Analyzing Subnational Immunization Coverage to Catch up and Reach the Unreached in Seven High-Priority Countries in the Eastern Mediterranean Region, 2019-2021

Yearly national immunization coverage reporting does not measure performance at the subnational level throughout the year and conceals inequalities within countries. We analyzed subnational immunization coverage from seven high-priority countries in our region. We analyzed subnational, monthly immunization data from seven high-priority countries. Five were Gavi eligible (i.e., Afghanistan, Pakistan, Somalia, Syria, and Yemen); these are countries that according to their low income are eligible for support from the Global Alliance on Vaccine and Immunization, while Iraq and Jordan were included because of a recent decrease in immunization coverage and contribution to the regional number of under and unimmunized children. DTP3 coverage, which is considered as the main indicator for the routine immunization coverage as the essential component of the immunization program performance, varied monthly in 2019-2021 before reaching pre-pandemic coverage in the last two months of 2021. Somalia and Yemen had a net gain in DTP3 coverage at the end of 2021, as improvement in 2021 exceeded the regression in 2020. In Pakistan and Iraq, DTP3 improvement in 2021 equaled the 2020 regression. In Afghanistan, Syria and Jordan, the regression in DTP3 coverage continued in 2020 and 2021. The number of districts with at least 6000 zero-dose children improved moderately in Afghanistan and substantially in Somalia throughout the follow-up period. In Pakistan, the geographical distribution differed between 2020 and 2021.Of the three countries with the highest number of zero-dose children, DTP1 coverage reached 109% in Q4 of 2020 after a sharp drop to 69% in Q2 of 2020. However, in Pakistan, the number of zero-dose children decreased to 1/10 of its burden in Q4 of 2021. In Afghanistan, the number of zero-dose children more than a doubled. Among the even countries, adaptation of immunization service to the pandemic varied, depending on the agility of the health system and the performance of the components of the expanded program on immunization. We recommended monitoring administrative monthly immunization coverage data at the subnational level to detect low-performing districts, plan catchup, identify bottlenecks towards reaching unvaccinated children and customize strategies to improve the coverage in districts with zero-dose children throughout the year and monitor progress.

Rotavirus genotypes in children under five years hospitalized with diarrhea in low and middle-income countries: Results from the WHO-coordinated Global Rotavirus Surveillance Network

Rotavirus is the most common pathogen causing pediatric diarrhea and an important cause of morbidity and mortality in low- and middle-income countries. Previous evidence suggests that the introduction of rotavirus vaccines in national immunization schedules resulted in dramatic declines in disease burden but may also be changing the rotavirus genetic landscape and driving the emergence of new genotypes. We report genotype data of more than 16,000 rotavirus isolates from 40 countries participating in the Global Rotavirus Surveillance Network. Data from a convenience sample of children under five years of age hospitalized with acute watery diarrhea who tested positive for rotavirus were included. Country results were weighted by their estimated rotavirus disease burden to estimate regional genotype distributions. Globally, the most frequent genotypes identified after weighting were G1P[8] (31%), G1P[6] (8%) and G3P[8] (8%). Genotypes varied across WHO Regions and between countries that had and had not introduced rotavirus vaccine. G1P[8] was less frequent among African (36 vs 20%) and European (33 vs 8%) countries that had introduced rotavirus vaccines as compared to countries that had not introduced. Our results describe differences in the distribution of the most common rotavirus genotypes in children with diarrhea in low- and middle-income countries. G1P[8] was less frequent in countries that had introduced the rotavirus vaccine while different strains are emerging or re-emerging in different regions.

Capacity-building for conducting COVID-19 vaccine effectiveness studies to enhance evidence-informed vaccination policymaking in the Eastern Mediterranean Region

BACKGROUND

Vaccine effectiveness studies provide evidence on the effects of vaccines for preventing disease and the adverse outcomes following a vaccination rollout programme in a country or a specific population.

AIMS

To document the technical and capacity-building support provided by WHO to countries in the Eastern Mediterranean Region to conduct COVID-19 vaccine effectiveness studies.

METHODS

WHO implemented interventions to enhance the capacity of EMR countries to conduct COVID-19 vaccine effectiveness and similar epidemiological studies. The intervention consisted of several components, including methodological and technical support as well as data and project management at national and regional levels. Two WHO generic protocols were adopted: cohort study among healthcare workers and test-negative design in severe acute respiratory infections surveillance sites.

RESULTS

Egypt, Islamic Republic of Iran, Jordan, and Pakistan participated in the programme. The research protocols were adjusted to country context and settings. WHO provided technical, financial and infrastructure support, including the establishment of quality assessment approaches, study conduct, data management, report development, statistical data analysis, and experience-sharing between the countries. Technical capacity-building was also offered to other countries not involved in the vaccine effectiveness studies.

CONCLUSION

COVID-19 pandemic provided an opportunity to enhance the research capacities of EMR countries for the conduct of vaccine effectiveness studies. The WHO consolidated efforts and its collaboration with countries resulted in enhancement of capacity and research infrastructure, especially in the 4 countries that were supported by this programme. The capacities acquired through the programme would be very useful for other vaccine-preventable communicable diseases, thus better informing national immunization programmes and policies in EMR countries.

Risk Factors for Mortality Among Children Younger Than Age 5 Years With Severe Diarrhea in Low- and Middle-income Countries: Findings From the World Health Organization-coordinated Global Rotavirus and Pediatric Diarrhea Surveillance Networks

BACKGROUND

Diarrhea is the second leading cause of death in children younger than 5 years of age globally. The burden of diarrheal mortality is concentrated in low-resource settings. Little is known about the risk factors for childhood death from diarrheal disease in low- and middle-income countries.

METHODS

Data from the World Health Organization (WHO)-coordinated Global Rotavirus and Pediatric Diarrhea Surveillance Networks, which are composed of active, sentinel, hospital-based surveillance sites, were analyzed to assess mortality in children <5 years of age who were hospitalized with diarrhea between 2008 and 2018. Case fatality risks were calculated, and multivariable logistic regression was performed to identify risk factors for mortality.

RESULTS

This analysis comprises 234 781 cases, including 1219 deaths, across 57 countries. The overall case fatality risk was found to be 0.5%. Risk factors for death in the multivariable analysis included younger age (for <6 months compared with older ages, odds ratio [OR] = 3.54; 95% confidence interval [CI], 2.81-4.50), female sex (OR = 1.18; 95% CI, 1.06-1.81), presenting with persistent diarrhea (OR = 1.91; 95% CI, 1.01-3.25), no vomiting (OR = 1.13; 95% CI, .98-1.30), severe dehydration (OR = 3.79; 95% CI, 3.01-4.83), and being negative for rotavirus on an enzyme-linked immunosorbent assay test (OR = 2.29; 95% CI, 1.92-2.74). Cases from the African Region had the highest odds of death compared with other WHO regions (OR = 130.62 comparing the African Region with the European Region; 95% CI, 55.72-422.73), whereas cases from the European Region had the lowest odds of death.

CONCLUSIONS

Our findings support known risk factors for childhood diarrheal mortality and highlight the need for interventions to address dehydration and rotavirus-negative diarrheal infections.

Inequities in the deployment of COVID-19 vaccine in the WHO Eastern Mediterranean Region, 2020-2021

The WHO Eastern Mediterranean Region (EMR) is characterised by a large range in routine immunisation coverage. We reviewed progress in access, deployment efforts, and use of COVID-19 vaccines in the EMR to identify bottlenecks and propose recommendations. We compiled and analysed data reported to WHO regarding the number of vaccines provided emergency use authorisation (EUA) in each country, the number of vaccine doses allocated and delivered by COVAX, the number of vaccine doses received bilaterally, the date of initiation of vaccination, vaccine usage rate and overall vaccination coverage. In June-July and October-November 2021, we conducted two rounds of a regional survey to assess vaccine acceptance and calculated the weighted proportion of individuals who would get vaccinated once a vaccine is available and recommended. We stratified the analysis according to four groups based on their participation status in COVAX, from the highest to lowest income, that is, (1) fully self-financing high-income countries (group 1), (2) fully self-financing upper middle-income countries (group 2), (3) Advance Market Commitment (AMC) countries not eligible to receive Gavi support (group 3) and (4) AMC countries eligible for Gavi support (group 4). As of 31 December 2021, the median number of vaccines provided with EUA was 6 for group 1, 11 for group 2, 8 for group 3 and 9 for group 4. On the same date, COVAX had delivered 179 793 310 doses to EMR countries. Vaccination started on 10 December 2020 in group 1, on 13 December 2020 in group 2, on 30 December 2020 in group 3 and on 20 January 2021 in group 4. The regional acceptance survey (first round) pointed to higher vaccine acceptance in group 1 (96%), than in others, including group 2 (73.9%), group 3 (78.8%) and group 4 (79.3%), with identical patterns in the second round (98%, 78%, 84% and 76%), respectively. Usage of vaccine allocated by COVAX to participating countries was 89% in group 1, 75% in group 2, 78% in group 3 and 42% in group 4. The full dose and partial dose coverage decreased with the income groups of countries, from 70% and 6% in group 1, to 43% and 8% in group 2, to 33% and 11% in group 3, and 20% and 8% in group 4. All 22 EMR countries introduced COVID-19 vaccines by 21 April 2021, but with major inequities in coverage. Additional efforts are needed to address the determinants of unequal vaccine coverage at all stages of the result chain to improve vaccine equity.

WHO's support for COVID-19 research and knowledge management in the Eastern Mediterranean Region

Health research, innovation and knowledge management remain major priorities of the WHO’s response to the COVID-19 pandemic. WHO’s Eastern Mediterranean Regional Office (EMRO) supports priority research initiatives that address gaps in current knowledge regarding the COVID-19 pandemic. Through a specific call for proposals, 122 research proposals were received and reviewed in 2020, of which 17 were recommended for funding from eight countries. Ten countries in the region participated in the global solidarity trial to assess potential therapies for COVID-19. In addition, WHO advocated for early serological and epidemiological investigations (‘COVID-19 Unity Studies’) on the general population, healthcare workers, pregnant women and neonates, and extending technical, financial and material support for them.

Starting in early 2020, scholarly articles on COVID-19 have been published in every issue of the Eastern Mediterranean Health Journal. More than 6300 publications on COVID-19 were made available on the WHO knowledge management portal in the last year alone. WHO is also supporting countries in conducting studies to assess the field effectiveness of vaccines deployed nationally. To build and strengthen country capacities, regional webinars and intercountry meetings were conducted on research ethics, national health information systems and evidence-based health policy making. With support from WHO EMRO’s new research and knowledge management pillar, countries in the region were well equipped to contribute to a global understanding of the novel virus’s characteristics, as well as employ a national response based on informed evidence.

The Global Landscape of Pediatric Bacterial Meningitis Data Reported to the World Health Organization-Coordinated Invasive Bacterial Vaccine-Preventable Disease Surveillance Network, 2014-2019

BACKGROUND

The World Health Organization (WHO) coordinates the Global Invasive Bacterial Vaccine-Preventable Diseases (IB-VPD) Surveillance Network to support vaccine introduction decisions and use. The network was established to strengthen surveillance and laboratory confirmation of meningitis caused by Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis.

METHODS

Sentinel hospitals report cases of children <5 years of age hospitalized for suspected meningitis. Laboratories report confirmatory testing results and strain characterization tested by polymerase chain reaction. In 2019, the network included 123 laboratories that follow validated, standardized testing and reporting strategies.

RESULTS

From 2014 through 2019, >137 000 suspected meningitis cases were reported by 58 participating countries, with 44.6% (n = 61 386) reported from countries in the WHO African Region. More than half (56.6%, n = 77 873) were among children <1 year of age, and 4.0% (n = 4010) died among those with reported disease outcome. Among suspected meningitis cases, 8.6% (n = 11 798) were classified as probable bacterial meningitis. One of 3 bacterial pathogens was identified in 30.3% (n = 3576) of these cases, namely S. pneumoniae (n = 2177 [60.9%]), H. influenzae (n = 633 [17.7%]), and N. meningitidis (n = 766 [21.4%]). Among confirmed bacterial meningitis cases with outcome reported, 11.0% died; case fatality ratio varied by pathogen (S. pneumoniae, 12.2%; H. influenzae, 6.1%; N. meningitidis, 11.0%). Among the 277 children who died with confirmed bacterial meningitis, 189 (68.2%) had confirmed S. pneumoniae. The proportion of pneumococcal cases with pneumococcal conjugate vaccine (PCV) serotypes decreased as the number of countries implementing PCV increased, from 77.8% (n = 273) to 47.5% (n = 248). Of 397 H. influenzae specimens serotyped, 49.1% (n = 195) were type b. Predominant N. meningitidis serogroups varied by region.

CONCLUSIONS

This multitier, global surveillance network has supported countries in detecting and serotyping the 3 principal invasive bacterial pathogens that cause pediatric meningitis. Streptococcus pneumoniae was the most common bacterial pathogen detected globally despite the growing number of countries that have nationally introduced PCV. The large proportions of deaths due to S. pneumoniae reflect the high proportion of meningitis cases caused by this pathogen. This global network demonstrated a strong correlation between PCV introduction status and reduction in the proportion of pneumococcal meningitis infections caused by vaccine serotypes. Maintaining case-based, active surveillance with laboratory confirmation for prioritized vaccine-preventable diseases remains a critical component of the global agenda in public health.The World Health Organization (WHO)-coordinated Invasive Bacterial Vaccine-Preventable Disease (IB-VPD) Surveillance Network reported data from 2014 to 2019, contributing to the estimates of the disease burden and serotypes of pediatric meningitis caused by Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis.

Evaluation of post-introduction COVID-19 vaccine effectiveness: Summary of interim guidance of the World Health Organization

Phase 3 randomized-controlled trials have provided promising results of COVID-19 vaccine efficacy, ranging from 50 to 95% against symptomatic disease as the primary endpoints, resulting in emergency use authorization/listing for several vaccines. However, given the short duration of follow-up during the clinical trials, strict eligibility criteria, emerging variants of concern, and the changing epidemiology of the pandemic, many questions still remain unanswered regarding vaccine performance. Post-introduction vaccine effectiveness evaluations can help us to understand the vaccine's effect on reducing infection and disease when used in real-world conditions. They can also address important questions that were either not studied or were incompletely studied in the trials and that will inform evolving vaccine policy, including assessment of the duration of effectiveness; effectiveness in key subpopulations, such as the very old or immunocompromised; against severe disease and death due to COVID-19; against emerging SARS-CoV-2 variants of concern; and with different vaccination schedules, such as number of doses and varying dosing intervals. WHO convened an expert panel to develop interim best practice guidance for COVID-19 vaccine effectiveness evaluations. We present a summary of the interim guidance, including discussion of different study designs, priority outcomes to evaluate, potential biases, existing surveillance platforms that can be used, and recommendations for reporting results.

Out Come of Wide Local Excision with and without Corticosteroid Therapy in Management of Idiopathic Granulomatous Mastitis

Introduction:

Idiopathic granulomatous mastitis is a rare benign breast disease. Initial reports from hospitals in Egypt from Departments of Pathology at Cancer Institutes of Cairo, Tanta and Mansoura Universities; indicate that the disease is not as rare as that in the developed countries. It often mimics breast carcinoma both clinically and radiologically. Histological examination is the gold standard for diagnosis. Management of Idiopathic granulomatous mastitis is still debatable. In our study, we aimed to evaluate the addition of corticosteroid therapy to surgical excision in management of idiopathic granulomatous mastitis.

Patients and Methods:

This is a comparative study was conducted at Ain-Shams University Hospital’s breast clinic on patients with idiopathic granulomatous mastitis from to August 2015 till September 2018. Thirty patients were divided into 2 groups. Group (A) includes patients who underwent surgical management only. Group (B) includes patients who received corticosteroid therapy according to the severity of the cases then surgical Excision was done for the residual lesion. Follow up of all cases up to 1-2 years was done to document the recurrence rate and compare the cosmetic outcome of both groups. Informed consent was obtained from all patients included in the study.

Results:

The mean age of the affected women was 38.80 and 33.13 in group (A) and group (B), respectively and it wasn’t statistically different (p value = 0.099). The most common presenting symptom was a palpable mass in the breast (66.7% and 93.3%) in group (A) and group (B) respectively. Recurrence rate was higher in group (A) (40%) with no recurrence documented in group (B) however 2 cases were omitted from the study due to steroid noncompliance and complications. Cosmetic outcome was excellent in 76.9% of group (B) and good in 53.3% of group (A).

Conclusion:

Systemic steroid therapy with surgical resection is the recommended as first-line treatment strategy for IGM as it shows less recurrence rate and surgical scarring. Increased awareness of IGM will increase their understanding and improve their management.

Global impact of rotavirus vaccine introduction on rotavirus hospitalisations among children under 5 years of age, 2008-16: findings from the Global Rotavirus Surveillance Network

Summary

Background

Rotavirus vaccine use in national immunisation programmes has led to declines in hospital admissions for rotavirus gastroenteritis among children; however, the global impact of rotavirus vaccine introduction has not been described using primary data. We describe the impact of rotavirus vaccine introduction on admissions for acute rotavirus gastroenteritis in primarily low-income and middle-income countries, using 9 years of data from the WHO-coordinated Global Rotavirus Surveillance Network (GRSN).

Methods

Between Jan 1, 2008, and Dec 31, 2016, children younger than 5 years of age who were admitted to hospital with acute gastroenteritis were prospectively enrolled in GRSN sites. We included sites that enrolled children and collected stool specimens monthly and tested at least 100 specimens annually in the impact analysis, with a separate analysis taking into account site continuity. We compared proportions of acute gastroenteritis cases positive for rotavirus in the pre-vaccine and post-vaccine periods and calculated mean proportion changes for WHO regions, with 95% CIs; these findings were then compared with interrupted time series analyses. We did further sensitivity analyses to account for rotavirus vaccination coverage levels and sites that collected specimens for at least 11 months per year and tested at least 80 specimens per year. We also analysed the age distribution of rotavirus-positive cases before and after vaccine introduction.

Findings

403 140 children younger than 5 years of age admitted to hospital with acute gastroenteritis from 349 sites in 82 countries were enrolled over the study period, of whom 132 736 (32.9%) were positive for rotavirus. We included 305 789 children from 198 sites in 69 countries in the impact analysis. In countries that had not introduced rotavirus vaccine in their national immunisation programmes, rotavirus was detected in 38.0% (95% CI 4.8–73.4) of admissions for acute gastroenteritis annually whereas in those that have introduced the vaccine, rotavirus was detected in 23.0% (0.7–57.7) of admissions for acute gastroenteritis, showing a 39.6% (35.4–43.8) relative decline following introduction. Interrupted time series analyses confirmed these findings. Reductions by WHO regions ranged from 26.4% (15.0–37.8) in the Eastern Mediterranean Region to 55.2% (43.0–67.4) in the European Region and were sustained in nine countries (contributing up to 31 sites) for 6–10 years. The age distribution of children with rotavirus gastroenteritis shifted towards older children after rotavirus vaccine introduction.

Interpretation

A significant and sustained reduction in the proportion of hospital admissions for acute gastroenteritis due to rotavirus was seen among children younger than 5 years in GRSN sites following rotavirus vaccine introduction. These findings highlight the need to incorporate rotavirus vaccines into immunisation programmes in countries that have not yet introduced them and underline the importance of high-quality surveillance.

Anterior Intercostal Artery Perforator Flap as a Simple Technique for Partial Breast Reconstruction: Our Institutional Initial Experience

Background:

The oncoplastic surgery has brought new dimensions to breast conserving surgery and added the aesthetic principles of breast surgery to breast cancer management. Recently there's a lot of volume replacement techniques without significant donor site morbidity .The anterior intercostal artery perforator (AICAP) flap is a suitable option in partial breast reconstruction for lower pole tumors in small and medium sized breasts.

Objectives:

The aim of this study is to report our clinical experience with anterior intercostal perforator flap in partial breast reconstruction

Methodology:

25 cases were performed between April 2018 to June 2019 at in Ain shams university hospitals for selected patients with lower breast pole tumors with small and medium sized breast and other option like reduction mMDTmoplasty wasn't favorable for them.

Results:

A total of 25 patient were selected by the multidisplinary team at Ain shams university hospital for partial breast reconstruction with anterior intercostal artery perforator flap . The mean age of the cases was 45.68 with mean body mass index of 32.32. The mean operative time for the flap was 64 minutes while the hospital stay was ranging from 1-2 days .Follow-up for local recurrence was from 6 to 14 months. There was 1 case with wound complication (4%). The cosmetic outcome was assessed by the MDT and a giving score from 1-5 was used with 1 is the least favorable cosmetic outcome and 5 is the best result 76% of the cases scored 5, 14% scored 4, 8% scored 3. According to patient satisfaction a score from 1 to 5 was used with the score 1 is least satisfied and score 5 represents the most satisfaction level, there was 80% of the patient gave the score 5, 12% of the cases gave the score 4 and 8% of the cases gave the score 3

Conclusions:

Based on our experience, partial breast reconstruction using AICAP flap is a reliable option for lower breast tumors in small-to-moderate breast size with perfect cosmetic outcome and negligible rate of complication.

Home-based records' quality and validity of caregivers' recall of children's vaccination in Lebanon

INTRODUCTION

Home-based records (HBRs) (also known as vaccination cards) and caregivers' recall are the main means to ascertain vaccination status; however, data on the quality of HBRs and the validity of recall vaccination data compared to HBRs is scarce. This manuscript presents results from two analyses related to HBRs, one on HBR pictures taken during a vaccination coverage survey, including an assessment of the HBR quality and legibility, and an evaluation of the agreement between caregivers' recall and the vaccination information in the HBRs.

METHODS

Using pictures from 500 randomly selected HBRs collected during the 2016 district-based immunization coverage evaluation survey in Lebanon, two independent researchers assessed the quality of the picture and then of the HBR itself against a pre-defined set of criteria. HBRs were classified into three types: private, public and all others. In addition, caregivers' recall was compared to data found in vaccination HBRs to assess measures of vaccination status agreement for 5713 children for whom both sources of data were available.

RESULTS

Over 90% of the 500 HBR pictures reviewed were considered adequate to assess the HBR quality. In the sample, most cards were type 1 (41%), followed by type 2 (34%). Most HBRs met the set criteria for quality in terms of physical condition and legibility, while, among the 28 different types of cards, vaccination cards' content and design met a moderate level of quality. Concordance, sensitivity, specificity, positive and negative predictive values, and the Kappa statistic showed diverse levels of agreement for vaccination status per vaccine dose between caregivers' recall and vaccination HBRs.

CONCLUSION

This study illustrates that taking pictures of HBRs in a coverage survey is feasible and useful to conduct secondary analyses related to HBRs, such as assessing their quality and comparing recall with HBRs when both sources of data are available.

Vaccination coverage in Lebanon following the Syrian crisis: results from the district-based immunization coverage evaluation survey 2016

Background

Following the Syrian crisis, a substantial influx of Syrian refugees into Lebanon posed new challenges to optimal vaccination coverage for all children residing in the country. In 2016, the district-based immunization coverage evaluation survey (CES) assessed routine immunization coverage at the district level in Lebanon among children aged 12–59 months.

Methods

A cross-sectional multistage cluster survey was conducted in all of Lebanon (with the exception of the Nabatieh district) using the World Health Organization (WHO) recommended Expanded Programme on Immunization (EPI) methodology adapted to the local context. A survey questionnaire consisting of closed and open-ended questions concerning demographic information and the child’s immunization status was administered to collect immunization status information.

Results

Among surveyed children aged 12–59 months, irrespective of nationality, vaccination coverage at the national level for any recommended last dose was below the targeted 95%. Generally, vaccination coverage levels increased with age and were higher among Lebanese than Syrian children. However, large variations were revealed when coverage rates were analyzed at the district level. Vaccination was significantly associated with nationality, age, mother’s educational status and the place of vaccination. Common reasons for undervaccination included the child’s illness at the time of vaccine administration, vaccination fees, lack of awareness or a doctor’s advice not to vaccinate during campaigns.

Conclusions

Substantial variability exists in vaccination coverage among children aged 12–59 months residing in different districts in Lebanon. Immunization coverage reached 90% or above only for the first doses of polio and pentavalent vaccines. A considerable dropout rate from the first dose of any vaccine is observed. Efforts to optimize coverage levels should include increased vaccination initiatives targeting both refugee children and children from vulnerable host communities, increased cooperation between public and private vaccine providers, improved training for vaccine providers to adhere to complete vaccine administration recommendations, and increased awareness among caregivers.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6418-9) contains supplementary material, which is available to authorized users.

Factors affecting age-appropriate timeliness of vaccination coverage among children in Lebanon

Background: The effect of immunization does not only depend on its completeness, but also on its timely administration. Routine childhood vaccinations schedules recommend that children receive the vaccine doses at specific ages. This article attempts to assess timeliness of routine vaccination coverage among a sub-sample of children from a survey conducted in 2016. Methods: This analysis was based on data from a cross-sectional multistage cluster survey conducted between December 2015 and June 2016 among caregivers of children aged 12-59 months in all of Lebanon using a structured survey questionnaire. The analysis used Kaplan-Meier curves and logistic regression to identify the predictors of age-appropriate immunization. Results: Among the 493 randomly selected children, timely administration of the third dose of polio vaccine, diphtheria-tetanus-pertussis (DTP)-containing vaccine and hepatitis B (HepB) vaccine occurred in about one-quarter of children. About two-thirds of children received the second dose of a measles-containing vaccine (MCV) within the age interval recommended by the Expanded Programme on Immunization (EPI). Several factors including socio-demographic, knowledge, beliefs and practices were found to be associated with age-appropriate vaccination; however, this association differed between the types and doses of vaccine. Important factors associated with timely vaccination included being Lebanese as opposed to Syrian and being born in a hospital for hepatitis B birth dose; believing that vaccination status was up-to-date was related to untimely vaccination. Conclusions: The results suggest that there is reason for concern over the timeliness of vaccination in Lebanon. Special efforts need to be directed towards the inclusion of timeliness of vaccination as another indicator of the performance of the EPI in Lebanon.

Introduction of Inactivated Polio Vaccine, Withdrawal of Type 2 Oral Polio Vaccine, and Routine Immunization Strengthening in the Eastern Mediterranean Region

The Global Polio Eradication Initiative has reduced the global incidence of polio by 99% and the number of countries with endemic polio from 125 to 3 countries. The Polio Eradication and Endgame Strategic Plan 2013–2018 (Endgame Plan) was developed to end polio disease. Key elements of the endgame plan include strengthening immunization systems using polio assets, introducing inactivated polio vaccine (IPV), and replacing trivalent oral polio vaccine with bivalent oral polio vaccine (“the switch”). Although coverage in the Eastern Mediterranean Region (EMR) with the third dose of a vaccine containing diphtheria, tetanus, and pertussis antigens (DTP3) was ≥90% in 14 countries in 2015, DTP3 coverage in EMR dropped from 86% in 2010 to 80% in 2015 due to civil disorder in multiple countries. To strengthen their immunization systems, Pakistan, Afghanistan, and Somalia developed draft plans to integrate Polio Eradication Initiative assets, staff, structure, and activities with their Expanded Programmes on Immunization, particularly in high-risk districts and regions. Between 2014 and 2016, 11 EMR countries introduced IPV in their routine immunization program, including all of the countries at highest risk for polio transmission (Afghanistan, Pakistan, Somalia, and Yemen). As a result, by the end of 2016 all EMR countries were using IPV except Egypt, where introduction of IPV was delayed by a global shortage. The switch was successfully implemented in EMR due to the motivation, engagement, and cooperation of immunization staff and decision makers across all national levels. Moreover, the switch succeeded because of the ability of even the immunization systems operating under hardship conditions of conflict to absorb the switch activities.

Experiences and Lessons From Polio Eradication Applied to Immunization in 10 Focus Countries of the Polio Endgame Strategic Plan

Nine polio areas of expertise were applied to broader immunization and mother, newborn and child health goals in ten focus countries of the Polio Eradication Endgame Strategic Plan: policy & strategy development, planning, management and oversight (accountability framework), implementation & service delivery, monitoring, communications & community engagement, disease surveillance & data analysis, technical quality & capacity building, and partnerships. Although coverage improvements depend on multiple factors and increased coverage cannot be attributed to the use of polio assets alone, 6 out of the 10 focus countries improved coverage in three doses of diphtheria tetanus pertussis containing vaccine between 2013 and 2015. Government leadership, evidence-based programming, country-driven comprehensive operational annual plans, community partnership and strong accountability systems are critical for all programs and polio eradication has illustrated these can be leveraged to increase immunization coverage and equity and enhance global health security in the focus countries.

Understanding the different physical examination tests for suspected meniscal tears

Meniscal tears are common in sport medicine practice. Many articles and textbooks discuss the relative validity of the different components of the physical examination with respect to their sensitivity, specificity, and positive/negative predictive values as if they were diagnostic tests. In this article, we demonstrate why this approach is limited, including the heterogeneous nature of meniscal tear pathology (e.g., posterior vs anterior). Therefore, in this article, we categorize all the published tests in the literature with regards to the mechanism underlying a positive test. We believe our approach provides the clinician with additional tools to diagnose tears. Future research should explore predictive models based on the different components accounting for heterogeneous pathology and different patient contexts.

Structural investigation of bacteriorhodopsin and some of its photoproducts by polarized Fourier transform infrared spectroscopic methods-difference spectroscopy and photoselection

The direction of selected IR-transition moments of the retinal chromophore of bacteriorhodopsin (BR) and functional active amino acid residues are determined for light- and dark-adapted BR and for the intermediates K and L of the photocycle. Torsions around single bonds of the chromophore are found to be present in all the investigated BR states. The number of twisted single bonds and the magnitude of these torsions decreases in the order K, L, light-adapted BR, dark-adapted BR. In the last, only the C(14)-C(15) single bond is twisted. The orientation of molecular planes and chemical bonds of such protein side chains, which are perturbed during the transition of light-adapted BR to the respective intermediates, are deduced and the results compared with the current three dimensional model of BR. Trp 86 and Trp 185 are found to form a rigid part of the protein, whereas Asp 96 and Asp 115 perform molecular rearrangements upon formation of the L-intermediate.

Metal binding by bacteria from uranium mining waste piles and its technological applications

Uranium mining waste piles, heavily polluted with radionuclides and other toxic metals, are a reservoir for bacteria that have evolved special strategies to survive in these extreme environments. Understanding the mechanisms of bacterial adaptation may enable the development of novel bioremediation strategies and other technological applications. Cell isolates of Bacillus sphaericus JG-A12 from a uranium mining waste pile in Germany are able to accumulate high amounts of toxic metals such as U, Cu, Pb, Al, and Cd as well as precious metals. Some of these metals, i.e. U, Cu, Pd(II), Pt(II) and Au(III), are also bound by the highly orderd paracrystalline proteinaceous surface layer (S-layer) that envelopes the cells of this strain. These special capabilities of the cells and the S-layer proteins of B. sphaericus JG-A12 are highly interesting for the clean-up of uranium contaminated waste waters, for the recovery of precious metals from electronic wastes, and for the production of metal nanoclusters. The fabricated nanoparticles are promising for the development of novel catalysts. This work reviews the molecular biology of the S-layer of the strain JG-A12 and the S-layer dependent interactions of the bacterial cells with metals. It presents future perspectives for their application in bioremediation and nanotechnology.

Properties and Planned Use of the Intense THz Radiation from ELBE at Dresden-Rossendorf

The radiation source ELBE atDresden-Rossendorf is centered around asuperconducting ELectron accelerator ofhigh Brilliance and low Emittance (ELBE) which produces electronbeams up to 40 MeV. This new facility delivers secondary radiation of differentkinds. Special emphasis will be given tothe production of intense THz radiationfrom its Free-Electron Lasers (FEL). This radiation will be usedfor various research activities including the life sciences. Two additionalfemtosecond Ti:sapphire laser systems allowto exploit different methods of THzgeneration for such investigations.

Transducin-dependent protonation of glutamic acid 134 in rhodopsin

A highly conserved carboxylic acid residue in rhodopsin, Glu(134), modulates transducin (G(t)) interaction. It has been postulated that Glu(134) becomes protonated upon receptor activation. We studied the interaction between rhodopsin and G(t) using Fourier transform infrared (FTIR) difference spectroscopy combined with attenuated total reflection (ATR). Formation of the complex between G(t) and photoactivated rhodopsin reconstituted into phosphatidylcholine vesicles caused prominent infrared absorption increases at 1641, 1550, and 1517 cm(-)(1). The rhodopsin mutant E134Q was also studied. When measured in the presence of G(t), replacement of Glu(134) by glutamine abolished the low-frequency part of a broad absorption band at 1735 cm(-)(1) that is normally superimposed on the light-induced absorption changes of Asp(83) and Glu(122) of rhodopsin. In addition, a negative absorption band at 1400 cm(-)(1) that is evoked by interaction of native metarhodopsin II (MII) with G(t) was not observed in the difference spectrum of the E134Q mutant. Thus, Glu(134) is ionized in the dark and exhibits a symmetrical COO(-) stretching vibration at 1400 cm(-)(1). Glu(134) becomes protonated in the G(t)-MII complex and displays a C=O stretching mode near 1730 cm(-)(1). The E134Q mutation also affects absorption changes attributable to lipids, suggesting that the protonation of Glu(134) is linked to transfer of the carboxylic acid side chain from a polar to a nonpolar environment by becoming exposed to the lipid phase when G(t) binds. These results show directly that Glu(134) becomes protonated in MII upon G(t) binding and suggest that changes in receptor conformation affect lipid-protein interactions.

Binding of transducin and transducin-derived peptides to rhodopsin studies by attenuated total reflection-Fourier transform infrared difference spectroscopy

Fourier transform infrared difference spectroscopy combined with the attenuated total reflection technique allows the monitoring of the association of transducin with bovine photoreceptor membranes in the dark. Illumination causes infrared absorption changes linked to formation of the light-activated rhodopsin-transducin complex. In addition to the spectral changes normally associated with meta II formation, prominent absorption increases occur at 1735 cm-1, 1640 cm-1, 1550 cm-1, and 1517 cm-1. The D2O sensitivity of the broad carbonyl stretching band around 1735 cm-1 indicates that a carboxylic acid group becomes protonated upon formation of the activated complex. Reconstitution of rhodopsin into phosphatidylcholine vesicles has little influence on the spectral properties of the rhodopsin-transducin complex, whereas pH affects the intensity of the carbonyl stretching band. AC-terminal peptide comprising amino acids 340-350 of the transducin alpha-subunit reproduces the frequencies and isotope sensitivities of several of the transducin-induced bands between 1500 and 1800 cm-1, whereas an N-terminal peptide (aa 8-23) does not. Therefore, the transducin-induced absorption changes can be ascribed mainly to an interaction between the transducin-alpha C-terminus and rhodopsin. The 1735 cm-1 vibration is also seen in the complex with C-terminal peptides devoid of free carboxylic acid groups, indicating that the corresponding carbonyl group is located on rhodopsin.

Spectroscopic evidence for altered chromophore--protein interactions in low-temperature photoproducts of the visual pigment responsible for congenital night blindness

The replacement of Gly90 by Asp in human rhodopsin causes congenital night blindness. It has been suggested that the molecular origin for the trait is an altered electrostatic environment of the protonated retinal Schiff base chromophore. We have investigated the corresponding recombinant bovine rhodopsin mutant G90D, as well as the related mutants E113A and G90D/E113A, using spectroscopy at low temperature. This allows the assessment of chromophore-protein interactions under conditions where conformational changes are mainly restricted to the retinal-binding site. Each of the mutant pigments formed bathorhodopsin- and isorhodopsin-like intermediates, but the concomitant visible absorption changes reflected differences in the electrostatic environment of the protonated Schiff base in each pigment. Fourier transform infrared-difference spectroscopy revealed effects on the chromophore fingerprint and hydrogen-out-of-plane vibrational modes, which were indicative of the removal of an electrostatic perturbation near C12 of the retinal chromophore in all three mutants. A comparison of the UV-visible and infrared-difference spectra of the mutant pigments strongly suggests that Glu113 is stably protonated in G90D. The corresponding carbonyl-stretching mode is assigned to a band at 1727 cm-1. In contrast to the case in native bathorhodopsin, the all-trans-retinal chromophores in the primary photoproducts of the mutant pigments are essentially relaxed. The peptide carbonyl vibrational changes in mutants G90D and G90D/ E113A suggest that this is due to a more flexible retinal-binding site. Therefore, the steric strain exerted on the chromophore in native bathorhodopsin may be caused by electrostatic forces that specifically involve glutamate 113.

Characterization of the mutant visual pigment responsible for congenital night blindness: a biochemical and Fourier-transform infrared spectroscopy study

A mutation in the gene for the rod photoreceptor molecule rhodopsin causes congenital night blindness. The mutation results in a replacement of Gly90 by an aspartic acid residue. Two molecular mechanisms have been proposed to explain the physiology of affected rod cells. One involves constitutive activity of the G90D mutant opsin [Rao, V. R., Cohen, G. B., & Oprian, D. D. (1994) Nature 367, 639-642]. A second involves increased photoreceptor noise caused by thermal isomerization of the G90D pigment chromophore [Sieving, P. A., Richards, J. E., Naarendorp F., Bingham, E. L., Scott, K., & Alpern, M. (1995) Proc. Natl. Acad. Sci. U.S.A. 92, 880-884]. Based on existing models of rhodopsin and in vitro biochemical studies of site-directed mutants, it appears likely that Gly90 is in the immediate proximity of the Schiff base chromophore linkage. We have studied in detail the mutant pigments G90D and G90D/E113A using biochemical and Fourier-transform infrared (FTIR) spectroscopic methods. The photoproduct of mutant pigment G90D, which absorbs maximally at 468 nm and contains a protonated Schiff base linkage, can activate transducin. However, the active photoproduct decays rapidly to opsin and free all-trans-retinal. FTIR studies of mutant G90D show that the dark state of the pigment has several structural features of metarhodopsin II, the active form of rhodopsin. These include a protonated carboxylic acid group at position Glu113 and increased hydrogen-bond strength of Asp83. Additional results, which relate to the structure of the active G90D photoproduct, are also reported. Taken together, these results may be relevant to understanding the molecular mechanism of congenital night blindness caused by the G90D mutation in human rhodopsin.

Photoactivated state of rhodopsin and how it can form

A variety of spectroscopic and biochemical studies of the photoreceptor rhodopsin have revealed conformation changes which occur upon its photoactivation. Assignment of these molecular alterations to specific regions in the receptor has been attempted by studying native opsin regenerated with synthetic retinal analogs or recombinant opsins regenerated with 11-cis retinal. We propose a model for the photoactivation mechanism which defines 'off' and 'on' states for individual molecular groups. These groups have been identified to undergo structural alterations during photoactivation. Analysis of mutant pigments in which specific groups are locked into their respective 'on' or 'off' states provides a framework to identify determinants of the active conformation as well as the minimal number of intramolecular transitions to switch to this conformation. The simple model proposed for the active-state of rhodopsin can be compared to structural models of its ground-state to localize chromophore-protein interactions that may be important in the photoactivation mechanism.

A mutant rhodopsin photoproduct with a protonated Schiff base displays an active-state conformation: a Fourier-transform infrared spectroscopy study

In the rhodopsin mutant E113A/A117E the position of the protonated Schiff base counterion, Glu113, is moved by one helix turn from position 113 to 117. The photoreaction of this mutant pigment was studied by Fourier-transform infrared (FTIR) difference spectroscopy. At acidic pH, formation of a 474-nm absorbing photoproduct previously characterized biochemically as a species that activates transducin caused infrared absorption changes typical of metarhodopsin II (MII) formation in native rhodopsin. Specific spectral alterations revealed a localized perturbation near the protonated Schiff base in the dark state. In addition, an infrared band assigned to the C = O stretching vibration of Glu113 in MII of rhodopsin was abolished in the mutant. Absorption changes caused by Asp83 and Glu122 C = O stretching vibrations characteristic of rhodopsin MII formation were not affected. At alkaline pH, mutant E113A/A117E formed predominantly a 382-nm absorbing photoproduct. It displayed infrared-difference absorption bands significantly different from those of native MII over a large spectral range. These results support the conclusion that the 474-nm photoproduct of mutant E113A/A117E, despite a protonated Schiff base linkage, displays a predominantly MII-like conformation capable of catalyzing guanine-nucleotide exchange by transducin.

A conserved carboxylic acid group mediates light-dependent proton uptake and signaling by rhodopsin

A carboxylic acid residue is conserved at the cytoplasmic border of the third transmembrane segment among nearly all G protein-coupled receptors. In the visual receptor rhodopsin, replacement of the conserved Glu134 by a neutral glutamine results in enhanced transducin activation. Here we show that a key event in forming the active state of rhodopsin is proton uptake by Glu134 in the metarhodopsin II (MII) photoproduct. Site-directed mutants E134D and E134Q were studied by flash photolysis, where formation rates of their photoproducts and rates of pH change could be monitored simultaneously. Both mutants showed normal MII formation rates. However, E134D displayed a slowed rate of proton uptake and E134Q displayed a loss of light-induced uptake of two protons from the aqueous phase. Thus, Glu134 mediates light-dependent proton uptake by MII. We propose that receptor activation requires a light-induced conformational change that allows protonation of Glu134 and subsequent protonation of a second group. The strong conservation of Glu134 in G protein-coupled receptors implies a general requirement for a proton acceptor group at this position to allow light- or ligand-dependent receptor activation.

Identification of glutamic acid 113 as the Schiff base proton acceptor in the metarhodopsin II photointermediate of rhodopsin

In order to investigate the molecular mechanism of rhodopsin photoactivation, site-directed mutants of bovine rhodopsin were studied by Fourier-transform infrared (FTIR) difference spectroscopy. Rhodopsin mutants E113D and E113A were prepared in which the retinylidene Schiff base counterion, Glu113, was replaced by Asp and Ala, respectively. FTIR difference spectra were recorded and compared with spectra of recombinant native rhodopsin. Both mutant pigments formed photoproducts at 0 degrees C with vibrational absorption bands typical of the metarhodopsin II (MII) state of rhodopsin. The FTIR difference spectrum of E113D was nearly identical to that of rhodopsin. A positive band at 1712 cm-1 caused by the protonation of an internal carboxylic acid in rhodopsin was shifted slightly to 1709 cm-1 in mutant E113D. E113A was studied at acidic pH in the presence of chloride as an inorganic counterion to the protonated Schiff base. The 1712-cm-1 (1709-cm-1) band was absent in the FTIR difference spectrum of mutant E113A. Therefore, we have assigned the 1712-cm-1 absorbance band to the C = O stretching vibration of protonated Glu113 in MII of rhodopsin. These results show that the Schiff base counterion of rhodopsin, the carboxylate side chain of Glu113, becomes protonated during MII formation.

Characterization of rhodopsin-transducin interaction: a mutant rhodopsin photoproduct with a protonated Schiff base activates transducin

Rhodopsin, a G protein-coupled seven-transmembrane helix receptor, contains an 11-cis-retinal chromophore covalently linked to opsin apoprotein by a protonated Schiff base. Photoisomerization of the chromophore followed by Schiff base deprotonation forms metarhodopsin II (MII, lambda max = 380 nm), the active state (R*) that catalyzes guanine nucleotide exchange in transducin, the G protein of the photoreceptor cell. Schiff base deprotonation is required for R* formation. The Schiff base positive charge in rhodopsin is stabilized by a carboxylic acid counterion, Glu113. The position of the carboxylate counterion was moved by one helix turn to position 117 by site-specific mutagenesis. Photolysis of the mutant pigment E113A/A117E (lambda max = 491 nm) resulted in a mixture of two photoproducts: (1) an MII-like form with an unprotonated Schiff base (lambda max = 382 nm) favored at alkaline pH; and (2) a photoproduct with a protonated Schiff base (lambda max = 474 nm), spectroscopically similar to metarhodopsin I, favored at acidic pH. Here, we have studied the interactions between the mutant E113A/A117E photoproducts and transducin in detail. Transducin slowed down thermal conversion of the 474 nm form to the 382 nm form by stabilizing the 474 nm photoproduct. This effect was maximal at the pH optimum of transducin activation by the mutant R* and was abolished in the presence of GTP gamma S. In addition, the amount of the 474 nm species correlated with transducin activation rates during the thermal conversion of the photoproduct mixture. Thus, the 474 nm photoproduct of the mutant pigment, which contained a protonated Schiff base, activated transducin.(ABSTRACT TRUNCATED AT 250 WORDS)

Protonation states of membrane-embedded carboxylic acid groups in rhodopsin and metarhodopsin II: a Fourier-transform infrared spectroscopy study of site-directed mutants

A method was developed to measure Fourier-transform infrared (FTIR) difference spectra of detergent-solubilized rhodopsin expressed in COS cells. Experiments were performed on native bovine rhodopsin, rhodopsin expressed in COS cells, and three expressed rhodopsin mutants with amino acid replacements of membrane-embedded carboxylic acid groups: Asp-83-->Asn (D83N), Glu-122-->Gln (E122Q), and the double mutant D83N/E122Q. Each of the mutant opsins bound 11-cis-retinal to yield a visible light-absorbing pigment. Upon illumination, each of the mutant pigments formed a metarhodopsin II-like species with maximal absorption at 380 nm that was able to activate guanine nucleotide exchange by transducin. Rhodopsin versus metarhodopsin II-like photoproduct FTIR-difference spectra were recorded for each sample. The COS-cell rhodopsin and mutant difference spectra showed close correspondence to that of rhodopsin from disc membranes. Difference bands (rhodopsin/metarhodopsin II) at 1767/1750 cm-1 and at 1734/1745 cm-1 were absent from the spectra of mutants D83N and E122Q, respectively. Both bands were absent from the spectrum of the double mutant D83N/E122Q. These results show that Asp-83 and Glu-122 are protonated both in rhodopsin and in metarhodopsin II, in agreement with the isotope effects observed in spectra measured in 2H2O. A photoproduct band at 1712 cm-1 was not affected by either single or double replacements at positions 83 and 122. We deduce that the 1712 cm-1 band arises from the protonation of Glu-113 in metarhodopsin II.

Light-dependent transducin activation by an ultraviolet-absorbing rhodopsin mutant

The photoactivation pathway of an ultraviolet-absorbing rhodopsin mutant was studied. The mutant pigment, in which the retinylidene Schiff base counterion, Glu113, was replaced by glutamine (E113Q), was known to exist in a pH-dependent equilibrium between spectral forms absorbing at about 380 and 490 nm. The 380-nm form contains an unprotonated Schiff base chromophore linkage, whereas the 490-nm form contains a protonated Schiff base chromophore linkage. The role of the Schiff base proton in photoactivation was investigated by measuring transducin activation as a function of photoactivation wavelength. The transducin activation action spectra of rhodopsin and of mutant E113Q were found to be very similar to their UV-visible absorption spectra. Thus, the 380-nm UV form of the mutant E113Q could be activated directly by UV light to catalyze nucleotide exchange by transducin. The quantum efficiency of photoactivation of the UV-absorbing form of E113Q was similar to that of its visible-absorbing form. These results show that the presence of a protonated Schiff base in the ground state is not necessarily required for efficient photoactivation of visual pigments. They support the hypothesis that the key role of the protonated Schiff base in visible-absorbing pigments is to stabilize the ground state and to allow absorbance at wavelengths above about 420 nm. The findings are also consistent with transducin activation studies of mutant apoproteins regenerated with all-trans-retinal, or of mutant apoproteins alone, suggesting that the active state of rhodopsin can be formed via a number of pathways.(ABSTRACT TRUNCATED AT 250 WORDS)

Regulation of the rhodopsin-transducin interaction by a highly conserved carboxylic acid group

Rhodopsin is a member of a family of G protein-coupled receptors which share structural and functional homologies. A tripeptide sequence (Glu or Asp/Arg/Tyr) at the cytoplasmic border of the third transmembrane segment is conserved among most of these receptors. This region is involved in G protein activation in rhodopsin as well as in other receptors. The role of the conserved Glu-134 was studied by site-specific mutagenesis of rhodopsin in combination with a real-time fluorescence assay of G protein (transducin) activation. Assay conditions were chosen under which the transducin activation rate was determined either by rhodopsin-transducin complex formation or by GTP gamma S-induced complex dissociation. Glu-134 was replaced by Gln in order to mimic the protonated state of the carboxylic acid group. This mutation caused the pH dependency of complex formation to extend to the alkaline range as compared with rhodopsin. Replacement of Glu-134 by Asp had an opposite but less pronounced effect on the pH dependency and lowered the overall efficiency of transducin activation. The acidity constant (pKa) of the residue at position 134 did not directly determine the pH sensitivity of complex formation, indicating that other amino acid residues contribute to a titratable binding domain that includes Glu-134. In contrast, the pH sensitivity of GTP gamma S-induced complex dissociation was not changed by the mutations, although absolute rates were affected. The data suggest that the protonated state of Glu-134 favors binding of rhodopsin to transducin and that Glu-134 is not titratable in the rhodopsin-transducin complex.

Aspartic acid-212 of bacteriorhodopsin is ionized in the M and N photocycle intermediates: an FTIR study on specifically 13C-labeled reconstituted purple membranes

Purple membrane was regenerated from the denatured proteolytic (protease V8) fragments V-1 and V-2 of bacteriorhodopsin (BR), native membrane lipids, and all-trans-retinal. FTIR difference spectra of M and N intermediates of the reconstituted system are in close correspondence to those obtained from native BR. Asp-212 is the only internal aspartic acid in the V-2 fragment (helices F and G). Reconstituting a V-2 fragment from a [4-13C]Asp-labeled BR preparation with an unmodified V-1 fragment and vice versa have allowed us to assign IR bands to either Asp-212 or any of the remaining aspartic acids on V-1 (helices A-E). A carboxylate vibration at 1392 cm-1 has been identified in the M and N intermediates and assigned to Asp-212. Since no contribution of this residue to C = O stretches of protonated carboxyl groups was detected, Asp-212 must be ionized in light-adapted BR as well. The effect of [4-13C]Asp labeling of V-1 revealed a carboxylate vibration at 1385 cm-1 in light-adapted BR. Since Asp-96 and Asp-115 are protonated, this band is caused by Asp-85. All absorption changes of C = O stretches of protonated carboxyl groups are due to Asp residues on V-1. Correspondingly, the proton acceptor for Schiff base deprotonation in M is located on V-1, and must be Asp-85 (the only ionized Asp on V-1). The band assignments are compared with those reported for BR mutants, and the potential role of Asp-212 for proton translocation is discussed.

Serum and endometrial copper, zinc, iron and cobalt with inert and copper-containing IUCDs

Serum and endometrial copper (Cu), zinc (Zn), iron (Fe) and serum cobalt (Co) were measured in the mid-follicular and mid-luteal phases of the menstrual cycles in 30 Lippes loops users, 30 CuT-200 IUCD users and 24 matched controls by atomic absorption spectrophotometry. In the control group, there was no statistically significant difference in mean mid-luteal, compared to mid-follicular, levels of serum Cu, Zn, Fe and Co and endometrial Zn. Mid-luteal endometrium contained significantly higher mean Cu, and lower mean Fe levels. In Lippes loop users, compared to controls, the only statistically significant differences were lower mean mid-follicular serum Zn, lower mean endometrial Zn and Fe, and higher mean mid-luteal endometrial Fe. In CuT-200 users, compared to controls, there was significantly higher mean mid-follicular serum Zn and lower mean mid-luteal serum Co, higher mean mid-follicular endometrial Cu and lower mean mid-follicular endometrial Fe levels. Compared to Lippes loop, CuT-200 users had significantly higher mean mid-follicular serum Co and endometrial Cu and Zn, and lower mean mid-follicular endometrial Fe.

Serum and endometrial sodium and potassium levels with inert and copper-containing IUCDs and relation to serum steroid levels

Serum and endometrial sodium (Na) and potassium (K) levels and serum estradiol, progesterone, testosterone and cortisol were measured in the mid-follicular and mid-luteal phases of the menstrual cycle in 20 Lippes loop and 20 CuT-200 IUCD users and 20 matched controls. Na and K were measured by atomic absorption spectrophotometry, while serum steroids were measured by RIA. Regarding steroids, the only significant difference between the three groups was a significantly lower mean mid-luteal serum estradiol in CuT-200 IUCD users compared to Lippes loop users (p less than 0.05). Regarding sodium in the control group, there was significantly lower mean mid-luteal serum and endometrial Na (p less than 0.01) that was not found in both groups of IUCD users. In the mid-follicular phase, there was significantly higher mean serum Na in both Lippes loop and CuT-200 groups compared to controls (p less than 0.05). Mean endometrial Na showed no significant difference between the three groups in both phases of the menstrual cycle. Regarding potassium in the control group, there was significantly lower mean levels in the mid-luteal-phase of the cycle (p less than 0.01) that was not seen with both groups of IUCD users. Serum K showed no significant difference in the three groups in both phases of the menstrual cycle. Endometrial K showed a significantly higher mean level in both Lippes loop and CuT-200 IUCD users compared to controls in the mid-luteal (p less than 0.01), but not in the mid-follicular phases of the cycle.

Effect of depo-medroxyprogesterone acetate on coagulation factors and serum lipids in Egyptian women

The short-term (3 months) and long-term (15 months) effect of DMPA contraception on various coagulation parameters (predictive of thrombosis) and on serum lipids (predictive of atherosclerosis) were prospectively studied in 30 Egyptian women, compared to their pretreatment levels. There were no significant changes in all the coagulation parameters studied after 3 months, and there was only a significant reduction in antithrombin III (AT III) level after 15 months (p less than 0.01). Concerning serum lipids, after 3 months, there were no significant changes in total lipids (TL), total cholesterol (TC) and triglycerides (Tg), while there was a significant decrease in high density lipoprotein cholesterol (HDL-C) (p less than 0.001), and a significant increase in low density lipoprotein cholesterol (LDL-C) (p less than 0.01). After 15 months there was a significant increase in TL, TC and LDL-C (p less than 0.001) and a significant decrease in HDL-C (p less than 0.001). Lipoprotein electrophoresis showed no significant change in pre-beta-lipoprotein percent, a significant decrease in alpha-lipoprotein percent and a significant increase in beta-lipoprotein percent after 3 and 15 months (p less than 0.001). Beta-lipoprotein band increased in 50% of DMPA users after 3 months and in 90% after 15 months and the type of hyperlipoproteinaemia was IIa. All calculated atherogenic indices showed significant changes (p less than 0.001) after 3 and 15 months of DMPA use. There was no significant correlation between AT III changes and changes in serum lipids. The study suggests no risk of thrombosis after 3 and 15 months of DMPA use. However, the risk of atherosclerosis appears to be possible as there were significant changes in serum lipids.

Effect of long-acting progestagen-only injectable contraceptives on carbohydrate metabolism and its hormonal profile

Two groups, each composed of 20 women, who used depomedroxyprogesterone acetate (DMPA) or norethisterone enanthate (NET-EN) injectable contraceptives were investigated for changes in 75-g OGTT and in the fasting and two-hour post oral glucose load (2-hours) levels of serum insulin, growth hormone, glucagon, cortisol and blood pyruvate. Samples were taken before and 3, 6 and 12 months after use of injectables. DMPA and NET-EN caused significant changes in mean blood glucose and pyruvate and in mean serum insulin, growth hormone and glucagon, but not in mean fasting cortisol. Changes with NET-EN started after 3 months, became maximal after 6 months and reverted to normal after 12 months of use, due to more frequent administration during the first 6 months of use (every 60 +/- 5 days) and to more spacing of the injections (every 84 +/- 5 days) after that. Changes with DMPA started after 3 months, and increased with the duration of use to become maximal after 12 months. Maximal changes were similar with DMPA and NET-EN and consisted of: a significant increase in fasting blood glucose and pyruvate and serum insulin; a significant increase in 2-hour blood glucose and pyruvate, serum insulin, growth hormone and glucagon. Although significant changes in blood glucose levels occurred with both DMPA and NET-EN, yet they did not reach the lower cut-off levels for impaired glucose tolerance in any user. With the same spacing of injections, i.e. every 84 +/- 5 days for NET-EN and every 90 +/- 5 days for DMPA, the effects on various parameters studied were less with NET-EN.

Levels of serum steroid hormones in intrauterine contraceptive device users

Serum progesterone, estradiol, testosterone and cortisol were assayed in the mid-follicular and mid-luteal phases of the menstrual cycles in 30 Lippe's loop and 30 Cu T-200 IUCD users, compared to 24 controls. Mean serum progesterone and estradiol levels were significantly higher in the mid-luteal, compared to the mid-follicular phase in each group (p less than 0.01). There were no significant differences between the mean levels of progesterone, testosterone and cortisol in IUCD users and controls in both the mid-follicular and mid-luteal phases. IUCD users had significantly higher levels of estradiol (p less than 0.01) in the mid-luteal phase but not in the mid-follicular phase, compared to controls. There was hormonal evidence of corpus luteum insufficiency in 8.3%, 14.3% and 20% in the controls, Lippe's loop and Cu T-200 IUCD users, respectively.

Postpartum colposcopy of the cervix: injury and healing

Colposcopic examination was done in 189 successive parturients within 6-48 h of delivery for evidence of type, site, and extent of cervical trauma and its relation to various obstetric factors. There was trauma in 66% of cases, as erosion in 79%, as laceration in 56%, as bruising in 30%, and as yellow areas in 17%. In about two-thirds of cases, the diameter of cervical erosion, or the length of laceration did not exceed 5 mm and 81% of lacerations were of first degree. Cervical injury was significantly more frequent in primiparae, in the anterior cervical lip, in occipito-posterior positions, and with premature rupture of membranes. In 117 parturients with cervical injury another colposcopic examination was done 6-8 weeks postpartum. In 8% there was residual cervical damage.

Cervical pathology with intrauterine contraceptive devices--a cyto-colpo-pathological study

One-hundred Lippes loop and 100 Cu T-200 intrauterine contraceptive device (IUCD) users, for more than one year, and 200 control non-users were examined clinically, cytologically, colposcopically and histopathologically for associated cervical pathological lesions. Nonspecific infection increased significantly in both Lippes loop and Cu T-200 IUCD users, compared to non-users (P less than 0.05). On the other hand, there was no statistically significant difference in the incidence of total, or individual, specific infections, dyskaryosis or CIN between both groups (P greater than 0.05). Colposcopically, there was a significant increase in inflammatory changes with both Lippes loop and Cu T-200 IUCD, compared to controls (P less than 0.05), but there was no difference in other colposcopic findings (P greater than 0.05).

The reliability and clinical use of a rapid phosphatidylglycerol assay in normal and diabetic pregnancies

Lecithin phosphorus concentration, the standard fetal lung maturity test in our institution, and phosphatidylglyercol were assayed in 69, 29, and 45 amniotic fluid samples from normal (GI), gestational (GII), and insulin-dependent diabetic (GIII) women by means of thin layer chromatography and Amniostat-FLM, respectively. Lecithin phosphorus concentration greater than or equal to 0.1 mg/dl and positive or strong positive Amniostat-FLM results were considered mature. The results of both assays were concordant in 79% of the samples. The discordance rate was highest in GIII patients. In our experience, respiratory distress syndrome did not develop in neonate infants of diabetic women delivered after a mature lecithin result. With lecithin phosphorus concentration as the reference standard, the predictive value of a mature Amniostat-FLM result was 96.2%, whereas that of an immature result was 58.5%. Respiratory distress syndrome occurred in only two GIII neonates who were delivered within 72 hours of both immature lecithin and Amniostat-FLM results. These findings support the use of Aminostat-FLM as a screening test for fetal lung maturity in both normal and diabetic pregnancies. Additional tests will be necessary to evaluate further fetal lung maturity only if the results are negative.

Uterine artery ligation to control postpartum hemorrhage

Bilateral uterine artery ligation was performed for 32 patients in order to control intractable postpartum hemorrhage in 25 of them (currative ligation) and as prophylaxis against postpartum hemorrhage in seven (elective ligation). Mass ligation was used for 29 patients and isolation ligation for three. Among the 25 patients for whom curative ligation was performed, successful hemostasis was achieved in 20 patients (80%) and the technique failed in five (20%). This failure was due to a clotting defect in three and placenta previa accreta in two patients. Twenty-four patients (96%) survived and one died as a result of a clotting defect. Among five patients followed up, normal menstruation occurred with pregnancy in three of them.

Prophylaxis against prostaglandin-induced gastrointestinal side effects

Prostaglandin F2 alpha was administered intravenous drip in 130 patients with missed, incomplete inevitable and septic abortion, intrauterine death and vesicular mole and for therapeutic termination of midtrimester pregnancies. In 84 patients (control group), no prophylactic antiemetic or antidiarrheal drugs were administered, while in 46 patients (study group), an antiemetic (prochlorperazine) and an antidiarrheal (diphenoxylate hydrochloride with atropine sulfate) drug were administered prophylactically before and during prostaglandin infusion. The incidence in vomiting and diarrhea was statistically much less in the study group (P less than 0.0005 for vomiting and P less than 0.005 for diarrhea). There was no statistically significant difference in the success rate of prostaglandin induction in the two groups.