Improving health outcomes and quality at the subdistrict level: Evaluation of the '3 feet model' in Waterberg District, Limpopo Province, South Africa

BACKGROUND

There is a gap in understanding of potential roles and actions at the subdistrict level to improve quality of care and health outcomes in South Africa (SA).

OBJECTIVES

To report on the evaluation of a subdistrict health system-strengthening initiative that aimed to reduce maternal, newborn and child mortality, referred to as the '3 feet model' in Waterberg District, Limpopo Province, SA. The model is centred on systems of real-time morbidity/mortality surveillance and co-ordinated responses. It was implemented in three of five Waterberg subdistricts over an 18-month period in 2021 and 2022.

METHODS

A prospective, process-tracing evaluation was conducted jointly between researchers, intervention partners and subdistrict decision-makers. Data sources combined ~100 hours of researcher participant observation, interviews with 14 health system actors, structured reflections by three subdistrict managers and information from the routine District Health Information System. Sources were triangulated and analysed based on a priori hypotheses on mechanisms of action.

RESULTS

Following uptake of the model, the perinatal mortality rate (PMR) improved by 28.8%, 11.5% and 28% in the three subdistricts, respectively, while the PMR worsened in two of four neighbouring subdistricts. Plausible factors in implementation successes were the presence of stable and committed hybrid (clinical-managerial) subdistrict leaders and their ability to overcome entrenched silos between a variety of system actors; new collaborative relationships between primary healthcare facilities, hospitals and emergency medical services; the generation and packaging of information in ways that directed responses ('actionable intelligence'); and support from senior district managers.

CONCLUSION

While not advocating for a cut-and-paste approach to improving quality and outcomes, positive experiences in Waterberg District suggest that the principles and mechanisms of action of the 3 feet model have wider relevance for policy and practice, especially as emphasis shifts towards the subdistrict as a core unit of population health and wellbeing in SA.

BRAVO self-confined expression through WOX5 in the Arabidopsis root stem-cell niche

In animals and plants, stem-cell niches are local microenvironments that are tightly regulated to preserve their unique identity while communicating with adjacent cells that will give rise to specialized cell types. In the primary root of Arabidopsis thaliana, two transcription factors, BRAVO and WOX5, among others, are expressed in the stem-cell niche. Intriguingly, BRAVO, a repressor of quiescent center divisions, confines its own gene expression to the stem-cell niche, as evidenced in a bravo mutant background. Here, we propose through mathematical modeling that BRAVO confines its own expression domain to the stem-cell niche by attenuating a WOX5-dependent diffusible activator of BRAVO. This negative feedback drives WOX5 activity to be spatially restricted as well. The results show that WOX5 diffusion and sequestration by binding to BRAVO are sufficient to drive the experimentally observed confined BRAVO expression at the stem-cell niche. We propose that the attenuation of a diffusible activator can be a general mechanism acting at other stem-cell niches to spatially confine genetic activity to a small region while maintaining signaling within them and with the surrounding cells.

Precise transcriptional control of cellular quiescence by BRAVO/WOX5 complex in Arabidopsis roots

Understanding stem cell regulatory circuits is the next challenge in plant biology, as these cells are essential for tissue growth and organ regeneration in response to stress. In the Arabidopsis primary root apex, stem cell-specific transcription factors BRAVO and WOX5 co-localize in the quiescent centre (QC) cells, where they commonly repress cell division so that these cells can act as a reservoir to replenish surrounding stem cells, yet their molecular connection remains unknown. Genetic and biochemical analysis indicates that BRAVO and WOX5 form a transcription factor complex that modulates gene expression in the QC cells to preserve overall root growth and architecture. Furthermore, by using mathematical modelling we establish that BRAVO uses the WOX5/BRAVO complex to promote WOX5 activity in the stem cells. Our results unveil the importance of transcriptional regulatory circuits in plant stem cell development.

Brassinosteroid signaling in plant development and adaptation to stress

Brassinosteroids (BRs) are steroid hormones that are essential for plant growth and development. These hormones control the division, elongation and differentiation of various cell types throughout the entire plant life cycle. Our current understanding of the BR signaling pathway has mostly been obtained from studies using Arabidopsis thaliana as a model. In this context, the membrane steroid receptor BRI1 (BRASSINOSTEROID INSENSITIVE 1) binds directly to the BR ligand, triggering a signal cascade in the cytoplasm that leads to the transcription of BR-responsive genes that drive cellular growth. However, recent studies of the primary root have revealed distinct BR signaling pathways in different cell types and have highlighted cell-specific roles for BR signaling in controlling adaptation to stress. In this Review, we summarize our current knowledge of the spatiotemporal control of BR action in plant growth and development, focusing on BR functions in primary root development and growth, in stem cell self-renewal and death, and in plant adaption to environmental stress.

Summary: This Review summarizes current knowledge of the spatiotemporal control of brassinosteroid function in plants, focusing on primary root development and growth, stem cell self-renewal and death, and adaptation to environmental stress.

Enzymatic activity, gene expression and posttranslational modifications of photosynthetic and non-photosynthetic phosphoenolpyruvate carboxylase in ammonium-stressed sorghum plants

Sorghum plants grown with 5mM (NH₄)₂SO₄ showed symptoms of stress, such as reduced growth and photosynthesis, leaf chlorosis, and reddish roots. Phosphoenolpyruvate carboxylase (PEPC) activity, by supplying carbon skeletons for ammonium assimilation, plays a pivotal role in tolerance to ammonium stress. This work investigated the effect of ammonium nutrition on PPC and PPCK gene expression, on PEPC activity, and on post-translational modifications (PTMs) of PEPC in leaves and roots of sorghum plants. Ammonium increased PEPC kinase (PEPCk) activity and the phosphorylation state of PEPC in leaves, both in light and in the dark, due to increased PPCK1 expression in leaves. This result resembled the effect of salinity on sorghum leaf PEPC and PEPCk, which is thought to allow a better functioning of PEPC in conditions that limit the income of reduced C. In roots, ammonium increased PEPC activity and the amount of monoubiquitinated PEPC. The first effect was related to increased PPC3 expression in roots. These results highlight the relevance of this specific isoenzyme (PPC3) in sorghum responses to ammonium stress. Although the role of monoubiquitination is not fully understood, it also increased in germinating seeds along with massive mobilization of reserves, a process in which the anaplerotic function of PEPC is of major importance.

TOPLESS mediates brassinosteroid control of shoot boundaries and root meristem development in Arabidopsis thaliana

The transcription factor BRI1-EMS-SUPRESSOR 1 (BES1) is a master regulator of brassinosteroid (BR)-regulated gene expression. BES1 together with BRASSINAZOLE-RESISTANT 1 (BZR1) drive activated or repressed expression of several genes, and have a prominent role in negative regulation of BR synthesis. Here, we report that BES1 interaction with TOPLESS (TPL), via its ERF-associated amphiphilic repression (EAR) motif, is essential for BES1-mediated control of organ boundary formation in the shoot apical meristem and the regulation of quiescent center (QC) cell division in roots. We show that TPL binds via BES1 to the promoters of the CUC3 and BRAVO targets and suppresses their expression. Ectopic expression of TPL leads to similar organ boundary defects and alterations in QC cell division rate to the bes1-d mutation, while bes1-d defects are suppressed by the dominant interfering protein encoded by tpl-1, with these effects respectively correlating with changes in CUC3 and BRAVO expression. Together, our data unveil a pivotal role of the co-repressor TPL in the shoot and root meristems, which relies on its interaction with BES1 and regulation of BES1 target gene expression.

Phosphoenolpyruvate carboxylase (PEPC) and PEPC-kinase (PEPC-k) isoenzymes in Arabidopsis thaliana: role in control and abiotic stress conditions

Arabidopsis ppc3 mutant has a growth-arrest phenotype and is affected in phosphate- and salt-stress responses, showing that this protein is crucial under control or stress conditions. Phosphoenolpyruvate carboxylase (PEPC) and its dedicated kinase (PEPC-k) are ubiquitous plant proteins implicated in many physiological processes. This work investigates specific roles for the three plant-type PEPC (PTPC) and the two PEPC-k isoenzymes in Arabidopsis thaliana. The lack of any of the PEPC isoenzymes reduced growth parameters under optimal growth conditions. PEPC activity was decreased in shoots and roots of ppc2 and ppc3 mutants, respectively. Phosphate starvation increased the expression of all PTPC and PPCK genes in shoots, but only PPC3 and PPCK2 in roots. The absence of any of these two proteins was not compensated by other isoforms in roots. The effect of salt stress on PTPC and PPCK expression was modest in shoots, but PPC3 was markedly increased in roots. Interestingly, both stresses decreased root growth in each of the mutants except for ppc3. This mutant had a stressed phenotype in control conditions (reduced root growth and high level of stress molecular markers), but was unaffected in their response to high salinity. Salt stress increased PEPC activity, its phosphorylation state, and L-malate content in roots, all these responses were abolished in the ppc3 mutant. Our results highlight the importance of the PPC3 isoenzyme for the normal development of plants and for root responses to stress.

Proline synthesis in barley under iron deficiency and salinity

This work investigates proline synthesis in six barley varieties subjected to iron deficiency, salinity or both stresses. The highest growth under Fe sufficiency corresponded to Belgrano and Shakira. A moderate augment of leaf phosphoenolpyruvate carboxylase (PEPC) activity was observed in all six varieties in response to Fe deficiency, consistently in leaves and sporadically in roots. All six varieties accumulated proline under Fe deficiency, to a higher extent in leaves than in roots. The decrease of Fe supply from 100 μM NaFe(III)-EDTA to 0.5 μM NaFe(III)-EDTA reduced growth and photosynthetic pigments similarly in the six barley varieties. On the contrary, differences between varieties could be observed with respect to increased or, conversely, decreased proline content as a function of the amount of NaFe(III)-EDTA supplied. These two opposite types were represented by Belgrano (higher proline under Fe deficiency) and Shakira (higher proline under Fe sufficiency). Time-course experiments suggested that leaf PEPC activity was not directly responsible for supplying C for proline synthesis under Fe deficiency. High proline levels in the leaves of Fe-deficient Belgrano plants in salinity were associated to a better performance of this variety under these combined stresses.

[Surgical voice rehabilitation in unilateral vocal fold paralysis]

Unilateral recurrent nerve paralysis leads to glottic insufficiency, significantly reducing vocal ability. Due to its unusually long course, the recurrent laryngeal nerve is prone to iatrogenic lesions involves many medical fields generally with little expertise in voice disorders. Whenever the etiology is uncertain, a complete diagnostic work-up is mandatory. Indirect laryngoscopy confirms the diagnosis. Laryngeal electromyography is of great value because it differentiates between paralysis and ankylosis of the cricoarytenoid joint. Moreover in many cases laryngeal electromyography yields a reliable prognosis of clinical outcome. While unfavorable results can be predicted with high accuracy, correct prognosis of complete recovery is more difficult. Speech therapy is the treatment of choice in cases of unilateral recurrent nerve palsy. Patients with persistent glottal gap may express the wish for surgical voice rehabilitation. Nowadays a broad spectrum of endoscopic and open approaches are available for this purpose. This review describes advanced techniques of voice-improving surgery available in specialized centers today.

Molecular genetic analysis of severe protein C deficiency

Severe protein C deficiency is a rare, early onset, venous thrombotic condition that is inherited as an autosomal recessive trait. The protein C (PROC) genes of nine unrelated individuals with severe protein C deficiency were sequenced yielding a total of 13 different lesions. Eight of these were novel, including a gross gene deletion, three missense mutations, two micro-deletions, a splicing mutation and a single base-pair substitution in the HNF-3 binding site in the PROC gene promoter. Evidence for the pathogenicity of the mutations detected was obtained by molecular modelling, in vitro splicing assay and reporter gene assay. Neither the plasma protein C activity level nor the nature of the PROC gene lesions detected were found to be a good prognostic indicator of the age of onset or clinical severity of thrombotic symptoms. Other factors may thus complicate the relationship between genotype and clinical phenotype. Indeed, in two patients, the inheritance of either one or two Factor V Leiden alleles in addition to two PROC gene lesions could have served to precipitate the thrombotic events. No association was however apparent between clinical severity and the possession of a particular promoter polymorphism genotype. Despite the absence of a clear genotype-phenotype relationship, the molecular genetic analysis of the severe recessive form of protein C deficiency potentiates both the counselling of affected families and the provision of antenatal exclusion diagnosis.

[The knowledge and application of regulations on smoking in secondary teaching centers]

OBJECTIVES

Despite the growing body of legal and normative regulations regarding promotion, sales and consumption of cigarettes, a few studies have already pointed to a low enforcement and commitment of these restrictions. This study explores the degree of awareness and compliance of these norms in the secondary school.

DESIGN

Cross-sectional, observational study. A telephone survey was carried out.

PARTICIPANTS

A simple of school principals or deputy principal was surveyed.

MEASUREMENTS

A questionnaire was designed to obtain respondents knowledge of the current policies regarding smoking, as well as on the existence of visible signals in the school wards. Besides, opinion on tolerance towards smoking behavior among the school teachers was ascertained.

RESULTS

Virtually at the respondents (98.8%) declared to know the existence of the regulations, although only 74.4% declared to have specific regulations at the school level. Smoking by teachers was allowed in their own offices in 61.6% of the centers. In open grounds, only 4.7% of the centers authorized adults to smoke while 18.6% permitted to smoke to the students. Public centers were less restrictive than private centers.

DISCUSSION

Principals of secondary schools are aware of the existing, policy, and in most cases largely restrict public consumption. However, there are still some important gaps regarding signals, consumption in outdoor public spaces and teachers consumption in their own offices. Specific interventions seem to be necessary to overcome this situation.

Prothrombin carora: hypoprothrombinaemia caused by substitution of Tyr-44 by Cys

Two members of a family from Carora, Venezuela, were found to have prothrombin activity levels at 4% of normal and undetectable antigen levels. All exons of the prothrombin gene from the proband were sequenced and a mutation at nucleotide 1305 was identified that would result in the substitution of Cys for Tyr at residue 44. Residue 44 is present in the aromatic stack region of the protein. Substitution of a Cys in this region would result in an abnormal folding of the protein which could be the cause for the observed lack of secretion of the abnormal prothrombin.

Further specificity characterization of von Willebrand factor inhibitors developed in two patients with severe von Willebrand disease

Circulating inhibitors against von Willebrand factor (vWF) that show the properties of heterologous IgG antibodies have been described in a few patients with severe von Willebrand disease (vWD). The present study provides further characterization of inhibitors from two patients with severe vWD. Inhibitors in both, like polyclonal rabbit antibody, detected all sizes of multimers and the complex structure of each multimer from platelets and plasma of normal individuals as well as from plasma of patients with IIA, IIB, and IIC vWD. Both inhibitors and the rabbit antibody reacted mainly with the intact 225-Kd vWF subunit and the 189-H and 140-Kd fragments in contrast to monoclonal antibodies specific for vWF fragments that detected a higher relative proportion of 176-Kd fragment. Furthermore, all these antibodies recognized fragment III, although one inhibitor and rabbit polyclonal antibody reacted poorly and the other inhibitor did not react at all with reduced fragment II of vWF digested with Staphylococcus aureus V-8 protease. These data suggest that although human inhibitors from severe vWD patients may behave, to some extent, as polyclonal heterologous antibodies against native vWF, the former show striking differences in their target specificity as well as a much broader specificity than that described for human factor VIII inhibitors.

An unusual case of hyper-production of IgE, treated by plasmapheresis

A 15-year-old boy with severe inflammatory skin lesions from an early age was found to have extremely elevated serum IgE levels (up to 376.000 IU/ml). His skin showed positive direct immunofluorescence for IgE and he had peripheral and bone marrow eosinophilia. No evidence for atopic disease was found, but he suffered intestinal helminthic infection of moderate intensity. He showed a somewhat depressed cell mediated immune response but a normal polymorphonuclear function. Various treatments that included anti-inflammatory, anti-allergic, anti-parasitic, anti-mycotic and PUVA therapy did not significantly improve his condition A therapeutic test using plasmapheresis produced marked, though short-lived clinical improvement. We believe that this case might result from the superimposition of the stimulatory effects of intestinal helminthiasis on a background of intrinsic hyper-production of IgE.