Subnational estimates of vitamin A supplementation coverage in children: a geospatial analysis of 45 low- and middle-income countries

OBJECTIVES

Vitamin A supplementation (VAS) can protect children from the adverse health consequences of vitamin A deficiency. Granular data on VAS coverage can guide global and national efforts to achieve universal VAS coverage. To provide geographically precise targeting of VAS programs and to monitor progress in reducing geographic disparities, we aimed to create high-resolution (5 × 5 km2) maps of VAS coverage in children under 5 years across VAS priority countries.

STUDY DESIGN

We used cross-sectional data from the Demographic and Health Surveys (DHS) program.

METHODS

We used data from the DHS program for United Nations Children's Fund -designated VAS priority countries between 2000 and 2017 with data available from 2005 or later. The outcome variable was the proportion of children under 5 years who received a vitamin A dose in each sampled cluster. We applied a Bayesian geostatistical approach incorporating geographic, climatic, and nutritional covariates to estimate VAS coverage for each cell. We estimated and mapped absolute VAS coverage, Bayesian uncertainty intervals, and exceedance probabilities.

RESULTS

Our sample included countries from Latin America and the Caribbean, Asia, and Africa. Most countries had estimated VAS coverage levels <70%, and our exceedance probabilities indicated high certainty that our estimates fell below this threshold in most grid cells. International variations were most notable in the Latin America and the Caribbean region and Africa. Intranational variations were greatest in some South Asian and West and Central African countries.

CONCLUSIONS

These prevalence and exceedance maps, especially used with data on indicators of VAS need, could help to improve equity.

Sublethal Impacts of Novaluron on Tarnished Plant Bug (Hemiptera: Miridae) Adults

Tarnished plant bug, Lygus lineolaris Palisot de Beauvois (Hemiptera: Miridae), has become a primary pest of cotton in the Midsouthern United States. Insect growth regulators such as novaluron are an important part of L. lineolaris management. While novaluron is lethal to nymphs, it does not kill adults, so it has been used when nymphs are the primary stage present. However, cotton yield protection was observed from an application of novaluron when adults were the predominant stage present. To explain this, a series of studies were conducted to examine sublethal impacts of novaluron to L. lineolaris adults. Novaluron ingestion by adults reduced hatch rate and sometimes reduced oviposition rate. Ingestion by either males or females reduced hatch rates, but the reduction was greater from female exposure. Contact exposure of adults with novaluron residues within 1 d of application reduced hatch rate by about 50%, but the impact on oviposition was inconsistent. A field study showed reduced hatch rate from contact exposure to mixed-age natural populations, but the overall net reproductive rate was not reduced. Surface exposure of eggs to novaluron did not reduce hatch rate. Overall, exposure of tarnished plant bug adults to novaluron, regardless of adult age or exposure route, reduced egg viability. However, the impact on oviposition rate and net reproductive rate varied with adult age and exposure route. This understanding of sublethal impacts of novaluron, in addition to lethal impacts on nymphs, should be considered when choosing application times to maximize effects on L. lineolaris populations.

Cardiopulmonary and metabolic physiology during hemodialysis and inter/intradialytic exercise

Hemodialysis is associated with numerous symptoms and side effects that, in part, may be due to subclinical hypoxia. However, acute cardiopulmonary and metabolic physiology during hemodialysis is not well defined. Intradialytic and interdialytic exercise appear to be beneficial and may alleviate these side effects. To better understand these potential benefits, the acute physiological response to exercise should be evaluated. The aim of this study was to compare and characterize the acute physiological response during hemodialysis, intradialytic exercise, and interdialytic exercise. Cardiopulmonary physiology was evaluated during three conditions: 1) hemodialysis without exercise (HD), 2) intradialytic exercise (IDEx), and 3) interdialytic exercise (Ex). Exercise consisted of 30-min constant load cycle ergometry at 90% V̇O₂AT (anaerobic threshold). Central hemodynamics (via noninvasive bioreactance) and ventilatory gas exchange were recorded during each experimental condition. Twenty participants (59 ± 12 yr, 16/20 male) completed the protocol. Cardiac output (Δ = -0.7 L/min), O₂ uptake (Δ = -1.4 mL/kg/min), and arterial-venous O₂ difference (Δ = -2.0 mL/O₂/100 mL) decreased significantly during HD. Respiratory exchange ratio exceeded 1.0 throughout HD and IDEx. Minute ventilation was lower (P = 0.001) during IDEx (16.5 ± 1.1 L/min) compared with Ex (19.8 ± 1.0 L/min). Arterial-venous O₂ difference was partially restored further to IDEx (4.6 ± 1.9 mL/O₂/100 mL) compared with HD (3.5 ± 1.2 mL/O₂/100 mL). Hemodialysis altered cardiopulmonary and metabolic physiology, suggestive of hypoxia. This dysregulated physiology contributed to a greater physiological demand during intradialytic exercise compared with interdialytic exercise. Despite this, intradialytic exercise partly normalized cardiopulmonary physiology during treatment, which may translate to a reduction in the symptoms and side effects of hemodialysis.NEW & NOTEWORTHY This study is the first, to our knowledge, to directly compare cardiopulmonary and metabolic physiology during hemodialysis, intradialytic exercise, and interdialytic exercise. Hemodialysis was associated with increased respiratory exchange ratio, blunted minute ventilation, and impaired O₂ uptake and extraction. We also identified a reduced ventilatory response during intradialytic exercise compared with interdialytic exercise. Impaired arterial-venous O₂ difference during hemodialysis was partly restored by intradialytic exercise. Despite dysregulated cardiopulmonary and metabolic physiology during hemodialysis, intradialytic exercise was well tolerated.

Ventilatory and chronotropic incompetence during incremental and constant load exercise in end-stage renal disease: a comparative physiology study

Maximal O₂ uptake is impaired in end-stage renal disease (ESRD), reducing quality of life and longevity. While determinants of maximal exercise intolerance are well defined, little is known of limitation during submaximal constant load exercise. By comparing individuals with ESRD and healthy controls, the aim of this exploratory study was to characterize mechanisms of exercise intolerance in participants with ESRD by assessing cardiopulmonary physiology at rest and during exercise. Resting spirometry and echocardiography were performed in 20 dialysis-dependent participants with ESRD (age: 59 ± 12 yr, 14 men and 6 women) and 20 healthy age- and sex-matched controls. Exercise tolerance was assessed with ventilatory gas exchange and central hemodynamics during a maximal cardiopulmonary exercise test and 30 min of submaximal constant load exercise. Left ventricular mass (292 ± 102 vs. 185 ± 83 g, P = 0.01) and filling pressure (E/e': 6.48 ± 3.57 vs. 12.09 ± 6.50 m/s, P = 0.02) were higher in participants with ESRD; forced vital capacity (3.44 ± 1 vs. 4.29 ± 0.95 L/min, P = 0.03) and peak O₂ uptake (13.3 ± 2.7 vs. 24.6 ± 7.3 mL·kg^-1·min^-1, P < 0.001) were lower. During constant load exercise, the relative increase in the arterial-venous O₂ difference (13 ± 18% vs. 74 ± 18%) and heart rate (32 ± 18 vs. 75 ± 29%) were less in participants with ESRD despite exercise being performed at a higher percentage of maximum minute ventilation (48 ± 3% vs. 39 ± 3%) and heart rate (82 ± 2 vs. 64 ± 2%). Ventilatory and chronotropic incompetence contribute to exercise intolerance in individuals with ESRD. Both are potential targets for medical and lifestyle interventions.

Cytokinetic bridge triggers de novo lumen formation in vivo

Multicellular rosettes are transient epithelial structures that serve as intermediates during diverse organ formation. We have identified a unique contributor to rosette formation in zebrafish Kupffer's vesicle (KV) that requires cell division, specifically the final stage of mitosis termed abscission. KV utilizes a rosette as a prerequisite before forming a lumen surrounded by ciliated epithelial cells. Our studies identify that KV-destined cells remain interconnected by cytokinetic bridges that position at the rosette's center. These bridges act as a landmark for directed Rab11 vesicle motility to deliver an essential cargo for lumen formation, CFTR (cystic fibrosis transmembrane conductance regulator). Here we report that premature bridge cleavage through laser ablation or inhibiting abscission using optogenetic clustering of Rab11 result in disrupted lumen formation. We present a model in which KV mitotic cells strategically place their cytokinetic bridges at the rosette center, where Rab11-associated vesicles transport CFTR to aid in lumen establishment.

Text2Quit: An analysis of user experiences with a mobile smoking cessation program

INTRODUCTION

Studies have shown that Text2Quit and other mobile cessation programs increase quit rates in adult smokers, but the mechanism of effects and user experiences are not well understood.

AIMS

This study reports on participants' experiences with the program and explores aspects of the program that they liked and disliked.

METHODS

Self-reported experiences of the program were collected through a follow-up survey conducted one month after enrollment (n=185). Participant responses to open-ended items were dual coded by independent coders.

RESULTS

Overall participants agreed that they liked the program (4.2/5), that the program was helpful (4.1/5) and that they would recommend the program to a friend (4.3/5). Top reasons for liking the program included that it served as a constant reminder of quitting (17.8%), the content (16.7%), the encouragement provided (13.3%), and the on-demand tools (12.2%). Top reasons for disliking the program were message frequency (20.5%), content (7.0%), and the lack of personal interaction (7.0%).

CONCLUSIONS

The constancy of messaging was both liked as a reminder and disliked as an annoyance. Future programs might be improved by pre-testing and customizing the content based on user preferences, and by adding in human interactions, while keeping a supportive tone and offering on-demand tools.

Dynamic genetic regulation of gene expression during cellular differentiation

Genetic regulation of gene expression is dynamic, as transcription can change during cell differentiation and across cell types. We mapped expression quantitative trait loci (eQTLs) throughout differentiation to elucidate the dynamics of genetic effects on cell type-specific gene expression. We generated time-series RNA sequencing data, capturing 16 time points during the differentiation of induced pluripotent stem cells to cardiomyocytes, in 19 human cell lines. We identified hundreds of dynamic eQTLs that change over time, with enrichment in enhancers of relevant cell types. We also found nonlinear dynamic eQTLs, which affect only intermediate stages of differentiation and cannot be found by using data from mature tissues. These fleeting genetic associations with gene regulation may explain some of the components of complex traits and disease. We highlight one example of a nonlinear eQTL that is associated with body mass index.

Quality of life measures predict cardiovascular health and physical performance in chronic renal failure patients

BACKGROUND

Patients with advanced chronic kidney disease (CKD) experience complex functional and structural changes of the cardiopulmonary and musculoskeletal system. This results in reduced exercise tolerance, quality of life and ultimately premature death. We investigated the relationship between subjective measures of health related quality of life and objective, standardised functional measures for cardiovascular and pulmonary health.

METHODS

Between April 2010 and January 2013, 143 CKD stage-5 or CKD5d patients (age 46.0±1.1y, 62.2% male), were recruited prospectively. A control group of 83 healthy individuals treated for essential hypertension (HTN; age 53.2±0.9y, 48.22% male) were recruited at random. All patients completed the SF-36 health survey questionnaire, echocardiography, vascular tonometry and cardiopulmonary exercise testing.

RESULTS

Patients with CKD had significantly lower SF-36 scores than the HTN group; for physical component score (PCS; 45.0 vs 53.9, p<0.001) and mental component score (MCS; 46.9 vs. 54.9, p<0.001). CKD subjects had significantly poorer exercise tolerance and cardiorespiratory performance compared with HTN (maximal oxygen uptake; VO2peak 19.9 vs 25.0ml/kg/min, p<0.001). VO2peak was a significant independent predictor of PCS in both groups (CKD: b = 0.35, p = 0.02 vs HTN: b = 0.27, p = 0.001). No associations were noted between PCS scores and echocardiographic characteristics, vascular elasticity and cardiac biomarkers in either group. No associations were noted between MCS and any variable. The interaction effect of study group with VO2peak on PCS was not significant (ΔB = 0.08; 95%CI -0.28-0.45, p = 0.7). However, overall for a given VO2peak, the measured PCS was much lower for patients with CKD than for HTN cohort, a likely consequence of systemic uremia effects.

CONCLUSION

In CKD and HTN, objective physical performance has a significant effect on quality of life; particularly self-reported physical health and functioning. Therefore, these quality of life measures are indeed a good reflection of physical health correlating highly with objective physical performance measures.

How do patients access the private sector in Chennai, India? An evaluation of delays in tuberculosis diagnosis

SETTING

The diagnosis and treatment of tuberculosis (TB) in India are characterized by heavy private-sector involvement. Delays in treatment remain poorly characterized among patients seeking care in the Indian private sector.

OBJECTIVE

To assess delays in TB diagnosis and treatment initiation among patients diagnosed in the private sector, and pathways to care in an urban setting.

DESIGN

Cross-sectional survey of 289 consecutive patients diagnosed with TB in the private sector and referred for anti-tuberculosis treatment through a public-private mix program in Chennai from January 2014 to February 2015.

RESULTS

Among 212 patients with pulmonary TB, 90% first contacted a formal private provider, and 78% were diagnosed by the first or second provider seen after a median of three visits per provider. Median total delay was 51 days (mean 68). Consulting an informal (rather than formally trained) provider first was associated with significant increases in total delay (absolute increase 22.8 days, 95%CI 6.2-39.5) and in the risk of prolonged delay >90 days (aRR 2.4, 95%CI 1.3-4.4).

CONCLUSION

Even among patients seeking care in the formal (vs. informal) private sector in Chennai, diagnostic delays are substantial. Novel strategies are required to engage private providers, who often serve as the first point of contact.

Residual and Systemic Efficacy of Chlorantraniliprole and Flubendiamide Against Corn Earworm (Lepidoptera: Noctuidae) in Soybean

Experiments were conducted in Mississippi from 2013 to 2015 to determine the systemic and residual efficacy of chlorantraniliprole and flubendiamide against corn earworm, Helicoverpa zea (Boddie), in soybean. Both insecticides were applied at V4 and R3. Ten leaves that were present at the time of application and 10 newly emerged leaves that were not present at the time of application were collected to measure residual and systemic efficacy, respectively. Ten pods were removed from each plot at R5.5. For all assays, corn earworm larvae were placed on plant material. Chlorantraniliprole appeared to provide systemic control of H. zea, but was dependent on soybean growth stage at the time of application. In the V4 experiment, chlorantraniliprole resulted in greater mortality than the control on new leaves at 7 d after treatment, but not at 14 d. In the R3 experiment, chlorantraniliprole resulted in greater than 90% mortality on new leaves at all evaluation intervals. Mortality of H. zea on new leaves was <17% for flubendiamide and was not different than the control. Both insecticides resulted in significant mortality of H. zea on leaves that were present at the time of application for at least 31 d after application. Chlorantraniliprole resulted in greater mortality than flubendiamide at 24 and 31 d. Neither insecticide resulted in mortality of H. zea feeding on reproductive structures. These results suggest that chlorantraniliprole moves to new vegetative structures but not to reproductive structures of soybean, and that flubendiamide does not move systemically.

Susceptibility of Helicoverpa zea (Lepidoptera: Noctuidae) Neonates to Diamide Insecticides in the Midsouthern and Southeastern United States

Corn earworm, Helicoverpa zea (Boddie), is a significant pest of agroecosystems in the midsouthern and southeastern regions of the United States. These insects have developed resistance to, or inconsistent control has occurred with, most insecticide classes. With their unique mode of action, insecticides in the diamide class have become a key component in management of agriculturally important lepidopteran pests. In this study, field populations of H. zea were collected in the southern United States and compared to susceptible laboratory colonies to generate baseline concentration-mortality data. LC50 and LC90 values were generated for flubendiamide and chlorantraniliprole using neonates. To achieve equivalent levels of mortality, a higher concentration of flubendiamide was required compared to chlorantraniliprole. Flubendiamide LC50 values for H. zea ranged from 16.45 to 30.74 ng/ml, with a mean of 23.53 ng/ml. Chlorantraniliprole LC50 values for H. zea ranged from 2.94 to 4.22 ng/ml, with a mean of 3.66 ng/ml. Significant differences were observed for some field populations relative to the laboratory colony. For flubendiamide, five populations had greater LC50 values and two populations had lower LC50 values compared to the laboratory colony. For chlorantraniliprole, three populations had greater LC50 values and three populations had lower LC50 values compared to the laboratory colony. The response of these populations most likely represents natural variability among populations and does not indicate a significant shift in susceptibility of this species.

Kidney Transplantation Significantly Improves Patient and Graft Survival Irrespective of BMI: A Cohort Study

Obesity and end-stage renal disease (ESRD) are on the increase worldwide. Kidney transplantation is the treatment of choice for ESRD. However, obesity is considered a contraindication for transplantation. We investigated the effect of BMI on mortality in transplanted and patients remaining on the waiting list in the United Kingdom. We analyzed the UK Renal Registry (RR) and the National Health Service Blood and Transplant (NHSBT) Organ Donation and Transplantation data for patients listed from January 1, 2004 to December 31, 2010, with follow-up until December 31, 2011. Seventeen thousand six hundred eighty-one patients were listed during the study period, with BMI recorded for 13 526 (77%). One- and five-year patient survival was significantly better in all BMI bands (<18.5, 18.5-<25, 25-<30, 30-<35, 35-<40, and 40+kg/m(2) ) in the transplant group when compared to those who remained on the waiting list (p < 0.0001). The analyses were repeated excluding live donor transplants and the results were essentially the same. On analyses of patient survival with BMI as a continuous variable or using 5 kg weight bands, there was no cut-off observed in the higher BMI patients where there would be no benefit to transplantation. For transplanted patients (N = 8088), there was no difference in patient or graft survival between the defined BMI bands. Thus, irrespective of BMI, patient survival is improved if transplanted.

Meeting report: 3rd international transplant conference: how much risk can you take?

The 3rd International Transplant Conference took place on 31st October and 1st November 2014 at the University of Warwick, Coventry, UK. Key focal points of the meeting were the exploration of the molecular basis of antibody-antigen interactions and their relation to clinical practice and to share experiences and knowledge regarding strategies to transplant the 'high-risk' patient. In addition, lively debate sessions were hosted where controversial clinical and immunological themes were discussed by leading experts in the field.

Are nurse-conducted brief interventions (NCBIs) efficacious for hazardous or harmful alcohol use? A systematic review

AIM

The aim of this study was to compare the efficacy of nurse-conducted brief interventions in reducing alcohol consumption, by looking at with treatment as usual compared with other treatments and general physician-delivered brief interventions within the literature.

BACKGROUND

Globally, the consumption of alcohol is at a worrying level and has significant effects on health when consumed to excess. Numerous studies have reported that brief intervention is effective in reducing excessive drinking. However, evidence on the efficacy of such interventions by nurses is still inconclusive.

METHODS

We included randomized controlled trials of brief interventions in which nurses were primarily involved as therapists, and were designed to achieve a reduction in alcohol consumption and related problems. We used online searches to locate randomized controlled trials in this area published from 1995 till 2012.

FINDINGS

Eleven trials were found meeting inclusion criteria, comparing nurse-conducted brief interventions with a control group or with other treatments. Five trials reported a statistically significant reduction in alcohol consumption in the intervention group with 6-12-month follow-up period and two trials concluded that brief interventions delivered by nurses was as efficacious as by physicians.

IMPLICATIONS FOR NURSING POLICY

The findings of the review have important policy implications for the preparation of nurses as therapists for brief interventions to reduce excessive drinking in a broad range of settings such as primary healthcare and hospital settings. The adoption of this intervention into contemporary nursing practice should be considered by the International Council of Nurses and nurses around the world as, according to the literature, it provides an evidence base for the independent functioning of nurses within the realms of nursing profession and addiction medicine.

CONCLUSION

The results of the review suggest that nurse-conducted brief interventions are an effective strategy for reducing alcohol consumption. We advocate more rigorous randomized controlled trials to underpin its efficacy in both research and real life scenario.

Meeting report: 2nd international conference: antibody incompatible transplantation and transplant infectious disease

The 2nd International Conference on Antibody Incompatible Transplantation and Transplant Infectious Disease took place at the University of Warwick on 23rd and 24th November 2012. The aims of the meeting were to discuss the pertinent clinical and laboratory issues surrounding antibody incompatible transplantation and to provide a contemporary analysis of transplant infectious disease. This report summarises the key points discussed at the meeting.

Peri-operative morbidity associated with abdominal myomectomy for very large fibroid uteri

OBJECTIVE

To evaluate the safety of abdominal myomectomy for very large fibroid uteri, and to assess the effect of relevant confounding variables on the occurrence of major peri-operative complications.

STUDY DESIGN

A cohort study of 200 abdominal myomectomies for fibroid uteri of 16 gestational weeks or greater. Logistic regression analysis was used to examine the influence of important clinical variables on the risk of complications. A systematic literature search was conducted for evidence related to peri-operative morbidity associated with abdominal myomectomy for very large fibroid uteri.

RESULTS

The mean (±standard deviation) uterine size was 21±5 weeks. The overall rate of major complications was 30%. Peri-operative bleeding necessitating blood transfusion occurred in 49 (24.5%) cases. During surgery, two patients had bowel injury, two had bladder injury, seven women returned to theatre and two (1%) had hysterectomy. Four patients were re-admitted within 14 days of surgery. Multivariable logistic regression analysis showed that the risk of major complications was significantly higher in cases with a uterine size of 20 gestational weeks or more [odds ratio (OR) 3.4, 95% confidence interval (CI) 1.1-10.2; p=0.03], where 10 or more fibroids were removed (OR 3.5, 95% CI 1.1-10.8; p=0.05) and where midline skin incision was required (OR 6.1, 95% CI 1.7-22.3; p=0.006). On comparison of primary vs repeat abdominal myomectomy, there was significantly higher blood loss (mean 1023±1112 ml vs 579±787 ml; p=0.02) and risk of major complications in the repeat myomectomy group (40% vs 5%; p<0.001). The systematic review identified only one study that reported a comparable risk of major complications related to abdominal myomectomy for very large fibroid uteri.

CONCLUSION

The risk of organ injury, hysterectomy, re-operation or hospital re-admission after abdominal myomectomy for very large fibroid uteri is low, but the procedure is associated with a significant risk of bleeding necessitating blood transfusion. This risk is increased after repeat myomectomy, and in patients with a uterine size of 20 gestational weeks or larger, requiring removal of 10 or more fibroids, and requiring a midline skin incision.

Circadian regulation of cellular homeostasis--implications for cell metabolism and clinical diseases

The major pathways involving nutrient and energy metabolism including cellular homeostasis are profoundly impacted by the circadian clock, which orchestrates diurnal rhythms in physiology and behavior. While the links between circadian and metabolic rhythms are unclear, recent studies imply a close link between the two with one feeding back on the other. In this discussion, we present the hypothesis that circadian clocks likely contribute to cellular homeostasis, especially proteostasis, through regulation of metabolic rhythms, which in turn feed-back on circadian oscillators. The disruption of circadian clocks leads to altered metabolic rhythms and metabolic disease states as a result of altered cellular homeostasis.

Change in knee osteoarthritis cartilage detected by delayed gadolinium enhanced magnetic resonance imaging following treatment with collagen hydrolysate: a pilot randomized controlled trial

OBJECTIVE

To determine whether either of two magnetic resonance imaging approaches - delayed gadolinium enhanced magnetic resonance imaging of cartilage (dGEMRIC), or T2 mapping - can detect short-term changes in knee hyaline cartilage among individuals taking a formulation of collagen hydrolysate.

DESIGN

Single center, prospective, randomized, placebo-controlled, double-blind, pilot trial of collagen hydrolysate for mild knee osteoarthritis (OA). Participants were allowed to continue the prior analgesic use. The primary outcome was change in dGEMRIC T1 relaxation time in the cartilage regions of interest at the 24-week timepoint. Secondary endpoints included the change in dGEMRIC T1 relaxation time between baseline and 48 weeks, the change in T2 relaxation time at 0, 24 and 48 weeks, the symptom and functional measures obtained at each of the visits, and overall analgesic use.

RESULTS

Among a sample of 30 randomized subjects the dGEMRIC score increased in the medial and lateral tibial regions of interest (median increase of 29 and 41 ms respectively) in participants assigned to collagen hydrolysate but decreased (median decline 37 and 36 ms respectively) in the placebo arm with the changes between the two groups at 24 weeks reaching significance. No other significant changes between the two groups were seen in the other four regions, or in any of the T2 values or in the clinical outcomes.

CONCLUSIONS

These preliminary results suggest that the dGEMRIC technique may be able to detect change in proteoglycan content in knee cartilage among individuals taking collagen hydrolysate after 24 weeks.

Impact of advocacy on the tuberculosis management practices of private practitioners in Chennai City, India

BACKGROUND

Innovative schemes to ensure the participation of private practitioners (PPs) in the Revised National Tuberculosis Control Programme (RNTCP) are necessary to identify and treat all patients with tuberculosis (TB). We developed a novel public-private mix (PPM) model to encourage PPs to practise DOTS and participate in the RNTCP while retaining their patients.

METHODS

The Resource Group for Education and Advocacy for Community Health (REACH) developed and implemented the programme in partnership with the Chennai local health authority and the Tuberculosis Research Centre, Chennai, India. PPs were sensitised to the RNTCP and DOTS through a one-to-one approach or group meetings, and were assisted in referring patients. Surveys were carried out at baseline and at the completion of the study to assess changes in attitudes and practices.

RESULTS

Six hundred PPs underwent sensitisation about the RNTCP, after which the proportion of PPs adopting DOTS increased significantly (P < 0.001), and the majority (72.8%) used sputum testing for diagnosing TB. The proportion of PPs who used X-ray alone for diagnosis declined to 16.0% from a baseline of 45.4%.

CONCLUSIONS

This PPM model, which emphasises sustained advocacy for DOTS and allows PPs to retain private patients, looks promising and needs to be tested at other sites.

Prolactin regulation of Bcl-2 family members: increased expression of bcl-xL but not mcl-1 or bad in Nb2-T cells

Prolactin (PRL)-dependent rat pre-T Nb2 (Nb2-11) cell lines serve as a useful model for investigation of mechanisms underlying lactogen-mediated suppression of apoptosis. Glucocorticoids, such as dexamethasone (DEX), induce apoptosis in Nb2-11 cells; the addition of PRL abrogates the cytolytic actions of DEX in this model, presumably because of increased expression of survival genes. In the present study, we investigated whether inhibition of DEX-induced apoptosis by PRL in Nb2-T cells was accompanied by altered expression of Bcl-2 family members, mcl-1, bad or bcl-x(L) determined by Northern and immunoblot analysis. The results indicated that a 0.9 kb bcl-x(L) transcript was rapidly induced by PRL. It reached maximal levels within 2 to 4 h (>20-fold) before declining toward basal values. Similar results were obtained in primary cultures of mouse thymocytes exposed to DEX in combination with PRL. In addition to increasing its mRNA expression, PRL also increased Bcl-xL protein levels by 6 h. Moreover, the effect of PRL to increase bcl-x(L) appeared to reflect direct and indirect mechanisms, since it was attenuated by the inhibition of protein synthesis. Results from other experiments suggest that PRL signaling to bcl-x(L) expression was independent of the Jak2/Stat pathway but appeared to require activation of a Src tyrosine kinase. In contrast, while a 1.1 kb mcl-1 transcript was detected in proliferating and quiescent cells, PRL did not alter its expression at either mRNA or protein levels. Moreover, neither bad mRNA nor its protein product were detectable under any of the experimental conditions evaluated. We have concluded that bad and mcl-1 are unlikely candidates for apoptosis regulatory genes modulated by PRL. However, the kinetic pattern of PRL-provoked bcl-x(L) expression is consistent with its playing a role as an apoptosis suppressor in Nb2-T cells and primary cultures of mouse thymocytes exposed to glucocorticoids.

Prolactin-Stimulated X-linked inhibitor of apoptosis protein expression during S phase cell cycle progression in rat Nb2 lymphoma cells

The rat Nb2 lymphoma is useful for studying prolactin (PRL) receptor signaling to mitogenesis and apoptosis suppression. Previous results showed that PRL rapidly induced expression of several apoptosis suppressor genes during the G1 phase of cell cycle in this model. The X-linked inhibitor of apoptosis protein (XIAP) gene product acts to suppress apoptosis by direct inhibition of caspases. The present study was conducted to determine whether PRL alters XIAP expression in lactogen-dependent Nb2-11 or -independent Nb2-SFJCD1 cells. Stationary Nb2-11 cultures expressed detectable levels of an 8.9-kb XIAP transcript. PRL (20 ng/mL) stimulated its expression, reaching maximal levels within 12 h. Expression of XIAP was also evaluated in Nb2-SFJCD1 cells subsequent to treatment with differentiating agents (sodium butyrate [2 mM, 72 h], all trans-retinoic acid [10 microM, 72 h], or 1,25-dihydroxycholecalciferol [100 nM, 24 h]). PRL significantly increased XIAP expression in cells previously treated with these compounds. Further analysis revealed that PRL stimulated XIAP expression during S phase of the cell cycle. To determine whether XIAP suppressed apoptosis, its cDNA was stably transfected into Nb2-11 cells. Compared to controls, cells overexpressing XIAP exhibited substantially less DNA fragmentation when apoptosis was induced by PRL deprivation or glucocorticoids. We conclude that PRL-stimulated XIAP expression likely serves to suppress apoptosis as cells progress through the later phases of the cell cycle.

Single-plate Molteno implants in complicated glaucomas: results, survival rates, and complications

Sixty-two single-plate single-stage Molteno implantations for complicated glaucomas were performed between March 1991 and November 1992. The charts of all these patients were reviewed to determine the intraocular pressure (IOP) control success rate (< 21 mm Hg with or without medications), visual success rate (retention or improvement of visual acuity from preoperative level) and the rate of complications encountered. A Kaplan-Meier life-table (survival) analysis was also performed. IOP control was obtained in 74.2% of cases. Mean postoperative IOP was 16.97 +/- 8.07 mm Hg (Mean +/- SD). Visual success was obtained in 51.6% of the eyes. Eyes with aphakia/pseudophakic glaucomas showed the best response with 80% of them achieving IOP control and 60% achieving visual success. The survival plot for IOP control revealed 75.81% and 74.19% success rates at 48 and 72 weeks, respectively. Complications encountered were either due to the early postoperative hypotony or were tube-related. These results were gratifying considering the severity of the glaucoma in these cases and they reaffirm the usefulness of the Molteno implant in the management of difficult glaucomas.

Effect of the concentration and duration of application of mitomycin C in trabeculectomy

Ninety-three consecutive trabeculectomies in which mitomycin C (MMC) was applied intraoperatively, either at a concentration of 0.5 mg/mL for 5 minutes (n = 48) or at a concentration of 0.4 mg/mL for 3 minutes (n = 45), were reviewed to determine whether there was a significant difference between the two groups in terms of intraocular pressure (IOP) control and the incidence of complications. Preoperative and postoperative IOPs in the two groups did not differ significantly (P = .817 and .131, respectively). The 5-minute group had a higher incidence of serous choroidal detachments (P = .001). The incidence of postoperative hypotony and filtration failure with uncontrolled IOP in the two groups did not significantly differ (P = .177 and .582, respectively). Thus, intraoperative application of MMC at a concentration of 0.4 mg/mL for 3 minutes controlled postoperative IOP as effectively as MMC at a concentration of 0.5 mg/mL for 5 minutes, with a significantly lower incidence of choroidal detachments.

Familial nanophthalmos: management and complications

Nanophthalmos is a rare form of congenital hypermetropia, in which, the individual is at a high risk of developing angle-closure glaucoma. We report a family of nanophthalmos affecting a brother and sister, as confirmed by biometry. Genetic analysis revealed an autosomal recessive mode of inheritance. The sister developed angle-closure glaucoma, which was refractory to medical and laser therapy. She underwent surgical interventions which resulted in complications. The clinical presentation, management, and complications encountered are discussed.

Tuberculous infection of skeletal muscle in a case of dermatomyositis

A patient with dermatomyositis associated with carcinoma was treated with steroids and antibiotics for possible tuberculosis. Autopsy showed an overwhelming diffuse nongranulomatous infection of Mycobacterium tuberculosis involving only the skeletal muscles and one inguinal lymph node. The rare localization of tuberculosis to skeletal muscle in this case is possibly due to steroid immunosuppression and the humoral immune attack on muscle blood vessels that is a part of dermatomyositis.

Immunoreactivity of lymphocytes from draining lymph nodes, peripheral blood and tumor infiltrates from oral cancer patients

Lymphocytes from metastatic (met) and nonmetastatic (non-met) regional lymph nodes, LNL peripheral blood (PBL) and tumor infiltrating lymphocytes (TIL) of patients with squamous cell carcinoma of the oral cavity and healthy donors were investigated for CD3, CD4, CD8 and HNK-1 phenotypes, Natural Killer (NK) cell Activity, Antibody Dependent Cellular Cytotoxicity (ADCC) and proliferative response to mitogen (PHA). Modulation of NK cytotoxicity with recombinant Interferon alpha (IFN-alpha) was also investigated in some cases. Lymphocytes from met and non-met lymph nodes showed no variation in the percentages of CD3+, CD4+ and CD8+ cells, when compared with each other and with PBL of oral cancer patients. TIL showed significantly less proportion of CD3+ and CD4+ cells. The percentage of HNK-1+ cells was significantly lower in LNL and TIL when compared to PBL of oral cancer patients. The mitogen responses of met and non-met LNL were comparable to each other and better than that of PBL from the same patients, while, TIL showed significant impairment in mitogen responses. The NK cytotoxicity and ADCC of PBL from oral cancer patients were comparable to healthy donors which could be augmented by rIFN alpha. LNL and TIL showed almost negligible NK and ADCC activities and NK activity could not be modulated by rIFN alpha. The results thus demonstrate that in oral cancer patients, lymphocytes from three compartments viz. PBL, LNL and TIL showed differential effector functions. The metastatic status of LN did not affect the immunoreactivity of LNL.

Lymphocyte subpopulations in Bancroftian filariasis: activated (DR+) CD8+ T cells in patients with chronic lymphatic obstruction

To examine the relationship between lymphocyte phenotypes and states of activation in patients with Bancroftian filariasis, dual colour flow cytometry and concurrent in vitro cell culture were performed on normal individuals (NV; n = 15), and on patients with either asymptomatic microfilaraemia (MF; n = 12) or elephantiasis (CP; n = 11). In contrast to findings by others in a population with Brugian filariasis, the percentages of total B lymphocytes (CD19), T lymphocytes (CD3), helper/inducer T lymphocytes (CD4), and suppressor/cytotoxic T lymphocytes (CD8) in both patient groups were found to be within the range defined by clinically normal individuals. Furthermore, there were no differences among the groups in the expression of the IL-2 receptor (CD25) on T cells. There was, however, a significantly greater proportion (P less than 0.01) of 'activated' cytotoxic/suppressor lymphocytes (defined by co-expression of CD8 and HLA-DR) in patients with elephantiasis (16.4 +/- 8.6%) than in the MF (8.9 +/- 2.6%) or NV (8.3 +/- 2.9%) groups. Further, when the expression of this activation antigen was examined in parallel with in vitro mitogen responsiveness, an inverse correlation between the percentage of CD8+ HLA-DR+ lymphocytes and pokeweed mitogen-induced proliferation was seen (r = -0.54; P less than 0.001). These data provide further definition of the immunoregulatory abnormalities seen in human filarial infections and suggest that activated CD8+ T lymphocytes may be involved in the pathogenesis of the chronic obstructed lymphatic form of this disease.

Lymphokine-activated killer-cell function of lymphocytes from peripheral blood, regional lymph nodes and tumor tissues of patients with oral cancer

Lymphokine-activated killer (LAK) cells, generated from peripheral blood lymphocytes (PBL) from patients with oral cancer or oral leukoplakia and from healthy donors showed comparable lysis of 6 target tumor cell lines, including 3 derived from head and neck and oral cancers. The tumor burden of the host did not appear to influence the systemic LAK activity. LAK activity of lymphocytes infiltrating the tumor tissues (TIL) was also comparable to that of the PBL. Both TIL and PBL showed a parallel increase in proportion of HNK-I+ and CD-25+ cells upon activation with IL-2. The lymph-node lymphocytes (LNL) from metastatic (met) and non-metastatic (non-met) draining lymph nodes, however, showed reduced LAK activity and an increase in CD8+ cells, in addition to CD25+ and HNK-I+ cells, when cultured with IL-2. When IL-2-activated LNL were co-cultured with autologous PBL during IL-2 activation of the latter, a strong suppressive effect was exerted by LNL. In contrast, IL-2-activated PBL did not suppress autologous LAK generation in spite of an increase in CD8+ cells seen after activation with IL-2. Frequency distribution of LAK precursors was significantly lower in LNL than in PBL from oral cancer patients. LAK precursor frequency in TIL was comparable to that of PBL. The results show that, in oral cancer, regional lymph nodes may not have adequate IL-2-inducible cytotoxic potential, due to a reduced number of LAK progenitors and possible activation of suppressor cells. Alternatively, TIL can be a potential source for LAK cell function.

Natural killer and lymphokine-activated killer cell-mediated cytotoxicity in patients with oral cancer

Peripheral blood lymphocytes (PBL) from untreated and treated oral cancer patients, lymph node lymphocytes (LNL) from metastatic (met) and nonmetastatic (non-met) lymph nodes, and tumor infiltrating lymphocytes (TIL) were tested for natural killer (NK) and lymphokine activated killer (LAK) cell cytotoxicity using appropriate targets in a short-term chromium release assay. The results showed that while both NK and LAK functions of PBL from oral cancer patients were comparable to those of normal healthy donors, the NK activity of metastatic and nonmetastatic LNL and TIL was highly compromised. On the other hand, potent LAK activity could be generated from all three lymphoid populations. Individual patients showing low NK activity displayed good LAK cytotoxicity, indicating that endogenous cells with low NK potential have adequate ability to respond to interleukin 2 (IL-2). LAK activity tested on autologous tumour targets revealed that TIL were the best source of LAK cells. followed by PBL and LNL.

Modification of the rate of ouabain binding to (Na+ + K+)ATPase by lithium ions

We report on the interactions of Li+, a congener of K+ with the (Na+ + K+)-ATPase from E Electricus as measured by their effects on the rate of [3H]-ouabain binding to this enzyme. Like K+, Li+ slows ouabain binding under both Type I (Na+ + ATP) and Type II (P1) conditions, but with lower affinity. In contrast to K+, the Li+ inhibition curve is hyperbolic, suggesting interaction at an uncoupled site. Also differing from the complete inhibition by high K+, a residual ouabain-binding rate persists at high Li+. The interactions of Li+ and K+ are synergistic: the apparent K+ affinity increases 3 to 4-fold in presence of Li+. These results are consistent with the conclusion that Li+ interacts with only one of the two K+ sites and may be of interest in interpreting lithium pharmacology.

Helical substructure of neurofilaments isolated from Myxicola and squid giant axons

Neurofilaments purified from invertebrate giant axons have been analyzed with the electron microscope. The neurofilaments have a helical substructure which is most easily observed when the neurofilaments are partially denatured with 0.5 M KCl or 2 M urea. When the ropelike structure comprising the neurofilaments untwists, two strands 4--5.5nm in diameter can be resolved. Upon further denaturation these strands break up into rod-shaped segments and subsequently these segments roll up into amorphous globular structures. Stained, filled densities can be resolved within the strand segments, and these resemble similar structures observed within the intact neurofilaments. The strands appear to consist of protofilaments 2--2.5 nm in diameter. These observations suggest that the neurofilament is a ropelike, helical structure composed of two strands twisted tightly around each other, and they su-port the filamentous rather than the golbular model of intermediate filament structure.