerebellar development, we also introduce PRDM6 expression into mouse embryonic stem cells (ESCs) for analysis via a new, in vivo cerebellar blastocyst complementation model. The latter approach is designed to ablate and repopulate early granule neural precursor cells in the embryonal cerebellum with progenitors derived from injected PRDM6-ESCs and thus to recapitulate pre- and postnatal cerebellar development in vivo. Together, our studies aim to understand the role of PRDM6 during normal cerebellar development and tumorigenesis and advance the understanding of the genetic drivers for Group 4 medulloblastoma.

OMIC-03. TRANSLATIONAL CONTROL IN MYC AND MYCN MEDULLOBLASTOMA

Medulloblastoma has been extensively characterized at the genomic and transcriptional levels, but little is known about how alterations in translational control underlie tumor development. Myc and Mycn are often deregulated in medulloblastoma and play important roles in tumor initiation, maintenance and progression. Although both proteins have similar structures and are functionally redundant in hindbrain development, their amplification in cerebellar granule neural precursor cells leads to different medulloblastoma subtypes. In this project we are employing ribosome profiling on mouse medulloblastoma tumors generated from granule neural precursor cells with enforced expression of Myc or Mycn. Ribosome-protected mRNA sequencing allows us to quantitatively assess the specific transcripts regulated at the level of translation, identify translation regulatory sequences within the mammalian transcriptome, and understand genotype-to-phenotype processes. We discovered that Myc- and Mycn-driven tumors exhibit many more changes at the translational rather than at the transcriptional level. In particular, we found that Mycn-driven medulloblastoma upregulates the translation of Myc target genes, while mRNA levels of those genes show no difference between Myc- and Mycn-driven tumors. Furthermore, we find that the most significant translationally upregulated Myc target genes in the Mycn tumors are transcripts that encode ribosome biogenesis factors. We will further study the role of Myc and Mycn on translational regulation of the medulloblastoma transcriptome using our xenograft model of human iPSC-derived neuroepithelial stem cells overexpressing Myc or Mycn. Our goal is to understand the regulatory function of the translational landscape in Myc- and Mycn-driven medulloblastoma and to decipher the oncogenic signaling cascades leading to different medulloblastoma subtypes.

Significance of a social mobilization intervention for engaging communities in polio vaccination campaigns: Evidence from CORE Group Polio Project, Uttar Pradesh, India

Background

Globally, community engagement is an integral part of most public health programs and the social mobilization (SM) intervention of India’s polio eradication program is one such example that contributed to eliminating polio from the country. CORE Group Polio Project (CGPP), a partner of Uttar Pradesh (U.P.) SM Network executed its activities through a network of social mobilizers called Community Mobilization Coordinators (CMCs). These were deployed in polio high risk areas to perform awareness generation and trust-building activities with communities and achieved high coverage of polio vaccination during Supplementary Immunization Activity campaigns (SIAs). This paper measures the extent and outcomes of CMC community engagement in SM interventions and polio SIAs.

Methods

This study used secondary, cluster-level data from Management Information System of CGPP India, including 52 SIAs held between January 2008 to September 2017 in 56 blocks/polio planning units, covering 12 districts of U.P. We used five indicators that reflected community engagement in polio SIAs and constructed a Community Engagement Index (CEI). Further, we estimated the difference in the CEI between CMC and non-CMC areas, using Generalized Estimating Equations (GEE) and also estimated treatment effects through Difference-in-Differences (DID) method using STATA.

Results

Overall, 78.6% (95% confidence interval (CI) = 78.3, 78.8) of families from the study area were engaged in the polio SIAs and the extent of community engagement increased over time. The mean CEI of entire study period in CMC areas (85.8%; 95% CI = 85.6, 86.0) was significantly higher (P < 0.001) than that of non-CMC areas (71.3%; 95% CI = 71.1, 71.5). Over time, the SM intervention led to at least 11 percentage points increase in the CEI of CMC areas with about 17% of this achievement attributable to CGPP India’s SM efforts.

Conclusions

The study findings suggest that intensive social mobilization efforts can significantly increase the extent of community engagement. The community engagement learnings of polio SM Network may be useful to achieve the desired outcomes of public health programs such as the National Health Mission (NHM) of India, that serves communities for multiple health issues.

TMOD-28. NEW APPROACHES FOR ELUCIDATING MEDULLOBLASTOMA DEVELOPMENT VIA HINDBRAIN BLASTOCYST COMPLEMENTATION

Understanding the etiology of brain cancers requires elucidation of developmental origins, genetic drivers, and the tumor microenvironment. This requires reliable in vivo approaches, which are currently lacking. Current in vivo models for pediatric brain tumors rely on generation of xenografts or allografts in immunodeficient mice or generation of transgenic mice. These approaches have severe limitations, including lack of a functional immune system, a restricted developmental time window defined by the cell of origin, or time-consuming workflows for the generation of transgenic mice. We recently developed neural blastocyst complementation (NBC), an organogenesis approach for the forebrain. NBC involves injection of donor mouse embryonic stem cells (ESC) into genetically-engineered blastocysts that are programmed to ablate dorsal telencephalic progenitors. This results in the formation of a donor-cell derived, intact forebrain. Based on this general approach, we are developing an in vivo platform for studies of brain cancer. We will report on our efforts and progress toward the generation of an organogenesis approach for the hindbrain and related studies that aim to define developmental origins and drivers of medulloblastoma.

Assessing coverage of essential maternal and child health interventions using health-facility data in Uganda

BACKGROUND

Nationally representative household surveys are the gold standard for tracking progress in coverage of life-saving maternal and child interventions, but often do not provide timely information on coverage at the local and health facility level. Electronic routine health information system (RHIS) data could help provide this information, but there are currently concerns about data quality. This analysis seeks to improve the usability of and confidence in electronic RHIS data by using adjustments to calculate more accurate numerators and denominators for essential interventions.

METHODS

Data from three sources (Ugandan Demographic and Health (UDHS) survey, electronic RHIS, and census) were used to provide estimates of essential maternal (> 4 antenatal care visits (ANC), skilled delivery, and postnatal care visit (PNC)) and child health interventions (diphtheria, pertussis, tetanus, and hepatitis B and Haemophilus influenzae type b and polio vaccination series, measles vaccination, and vitamin A). Electronic RHIS data was checked for quality and both numerators and denominators were adjusted to improve accuracy. Estimates were compared between the three sources.

RESULTS

Estimates of maternal health interventions from adjusted electronic RHIS data were lower than those of the UDHS, while child intervention estimates were typically higher. Adjustment of electronic RHIS data generally improved accuracy compared with no adjustment. There was considerable agreement between estimates from adjusted, electronic RHIS data, and UDHS for skilled delivery and first dose of childhood vaccination series, but lesser agreement for ANC visits and second and third doses of childhood vaccinations.

CONCLUSIONS

Nationally representative household surveys will likely continue being the gold standard of coverage estimates of maternal and child health interventions, but this analysis shows that current approaches to adjusting health facility estimate works better for some indications than others. Further efforts to improve accuracy of estimates from RHIS sources are needed.

Digital all-sky polarization imaging of the total solar eclipse on 21 August 2017 in Rexburg, Idaho, USA

All-sky polarization images were measured from sunrise to sunset and during a cloud-free totality on 21 August 2017 in Rexburg, Idaho using two digital three-camera all-sky polarimeters and a time-sequential liquid-crystal-based all-sky polarimeter. Twenty-five polarimetric images were recorded during totality, revealing a highly dynamic evolution of the distribution of skylight polarization, with the degree of linear polarization becoming nearly zenith-symmetric by the end of totality. The surrounding environment was characterized with an infrared cloud imager that confirmed the complete absence of clouds during totality, an AERONET solar radiometer that measured aerosol properties, a portable weather station, and a hand-held spectrometer with satellite images that measured surface reflectance at and near the observation site. These observations confirm that previously observed totality patterns are general and not unique to those specific eclipses. The high temporal image resolution revealed a transition of a neutral point from the zenith in totality to the normal Babinet point just above the Sun after third contact, providing the first indication that the transition between totality and normal daytime polarization patterns occurs over of a time period of approximately 13 s.

Strong community-based health systems and national governance predict improvement in coverage of oral rehydration solution (ORS): a multilevel longitudinal model

Diarrheal disease remains a leading cause of child death globally, especially in low and middle-income countries. Use of oral rehydration solution (ORS) for treatment of diarrhea in children, a very cost-effective intervention, remains below 50% in many countries. Here we use a multi-level longitudinal model to reveal important predictors of ORS use at the national level. The findings suggest that increasing government effectiveness along with increased implementation and affordability of community-based health programs can lead to substantial increases in ORS use. Key informant interviews with national health leaders in countries that significantly improved ORS coverage support these quantitative findings.

Availability of health facilities and utilization of maternal and newborn postnatal care in rural Malawi

BACKGROUND

This study explored the role of health facility availability as it relates to maternal and newborn PNC use in rural Malawi.

METHODS

Malawi Demographic and Health Survey (MDHS) 2015-16 data, MDHS 2015-16 household cluster GPS data, Malawi Service Provision Assessment (MSPA) 2013-14 data and MSPA 2013-14 facility GPS data were used. Household clusters were spatially linked with facilities using buffers. Descriptive analyses were performed and generalized estimating equations (GEE) were used to determine the effects of having different types of facilities at varying distances from household clusters on receipt of maternal and newborn PNC in rural Malawi.

RESULTS

In rural Malawi, around 96% of women had facilities providing PNC within 10 km of where they live. Among women who have clinic-level facilities within 5 km of where they live, around 25% had clinic-level facilities that provide PNC. For rural women who gave birth in the past 5 years preceding the survey, only about 3% received maternal PNC within 24 h and about 16% received maternal PNC within the first week. As for newborn PNC, 3% of newborns had PNC within 24 h and about 26% had newborn PNC within the first week. PNC mostly took place at facilities (94% for women and 95% for newborns). For women who delivered at home, having a health center providing PNC within 5 km was positively associated with maternal and newborn PNC. For women who delivered at facilities, having a health center providing PNC within 5 km was positively associated with maternal PNC and having a health center providing PNC between 5 km and 10 km was positively associated with both maternal and newborn PNC. Regardless of the place of delivery and distance band, having a clinic-level facility providing PNC did not have significant positive effects on maternal and newborn PNC.

CONCLUSIONS

Providers should be trained to perform quality PNC at all facilities. It would also be important to address concerns related to health workers. Lastly, it would be key to increase community awareness about the importance of seeking timely PNC and about the utility of lower-level facilities for receiving preventative PNC.

Medulloblastoma has a global impact on health related quality of life: Findings from an international cohort

Background

Understanding the global impact of medulloblastoma on health related quality of life (HRQL) is critical to characterizing the broad impact of this disease and realizing the benefits of modern treatments. We evaluated HRQL in an international cohort of pediatric medulloblastoma patients.

Methods

Seventy‐six patients were selected from 10 sites across North America, Europe, and Asia, who participated in the Medulloblastoma Advanced Genomics International Consortium (MAGIC). The Health Utilities Index (HUI) was administered to patients and/or parents at each site. Responses were used to determine overall HRQL and attributes (ie specific subdomains). The impact of various demographic and medical variables on HRQL was considered—including molecular subgroup.

Results

The majority of patients reported having moderate or severe overall burden of morbidity for both the HUI2 and HUI3 (HUI2 = 60%; HUI3 = 72.1%) when proxy‐assessed. Self‐care in the HUI2 was rated as higher (ie better outcome) for patients from Western versus Eastern sites, P = .02. Patients with nonmetastatic status had higher values (ie better outcomes) for the HUI3 hearing, HUI3 pain, and HUI2 pain, all P < .05. Patients treated with a gross total resection also had better outcomes for the HUI3 hearing (P = .04). However, those who underwent a gross total resection reported having worse outcomes on the HUI3 vision (P = .02). No differences in HRQL were evident as a function of subgroup.

Conclusions

By examining an international sample of survivors, we characterized the worldwide impact of medulloblastoma. This is a critical first step in developing global standards for evaluating long‐term outcomes.

A conceptual framework for measuring community health workforce performance within primary health care systems

BACKGROUND

With the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries.

METHODS

A review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input.

RESULTS

Twenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited.

CONCLUSIONS

Better data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs.

DDIS-33. SELECTIVE AND COMPLETE INHIBITION OF mTORC1 BY BI-STERIC mTOR INHIBITORS DRIVES THERAPEUTIC RESPONSE IN GLIOBLASTOMA

Activation of phosphatidylinositol 3-kinase (PI3K)/PTEN pathway and oncogenic signaling via the mechanistic target of rapamycin (mTOR) occur in a majority of high-grade glial brain tumors. Allosteric mTOR inhibitors, such as rapamycin and other rapalogs, incompletely block mTORC1 by reducing phosphorylation of some substrates, including S6K1, but not 4EBP1. In contrast, ATP-competitive inhibitors, such as sapanisertib, fully inhibit mTORC1. However these inhibitors are also active against mTORC2 and lipid kinases, likely enhancing toxicity. A new class of selective mTORC1 inhibitor that interacts with both the ATP- and FKBP12/FRB-binding sites has been developed, which we term ‘bi-steric’. The prototype bi-steric inhibitor, RapaLink-1, blocks phosphorylation of many mTORC1 substrates, including 4EBP1. Importantly, RapaLink-1 showed improved efficacy in glioblastoma models in vivo as compared to rapamycin or sapanisertib (Fan et al., Cancer Cell 2017). Revolution Medicines has developed novel next-generation bi-steric mTORC1-selective inhibitors that exhibit potent and selective (>10-fold) inhibition of mTORC1 over mTORC2 in vitro in cell line models. Two of these compounds, RM-001 and RM-006, showed sustained blockade of mTORC1 signaling, including dephosphorylation of 4EBP1, following weekly ip dosing in an orthotopic U87MG-Luc model of glioblastoma. Repeated weekly administration of these agents resulted in significantly greater anti-tumor efficacy, as assessed via tumor burden (bioluminescence imaging) and overall survival in comparison to daily sapanisertib and the rapalog everolimus, and weekly dosing of the first generation bi-steric RapaLink-1, all at maximally tolerated doses. In summary, our data demonstrate that bi-steric mTORC1 selective inhibitors elict marked anti-tumor efficacy at doses that are well tolerated in a preclinical model of glioblastoma. Our study emphasizes the importance of mTOR as a central target in glioblastoma, and showcases the therapeutic potential of novel and selective clinical bi-steric mTORC1 inhibitors under development as investigational new drugs.

CSIG-06. DEPATUXIZUMAB MAFODOTIN (ABT-414)-INDUCED GLIOBLASTOMA CELL DEATH REQUIRES EGFR OVEREXPRESSION, BUT NOT PHOSPHORYLATION

Glioblastomas commonly (40%) exhibit epidermal growth factor receptor (EGFR) amplification, half of these tumors carry the EGFRvIII deletion variant characterized by an in-frame deletion of exons 2–7, resulting in constitutive EGFR activation. Although EGFR tyrosine kinase inhibitors had only modest effects in glioblastoma, novel therapeutic agents targeting amplified EGFR or EGFRvIII continue to be developed. Depatuxizumab mafodotin (ABT-414) is an antibody drug conjugate consisting of the monoclonal antibody 806 and, as its toxic payload, monomethyl auristatin F, designed to target EGFR-overexpressing tumor cells. Since long-term glioma cell lines and patient-derived glioma-initiating cell lines appeared to express too little EGFR in vitro to be sensitive to ABT-414, we generated glioma sublines overexpressing EGFR or EGFRvIII to explore the determinants of ABT-414-induced glioma cell death. Overexpression of EGFRvIII induces sensitization to ABT-414 more readily than overexpression of EGFR. There is no bystander killing of cells devoid of EGFR or EGFRvIII expression. Surprisingly, either exposure to EGF or to EGFR tyrosin kinase inhibitors reduce EGFR protein levels and are thus no strategies to promote ABT-414-induced cell killing. Furthermore, glioma cells overexpressing kinase-dead EGFR or EGFRvIII retain binding of mAb 806 and sensitivity to ABT-414, allowing to dissociate EGFR phosphorylation from the emergence of the “active” EGFR conformation required for ABT-414 binding. The combination of EGFR-targeting antibody drug conjugates with EGFR tyrosine kinase inhibitors carries a high risk of failure. Promoting mere EGFR expression rather than phosphorylation should result in glioblastoma cell sensitization to ABT-414 or related agents.

Lessons Learned from the CORE Group Polio Project and Their Relevance for Other Global Health Priorities

Despite numerous setbacks, the Global Polio Eradication Initiative has implemented various community strategies with potential application for other global health issues. This article reviews strategies implemented by the CORE Group Polio Project (CGPP), including pursuit of the missed child, microplanning, independent campaign monitoring, using community health workers and community mobilizers to build community engagement, community-based surveillance, development of the capacity to respond to other health needs, targeting geographic areas at high risk, the secretariat model for non-governmental organization collaboration, and registration of vital events. These strategies have the potential for contributing to the reduction of child and maternal mortality in hard-to-reach, underserved populations around the world. Community-based surveillance as developed by the CGPP also has potential for improving global health security, now a global health priority.

Advances in the measurement of coverage for RMNCH and nutrition: from contact to effective coverage

Current methods for measuring intervention coverage for reproductive, maternal, newborn, and child health and nutrition (RMNCH+N) do not adequately capture the quality of services delivered. Without information on the quality of care, it is difficult to assess whether services provided will result in expected health improvements. We propose a six-step coverage framework, starting from a target population to (1) service contact, (2) likelihood of services, (3) crude coverage, (4) quality-adjusted coverage, (5) user-adherence-adjusted coverage and (6) outcome-adjusted coverage. We support our framework with a comprehensive review of published literature on effective coverage for RMNCH+N interventions since 2000. We screened 8103 articles and selected 36 from which we summarised current methods for measuring effective coverage and computed the gaps between ‘crude’ coverage measures and quality-adjusted measures. Our review showed considerable variability in data sources, indicator definitions and analytical approaches for effective coverage measurement. Large gaps between crude coverage and quality-adjusted coverage levels were evident, ranging from an average of 10 to 38 percentage points across the RMNCH+N interventions assessed. We define effective coverage as the proportion of individuals experiencing health gains from a service among those who need the service, and distinguish this from other indicators along a coverage cascade that make quality adjustments. We propose a systematic approach for analysis along six steps in the cascade. Research to date shows substantial drops in effective delivery of care across these steps, but variation in methods limits comparability of the results. Advancement in coverage measurement will require standardisation of effective coverage terminology and improvements in data collection and methodological approaches.

Saving Mothers, Giving Life: It Takes a System to Save a Mother (Republication)

A multi-partner effort in Uganda and Zambia employed a districtwide health systems strengthening approach, with supply- and demand-side interventions, to address timely use of appropriate, quality maternity care. Between 2012 and 2016, maternal mortality declined by approximately 40% in both partnership-supported facilities and districts in each country. This experience has useful lessons for other low-resource settings.

Background:

Ending preventable maternal and newborn deaths remains a global health imperative under United Nations Sustainable Development Goal targets 3.1 and 3.2. Saving Mothers, Giving Life (SMGL) was designed in 2011 within the Global Health Initiative as a public–private partnership between the U.S. government, Merck for Mothers, Every Mother Counts, the American College of Obstetricians and Gynecologists, the government of Norway, and Project C.U.R.E. SMGL's initial aim was to dramatically reduce maternal mortality in low-resource, high-burden sub-Saharan African countries. SMGL used a district health systems strengthening approach combining both supply- and demand-side interventions to address the 3 key delays to accessing effective maternity care in a timely manner: delays in seeking, reaching, and receiving quality obstetric services.

Implementation:

The SMGL approach was piloted from June 2012 to December 2013 in 8 rural districts (4 each) in Uganda and Zambia with high levels of maternal deaths. Over the next 4 years, SMGL expanded to a total of 13 districts in Uganda and 18 in Zambia. SMGL built on existing host government and private maternal and child health platforms, and was aligned with and guided by Ugandan and Zambian maternal and newborn health policies and programs. A 35% reduction in the maternal mortality ratio (MMR) was achieved in SMGL-designated facilities in both countries during the first 12 months of implementation.

Results:

Maternal health outcomes achieved after 5 years of implementation in the SMGL-designated pilot districts were substantial: a 44% reduction in both facility and districtwide MMR in Uganda, and a 38% decrease in facility and a 41% decline in districtwide MMR in Zambia. Facility deliveries increased by 47% (from 46% to 67%) in Uganda and by 44% (from 62% to 90%) in Zambia. Cesarean delivery rates also increased: by 71% in Uganda (from 5.3% to 9.0%) and by 79% in Zambia (from 2.7% to 4.8%). The average annual rate of reduction for maternal deaths in the SMGL-supported districts exceeded that found countrywide: 11.5% versus 3.5% in Uganda and 10.5% versus 2.8% in Zambia. The changes in stillbirth rates were significant (−13% in Uganda and −36% in Zambia) but those for pre-discharge neonatal mortality rates were not significant in either Uganda or Zambia.

Conclusion:

A district health systems strengthening approach to addressing the 3 delays to accessing timely, appropriate, high-quality care for pregnant women can save women's lives from preventable causes and reduce stillbirths. The approach appears not to significantly impact pre-discharge neonatal mortality.

Saving Mothers, Giving Life: It Takes a System to Save a Mother

BACKGROUND

Ending preventable maternal and newborn deaths remains a global health imperative under United Nations Sustainable Development Goal targets 3.1 and 3.2. Saving Mothers, Giving Life (SMGL) was designed in 2011 within the Global Health Initiative as a public-private partnership between the U.S. government, Merck for Mothers, Every Mother Counts, the American College of Obstetricians and Gynecologists, the government of Norway, and Project C.U.R.E. SMGL's initial aim was to dramatically reduce maternal mortality in low-resource, high-burden sub-Saharan African countries. SMGL used a district health systems strengthening approach combining both supply- and demand-side interventions to address the 3 key delays to accessing effective maternity care in a timely manner: delays in seeking, reaching, and receiving quality obstetric services.

IMPLEMENTATION

The SMGL approach was piloted from June 2012 to December 2013 in 8 rural districts (4 each) in Uganda and Zambia with high levels of maternal deaths. Over the next 4 years, SMGL expanded to a total of 13 districts in Uganda and 18 in Zambia. SMGL built on existing host government and private maternal and child health platforms, and was aligned with and guided by Ugandan and Zambian maternal and newborn health policies and programs. A 35% reduction in the maternal mortality ratio (MMR) was achieved in SMGL-designated facilities in both countries during the first 12 months of implementation.

RESULTS

Maternal health outcomes achieved after 5 years of implementation in the SMGL-designated pilot districts were substantial: a 44% reduction in both facility and districtwide MMR in Uganda, and a 38% decrease in facility and a 41% decline in districtwide MMR in Zambia. Facility deliveries increased by 47% (from 46% to 67%) in Uganda and by 44% (from 62% to 90%) in Zambia. Cesarean delivery rates also increased: by 71% in Uganda (from 5.3% to 9.0%) and by 79% in Zambia (from 2.7% to 4.8%). The average annual rate of reduction for maternal deaths in the SMGL-supported districts exceeded that found countrywide: 11.5% versus 3.5% in Uganda and 10.5% versus 2.8% in Zambia. The changes in stillbirth rates were significant (-13% in Uganda and -36% in Zambia) but those for pre-discharge neonatal mortality rates were not significant in either Uganda or Zambia.

CONCLUSION

A district health systems strengthening approach to addressing the 3 delays to accessing timely, appropriate, high-quality care for pregnant women can save women's lives from preventable causes and reduce stillbirths. The approach appears not to significantly impact pre-discharge neonatal mortality.

Maternal postnatal care in Bangladesh: a closer look at specific content and coverage by different types of providers

Background

The first 48 hours after birth is a critical window of time for the survival for both mothers and their newborns. Timely and adequate postnatal care (PNC) is being promoted as a strategy to reduce both maternal and newborn mortality. Whether or not a woman has received a postnatal check within 48 hours has been well studied, however, specific content and type of provider are also important for understanding the quality of the check. The objective of this paper is to understand who receives specific PNC interventions by type of provider in Bangladesh.

Methods

Data from the 2014 Bangladesh Demographic and Health Survey (DHS) were used to study receipt of specific PNC interventions - breast exam, vaginal discharge exam, temperature check and counseling on danger signs - within 2 days of birth. Descriptive bivariate analyses and regression analyses using generalized estimating equations (GEE) were used to understand if receipt of an intervention differed by socio-economic and health-related factors. A key factor studied was the type of provider of the PNC.

Results

The proportion of women receiving specific interventions during maternal PNC was mostly low (41.81% for breast exam, 39.72% for vaginal discharge, 82.22% for temperature check, 55.56% for counseling on danger signs and 16.95% for all four interventions). Findings from the regression analyses indicated that compared to having postnatal contact with formal providers (doctors, nurses, midwives and paramedics), having postnatal contact with village doctors was significantly associated with lower probabilities of receiving a breast exam, vaginal discharge exam and receiving all four interventions. PNC provided by NGO workers and other community attendants was significantly associated with a lower probability of receiving a vaginal discharge exam but a higher probability of receiving counseling on danger signs.

Conclusions

During PNC, women were much more likely to receive a temperature check than counseling on danger signs, breast exams or vaginal discharge exams. Very few women received all four interventions. In the situation where Bangladesh is experiencing a shortage of high-level providers, training more types of providers, particularly informal village doctors, may be an important strategy for improving the quality of PNC.

NON-RADIOLOGICAL IMPACT OF A NUCLEAR EMERGENCY: PREPAREDNESS AND RESPONSE WITH THE FOCUS ON HEALTH

Available experience from Chernobyl and Fukushima clearly demonstrate that nuclear emergencies may result in low and very low exposure levels, at which psychological and social effects among the affected population will dominate over the actual biological effects of ionising radiation. International protection standards and guidelines request, that both radiological and non-radiological health consequences have to be considered in preparedness and response to an actual emergency and there is a need to broaden the radiation protection system's philosophy beyond the metrics of radioactivity and radiation dose. During the past decade a number of multidisciplinary projects were set up with the aim of evaluating management options according to social, economic and ethical criteria, in addition to technical feasibility to achieve this goal. WHO and partners from the Inter-Agency Standing Committee Task Force on Mental Health and Psychosocial Support in Emergency Settings have developed a comprehensive framework and guidelines, which can be applied to any type of an emergency or disaster regardless of its origin. There is a need to include the available scientific expertise and the technical, managerial and personal resources to be considered within a similar 'decision framework' that will apply to radiation emergencies. Key areas of the required expertise needed to develop such a framework are radiation protection, medical support (especially primary care and emergency medicine, mental health support), social sciences (anthropology, psychology, ethics) and communications experts. The implementation of such a multidisciplinary concept in the operational world requires education and training well beyond the level currently available.

Stress and Exposure Time on von Willebrand Factor Degradation

Despite the prevailing use of the continuous flow left ventricular assist devices (cf-LVAD), acquired von Willebrand syndrome (AvWS) associated with cf-LVAD still remains a major complication. As AvWS is known to be dependent on shear stress (τ) and exposure time (t_exp ), this study examined the degradation of high molecular weight multimers (HMWM) of von Willebrand factor (vWF) in terms of τ and t_exp . Two custom apparatus, i.e., capillary-tubing-type degrader (CTD) and Taylor-Couette-type degrader (TCD) were developed for short-term (0.033 sec ≤ t_exp  ≤ 1.05 s) and long-term (10 s ≤ t_exp  ≤ 10 min) shear exposures of vWF, respectively. Flow conditions indexed by Reynolds number (Re) for CTD were 14 ≤ Re ≤ 288 with corresponding laminar stress level of 52 ≤  τ CTD  ≤ 1042 dyne/cm² . Flow conditions for TCD were 100 ≤ Re ≤ 2500 with corresponding rotor speed of 180 ≤ _o  ≤ 4000 RPM and laminar stress level of 50 ≤  τ TCD  ≤ 1114 dyne/cm² . Due to transitional and turbulent flows in TCD at Re > 1117, total stress (i.e., τ total  = laminar + turbulent) was also calculated using a computational fluid dynamics (CFD) solver, Converge CFD (Converge Science Inc., Madison, WI, USA). Inhibition of ADAMTS13 with different concentration of EDTA (5 mM and 10 mM) was also performed to investigate the mechanism of cleavage in terms of mechanical and enzymatic aspects. Degradation of HMWM with CTD was negligible at all given testing conditions. Although no degradation of HMWM was observed with TCD at Re < 1117 ( τ total  = 1012 dyne/cm² ), increase in degradation of HMWM was observed beyond Re of 1117 for all given exposure times. At Re ~ 2500 ( τ total  = 3070 dyne/cm² ) with t_exp  = 60 s, a severe degradation of HMWM (90.7 ± 3.8%, abnormal) was observed, and almost complete degradation of HMWM (96.1 ± 1.9%, abnormal) was observed with t_exp  = 600 s. The inhibition studies with 5 mM EDTA at Re ~ 2500 showed that loss of HMWM was negligible (<10%, normal) for all given exposure times except for t_exp  = 10 min (39.5 ± 22.3%, borderline-abnormal). With 10 mM EDTA, no degradation of HMWM was observed (11.1 ± 4.4%, normal) even for t_exp  = 10 min. This study investigated the effect of shear stress and exposure time on the HMWM of vWF in laminar and turbulent flows. The inhibition study by EDTA confirms that degradation of HMWM is initiated by shear-induced unfolding followed by enzymatic cleavage at given conditions. Determination of magnitude of each mechanism needs further investigation. It is also important to note that the degradation of vWF is highly dependent on turbulence regardless of the time exposed within our testing conditions.