Social and cultural determinants of antibiotics prescriptions: analysis from a public community health centre in North India

This paper explores the socio cultural and institutional determinants of irresponsible prescription and use of antibiotics which has implications for the rise and spread of antimicrobial resistance (AMR). This study describes the patterns of prescription of antibiotics in a public facility in India and identifies the underlying institutional, cultural and social determinants driving the irresponsible use of antibiotics. The analysis is based on an empirical investigation of patients' prescriptions that reach the in-house pharmacy following an outpatient department (OPD) encounter with the clinician. The prescription analysis describes the factors associated with use of broad-spectrum antibiotics, and a high percentage of prescriptions for dental outpatient department prescribed as a precautionary measure. This paper further highlights the need for future research insights in combining socio-cultural approach with medical rationalities, to further explore questions our analysis highlights like higher antibiotic prescription, etc., Along with the recommendations for further research.

District health information system (DHIS2) as integrated antimicrobial resistance surveillance platform: An exploratory qualitative investigation of the one health stakeholders' viewpoints in Ethiopia

INTRODUCTION

There is an unmet need for One Health (OH) surveillance and reporting systems for antimicrobial resistance (AMR) in resource poor settings. District health information system, version 2 (DHIS2), is a globally recognized digital surveillance platform which has not been widely utilized for AMR data yet. Our study aimed to understand the local stakeholders' viewpoints on DHIS2 as OH-AMR surveillance platform in Jimma, Ethiopia which will aid its further context specific establishment.

METHODS

We performed an exploratory qualitative study using semi-structured key informant interviews (KIIs) in Jimma Zone at Southwest Ethiopia. We interviewed 42 OH professionals between November 2020 and February 2021. Following verbatim transcription of the audio recordings of KIIs, we conducted thematic analysis.

RESULTS

We identified five major themes which are important for understanding the trajectory of OH-AMR surveillance in DHIS2 platform. The themes were: (1) Stakeholders' current knowledge on digital surveillance platforms including DHIS2. (2) Stakeholders' perception on digital surveillance platform including DHIS2. (3) Features suggested by stakeholders to be included in the surveillance platform. (4) Comments from stakeholders on system implementation challenges. (5) Stakeholders' perceived role in the process of implementation. Despite several barriers and challenges, most of the participants perceived and suggested DHIS2 as a suitable OH-AMR surveillance platform and were willing to contribute at their current professional roles.

CONCLUSIONS

Our study demonstrates the potential of the DHIS2 as a user friendly and acceptable interoperable platform for OH-AMR surveillance if the technology designers accommodate the stakeholders' concerns. Piloting at local level and using performance appraisal tool in all OH disciplines should be the next step before proceeding to workable format.

Microfoundations of Data-Driven Antimicrobial Stewardship Policy (ASP)

This paper introduces a comprehensive framework that elucidates the microfoundations of data-driven antimicrobial stewardship programs (ASPs), specifically focusing on resource-constrained settings. Such settings necessitate the utilization of available resources and engagement among multiple stakeholders. The microfoundations are conceptualized as interlinked components: input, process, output, and outcome. Collectively, these components provide a comprehensive framework for understanding the development and implementation of data-driven ASPs in resource-constrained settings. It underscores the importance of considering both the social and material dimensions when evaluating microbiological, clinical, and social impacts. By harmonizing technology, practices, values, and behaviors, this framework offers valuable insights for the development, implementation, and assessment of ASPs tailored to resource-constrained environments.

Systems thinking based approaches to engage with health inequities shaping Antimicrobial Resistance in low and lower-middle-income countries

This paper argues for 'systems thinking' as a conceptual framework to address antimicrobial resistance, especially focusing on the context of low and lower middle-income countries (LLMICs), which are plagued with health inequities that magnify the AMR threat. Systems thinking provides two avenues to enhance these mitigation efforts: i) it helps go beyond a purely biomedical approach to incorporate considerations of the social and informational; ii) particularly relevant as is it helps to understand the role of health inequities in shaping AMR related prevention and care processes.

Safety and efficacy of transitioning from selexipag to oral treprostinil in pulmonary arterial hypertension: Findings from the ADAPT registry

PURPOSE

Oral treprostinil and selexipag are drugs targeting the prostacyclin pathway and are approved for treatment of pulmonary arterial hypertension (PAH). In the setting of unsatisfactory clinical response or tolerability issues while on selexipag, there is little data on clinical benefit, safety, or strategies on transitioning to oral treprostinil. Using prospective data from the ADAPT registry, we aimed to evaluate clinical outcomes, safety, and transition strategies in ten patients with PAH transitioning from selexipag to oral treprostinil.

METHODS

ADAPT was a prospective, real-world, multicenter, United States-based registry of patients with PAH newly started on oral treprostinil, with a cohort of patients (n = 10) transitioning from selexipag to oral treprostinil. PAH variables of interest were collected from standard-of-care clinic visits. Clinical improvement was defined by modified REPLACE criterion, and risk was assessed by REVEAL Lite 2 from baseline to last follow-up. Real world transition strategies were recorded. Healthcare utilization or worsening PAH was evaluated within 30 days of transitions.

RESULTS

Seven patients transitioned due to worsening PAH or lack of efficacy on selexipag, and three patients transitioned due to tolerability issues. Based on the modified REPLACE criterion, five patients demonstrated clinical improvement after transition from selexipag to oral treprostinil. Using REVEAL Lite 2 to assess risk, three patients improved and five patients maintained risk category from baseline to last follow-up. All transitions occurred in an outpatient setting either as abrupt stop/start or cross-titration, without parenteral treprostinil bridging.

CONCLUSION

Transition from selexipag to oral treprostinil was safe, performed without parenteral prostacyclin bridging, and resulted in clinical and categorical risk improvements in some patients.

"A living lab within a lab": approaches and challenges for scaling digital public health in resource-constrained settings

A living lab is an emerging concept, particularly in Europe, as a vehicle to develop digital innovations through a process of co-produced design and development, which takes place, physically and socially, in real-life use contexts. However, there is limited research relating to guiding our understanding of the process by which such labs are established, and digital innovations are co-created and scaled to other settings requiring similar solutions. Furthermore, beyond Europe, the concept of a living lab has not found widespread application in low- and middle-income countries (LMICs), particularly in their public health contexts. Public health systems offer the unique scaling challenge of "all or nothing", implying that data are required from the whole population rather than isolated pilot settings. The living lab approach promises the rich potential to strengthen public systems but comes with twin interconnected challenges. First, for building appropriate digital solutions to address local public health challenges, and second, in scaling them to other public health facilities. This article investigates these twin challenges through ongoing empirical work in India and identifies three key domains of analysis, which are as follows: the first concerns the process of establishing an enabling structure of a "living lab within a lab"; the second concerns leveraging the capabilities offered by free and open-source digital technologies; and the third concerns the driving impetus to scaling through agile and co-constructed technical support.

Personal data governance and privacy in digital reproductive, maternal, newborn, and child health initiatives in Palestine and Jordan: a mapping exercise

Introduction

There is a rapid increase in using digital technology for strengthening delivery of reproductive, maternal, newborn, and child health (RMNCH) services. Although digital health has potentially many benefits, utilizing it without taking into consideration the possible risks related to the security and privacy of patients' data, and consequently their rights, would yield negative consequences for potential beneficiaries. Mitigating these risks requires effective governance, especially in humanitarian and low-resourced settings. The issue of governing digital personal data in RMNCH services has to date been inadequately considered in the context of low-and-middle-income countries (LMICs). This paper aimed to understand the ecosystem of digital technology for RMNCH services in Palestine and Jordan, the levels of maturity of them, and the implementation challenges experienced, particularly concerning data governance and human rights.

Methods

A mapping exercise was conducted to identify digital RMNCH initiatives in Palestine and Jordan and mapping relevant information from identified initiatives. Information was collected from several resources, including relevant available documents and personal communications with stakeholders.

Results

A total of 11 digital health initiatives in Palestine and 9 in Jordan were identified, including: 6 health information systems, 4 registries, 4 health surveillance systems, 3 websites, and 3 mobile-based applications. Most of these initiatives were fully developed and implemented. The initiatives collect patients' personal data, which are managed and controlled by the main owner of the initiative. Privacy policy was not available for many of the initiatives.

Discussion

Digital health is becoming a part of the health system in Palestine and Jordan, and there is an increasing use of digital technology in the field of RMNCH services in both countries, particularly expanding in recent years. This increase, however, is not accompanied by clear regulatory policies especially when it comes to privacy and security of personal data, and how this data is governed. Digital RMNCH initiatives have the potential to promote effective and equitable access to services, but stronger regulatory mechanisms are required to ensure the effective realization of this potential in practice.

Costing analysis of an information & communications technology-enabled primary healthcare facility in India

BACKGROUND & OBJECTIVES

Information and communications technology (ICT) has often been endorsed as an effective tool to improve primary healthcare. However, evidence on the cost of ICT-enabled primary health centre (PHC) is lacking. The present study aimed at estimating the costs for customization and implementation of an integrated health information system for primary healthcare at a public sector urban primary healthcare facility in Chandigarh.

METHODS

We undertook economic costing of an ICT-enabled PHC based on health system perspective and bottom-up costing. All the resources used for the provision of ICT-enabled PHC, capital and recurrent, were identified, measured and valued. The capital items were annualized over their estimated life using a discount rate of 3 per cent. A sensitivity analysis was undertaken to assess the effect of parameter uncertainties. Finally, we assessed the cost of scaling up ICT-enabled PHC at the state level.

RESULTS

The estimated overall annual cost of delivering health services through PHC in the public sector was ₹ 7.88 million. The additional economic cost of ICT was ₹ 1.39 million i.e. 17.7 per cent over and above a non-ICT PHC cost. In a PHC with ICT, the cost per capita increased by ₹ 56. On scaling up to the state level (with 400 PHCs), the economic cost of ICT was estimated to be ₹ 0.47 million per year per PHC, which equates to approximately six per cent expenditure over and above the economic cost of a regular PHC.

INTERPRETATION & CONCLUSIONS

Implementing a model of information technology-PHC in a state of India would require an augmentation of cost by about six per cent, which seems fiscally sustainable. However, contextual factors related to the availability of infrastructure, human resources and medical supplies for delivering quality PHC services will also need to be considered.

Maturity Level of Digital Reproductive, Maternal, Newborn, and Child Health Initiatives in Jordan and Palestine

Background While there is a rapid increase in digital health initiatives focusing on the processing of personal data for strengthening the delivery of reproductive, maternal, newborn, and child health (RMNCH) services in fragile settings, these are often unaccompanied at both the policy and operational levels with adequate legal and regulatory frameworks.

Objective The main aim was to understand the maturity level of digital personal data initiatives for RMNCH services within fragile contexts. This aim was performed by choosing digital health initiatives from each country (two in Jordan and three in Palestine) based on RMNCH.

Methods A qualitative study design was adopted. We developed a digital maturity assessment tool assessing two maturity levels: the information and communications technology digital infrastructure, and data governance and interoperability in place for the five selected RMNCH initiatives in Jordan and Palestine.

Results Overall, the digital infrastructure and technological readiness components are more advanced and show higher maturity levels compared with data governance and interoperability components in Jordan and Palestine. In Jordan, the overall Jordan stillbirths and neonatal deaths surveillance initiative maturity indicators are somehow less advanced than those of the Electronic Maternal and Child Health Handbook-Jordan (EMCH-J) application. In Palestine, the Electronic Maternal and Child Health-registry initiative maturity indicators are more advanced than both Avicenna and EMCH-Palestine initiatives.

Discussions The findings highlighted several challenges and opportunities around the application and implementation of selected digital health initiatives in the provision of RMNCH in Jordan and Palestine. Our findings shed lights on the maturity level of these initiatives within fragile contexts. The maturity level of the five RMNCH initiatives in both countries is inadequate and requires further advancement before they can be scaled up and scaled out. Taking the World Health Organization recommendations into account when developing, implementing, and scaling digital health initiatives in low- and middle-income countries can result in successful and sustainable initiatives, thus meeting health needs and improving the quality of health care received by individuals especially those living in fragile contexts.

A critical review of the role of technology and context in digital health research

Digital health represents a research field dedicated to realising digital technologies’ potential and developing knowledge about their feasibility and impacts. Yet, drawing on a critical review of the articles in the most prominent multidisciplinary digital health journals, this paper argues that the digital health field has not profoundly engaged with its core subject, namely technology. The features of digital technologies remain in the background, and research is disconnected from the complexities of healthcare settings, including multiple technologies, established practices and people. Instead, the overarching focus in the digital health literature is the processing capabilities of digital technologies and their posited impacts. This paper proposes a research direction in digital health where technology and the context of use take a more prominent role. It argues that realising the potential of digital health requires intensive investigation drawing on different disciplines, grounded on understanding healthcare processes, related informational needs and the concrete features of digital technologies.

Stakeholders' Perceptions of the Implementation of a Patient-Centric Digital Health Application for Primary Healthcare in India

OBJECTIVES

Health systems are shifting from traditional methods of healthcare delivery to delivery using digital applications. This change was introduced at a primary care centre in Chandigarh, India that served a marginalised population. After establishing the digital health system, we explored stakeholders' perceptions regarding its implementation.

METHODS

Ethnographic methods were used to explore stakeholders' perceptions regarding the implementation of the Integrated Health Information System for Primary Health Care (IHIS4PHC), which was developed as a patient-centric digital health application. Data were collected using focus group discussions and in-depth interviews. Participatory observations were made of day-to-day activities including outpatient visits, outreach field visits, and methods of health practice. The collected information was analysed using thematic coding.

RESULTS

Healthcare workers highlighted that working with the digital health system was initially arduous, but they later realised its usefulness, as the digital system made it easier to search records and generate reports, rapidly providing evidence to make decisions. Auxiliary nurse midwives reported that recording information on computers saved time when generating reports; however, systematic and mandatory data entry made recording tedious. Staff were apprehensive about the use of computer-based data for monitoring their work performance. Patients appreciated that their previous records were now available on the computer for easy retrieval.

CONCLUSIONS

The usefulness of the digital health application was appreciated by various primary healthcare stakeholders. Barriers persisted due to perceived needs for flexibility in delivering healthcare services, and apprehensions continued because of increased transparency, accountability, and dependence on computers and digital technicians.

Field testing of a digital health information system for primary health care: A quasi-experimental study from India

INTRODUCTION

Information and Communication Technologies (ICTs) are acknowledged as vital tools to strengthen Primary Health Care (PHC) in low- and middle-income countries (LMICs). However, these technologies have been used only for selected services. Moreover, there is limited evidence on how effective these interventions are in improving comprehensive primary health care in LMICs. Therefore, we developed an integrated digital solution and field-tested its impact on PHC services in an urban community of India.

METHODS

An integrated health information system for primary health care (IHIS4PHC) was designed on a free and open source digital platform which provided multiple features for registration of population and tracking for promotive, preventive, and curative health services (e.g. Antenatal Care, Immunization, TB, Malaria, and Hypertension Treatment etc.), and for generation of aggregate reports for real-time monitoring. The IHIS4PHC was implemented in an urban health centre of Chandigarh (India) which catered to about 25,000 population. A quasi-experimental study design was chosen for analysing the impact of IHIS4PHC on PHC services. Household sample surveys were conducted at baseline and endline in the intervention and comparison community to estimate the coverage of selected health indicators using standard questionnaires. Difference-in-difference method with adjusted generalised estimating equation was used for the assessment of the net impact of IHIS4PHC.

RESULTS

In relation to the comparison community, statistically significant (p < 0.05) increase was observed at the IHIS4PHC implementing centre in primary health care adequacy (7.2 %), and in the care-seeking behaviour for chronic illness (16.5 %). Improvements were also noticed in other health indicators such as mean blood pressure, adherence to antihypertensive medication, intake of dietary salt by hypertensives, intention to quit tobacco, and vitamin A supplementation.

CONCLUSIONS

The digital IHIS4PHC design was found to be effective in improving PHC-based health services. Therefore, IHIS4PHC like digital solutions should be considered for strengthening PHC services in LMICs.

Strengthening health systems through informatics capacity development among doctors in low-resource contexts: the Sri Lankan experience

In the process of strengthening health systems, a lack of health-informatics capacity within low- and middle-income country settings is a considerable challenge. Many capacity-development initiatives on health informatics exist, most of which focus on the adoption of eHealth tools by front-line health-care workers. By contrast, there are only a few programmes that focus on empowering medical doctors in low- and middle-income countries to become champions of digital health innovation and adoption. Sri Lanka has a dynamic eHealth ecosystem, resulting largely from the country’s community of medical doctors who are also health informaticians. They are the result of a decade-long programme centred on a Master of Science degree course in biomedical informatics, which has trained over 150 medical doctors to date, and has now been extended to a specialist training programme. This paper evaluates this unique capacity-development effort from the perspective of strengthening health systems and how those in other low- and middle-income country contexts may learn from the Sri Lankan experience when implementing capacity-development programmes in health informatics.

Perceptions and preparedness of veterinarians to combat brucellosis through Brucellosis Control Programme in India

Background and Aim:

Brucellosis caused by bacteria belongs to the genus Brucella is an important zoonosis and constitutes a serious public health hazard worldwide including India. The present study aimed to estimate the knowledge of veterinarians on brucellosis, its public health threat, diagnosis, and vaccination.

Materials and Methods:

This cross-sectional study was conducted during 2013-2015 and 453 veterinarians representing 11 states/Union Territories (UT) of India (Assam, Tripura, Meghalaya, Goa, Karnataka, Madhya Pradesh, Uttar Pradesh, Delhi, Jammu and Kashmir, Tamil Nadu, and Punjab) were interviewed using self-administered questionnaire.

Results:

Out of 453 veterinarians, 71.74% stated handling of the animals on day-to-day basis and 28.25% were engaged in administration activities. The veterinarians ranked foot-and-mouth disease and brucellosis at the first and fourth ranks among the list of ten economic impacted diseases in the country. A significant association was observed between laboratory confirmation with those who handled brucellosis-suspected cases (p=0.000). Similarly, significant association was noted for the availability of vials/slides (p=0.114), vacutainers (p=0.008), icebox (p=0.103), and refrigerator (p=0.106) for those who preferred laboratory diagnosis. Only 20% of the veterinarians recommended vaccination against bovine brucellosis, and 17% obtained laboratory confirmation for the brucellosis-suspected cases.

Conclusion:

The study highlighted the need for awareness programs, laboratory facilities, veterinary doctors, and protective measures for the veterinarians for combating brucellosis through the control program in the country.

Public health information systems for primary health care in India: A situational analysis study

Introduction:

Information communication technology (ICT) based health information systems (HISs) are expected to transform health system functionality. The present study was aimed to evaluate HISs in India with a focus on primary health care (PHC).

Methodology:

The study used a qualitative method to evaluate and understand various ICT-based HIS implemented at the state/union territory (UT) level in India. After initial scoping research on HIS through literature search and observation, in-depth interviews of key informants at various levels (programme managers, analysts, co-ordinators, data entry operator and health care providers) was carried out to have an insight on the user experience of these systems. An inductive applied thematic coding of qualitative data was done for analysing the data.

Results:

Multiple applications have been developed under national health programmes to meet the health information needs, but at present, there is a limited role of these HISs in enhancing the effectiveness of comprehensive PHC. Many of these systems are proprietary-based, and the long-term sustainability and integration of these systems remain a challenge.

Conclusion:

A change is required in the approach to design a HIS that will cater to the needs of PHC. Moreover, HIS should be people-centred rather than technology-centric with focus on integration and sustainability.

'Hybrid Doctors' Can Fast Track the Evolution of a Sustainable e-Health Ecosystem in Low Resource Contexts: The Sri Lankan Experience

Although e-health is an area recognized as essential in the rapid development of healthcare systems in low resource contexts, many challenges prevent the emergence of an effective e-health ecosystem. Lack in capacity around health informatics is one of the main challenges. Based on a longitudinal case study gathering data pertaining to a master's program in biomedical informatics in Sri Lanka designed for doctors, in this paper we demonstrate that creating 'hybrid doctors' may be the way forward. We illustrate how hybrid doctors conversant in healthcare and information and communication technology (ICT) are able to facilitate the creation of an e-health ecosystem in a way that it would contribute significantly to the ICT driven healthcare reforms. Through this case study we highlight the importance of multidisciplinarity, participatory design, strategic investments, learning that aligns with developmental needs, networking, gaining legitimacy and re-packaging perspectives on 'health informatics capacity development'.

An Institutional Perspective on Health Sector Reforms and the Process of Reframing Health Information Systems

Health sector reform, including structural and process changes such as the incorporation of feasible information and communication technologies, is a priority in many least developed countries. However, such changes have not been particularly effective, the reasons for which will be explored in this article. Particular attention will be paid to attempts to integrate information systems in HIV/AIDS program in Mozambique. The article draws on new institutional theory to argue that the focus of this program on formal rules (i.e., Sector Wide Approach policy and national plans), which deemphasize the informal constraints at the point of service delivery (i.e., priority given to health care over reporting), has resulted in limited change. Furthermore, the limited overlap between the formal and informal domains raises the need for enhancing incentives and enforcement as key mechanisms through which more effective change can be enabled in the future.

Implementation of Information Technology: A Time-Space Perspective

This paper has two broad objectives. First, to emphasize the importance of integrating a time-space analysis into the body of information technology (IT) implementation research. This is done by discussing two evolutionary trends currently visible in the IS research domain: one, a shifting emphasis towards the use of more integrative approaches of study from those that were largely functional and reductionist; and two, the increasing acceptance of interpretiv ism as a basis for studying IS in organizations. The role of time and space is discussed in terms of how its analysis can contribute to strengthen further and refine existing thought. The second objective is to develop a framework which will allow the integration of a time-space analysis into IT research, and thus enable a more holistic and coherent view of the implementation problem. To build this framework, Harvey's (1989) ideas on the role of space and time in the structuring of spatial practices are drawn upon and expanded. The frame work represents an analytical scheme developed around the relationships between technology, time-space, and social structure. The study contributes to organization and IT studies in two ways. One, it provides a novel way of understanding how the social context and processes of technology implementa tion may relate to each other. Two, by explicitly acknowledging the multiple subjective-objective elements of time-space inherent in various social prac tices, the framework provides certain broad guidelines regarding areas for empirical investigation.

Social Structure and Managerial Agency in India

In this paper, we argue the need to understand the relationship between mana gerial agency and social structure within a broad societal context. Managers are members of different social systems arising from both work and non-work related activities. These systems have various sets of rules and resources embedded within them which managers draw upon to create agency, which in turn can either reinforce or change social structure. Drawing upon sociological approaches to the study of human agency, we propose a framework to describe possible influences that social structure has on the shaping of managerial atti tudes in India. We then use this framework to provide the lens through which a specific Indian-government-initiated, information-technology project is ana lyzed. We see the approach that has been illustrated in this paper to have implications for management studies in three areas: the management of cross- cultural projects; management practice in India; and future research on man agement in organizations.

Impact of GSTM1, GSTT1 and GSTP1 gene polymorphism and risk of ARV-associated hepatotoxicity in HIV-infected individuals and its modulation

Glutathione S-transferase (GST) family is involved in a two-stage detoxification process of a wide range of environmental toxins, carcinogen and antiretroviral (ARV) therapy (ART) drugs. The aim of this study is to describe the impact of genetic polymorphisms of GSTM1, GSTT1 and GSTP1-313A/G in the risk of ARV-associated hepatotoxicity in HIV-infected individuals and its modulation in hepatotoxic patients. We enrolled a total of 34 patients with hepatotoxicity, 131 HIV-infected individuals without hepatotoxicity under non-nucleoside reverse transcriptase inhibitor containing ART and 153 unrelated healthy individuals. With a case-control design, polymorphisms of GSTM1, GSTT1 and GSTP1-313A/G gene were genotyped by PCR and restriction enzyme-length polymorphism. Genotypes of GSTT1 null were significantly higher in HIV-infected individuals as compared with healthy controls (P=0.01, odds ratio (OR)=1.54). HIV-infected individuals with GSTM1-null genotype showed higher risk (P=0.09, OR=1.37) for hepatotoxicity, but risk was not significant. On evaluating gene-gene interaction models, GSTM1 null and GSTT1 null showed significant association with the risk of hepatotoxicity in HIV-infected individuals (P=0.004, OR=2.67) owing to synergistic effect of these genes. Individuals with GSTT1-null and GSTM1-null genotypes showed higher risk of hepatotoxicity with advanced stage of (CD4<200) of HIV infection (P=0.18, OR=1.39; P=0.63, OR=1.13). In case-only analysis, GSTT1-null genotype among alcohol users showed elevated risk of hepatotoxicity in HIV-infected individuals (P=0.12, OR=1.36, 95% confidence interval (CI): 0.94-1.97) as compared with GSTT1 genotypes. The carriers GSTM1-null+GSTT1-null genotype among nevirapine user showed prominent risk of hepatotoxicity in HIV-infected individuals (P=0.12, OR=4.21, 95% CI: 0.60-29.54). Hence, we can conclude that GSTT1-null and GSTM1-null genotypes alone and in combination may predict the acquisition of hepatotoxicity.

MELD exceptions for portopulmonary hypertension: current policy and future implementation

Since 2006, waitlist candidates with portopulmonary hypertension (POPH) have been eligible for standardized Model for End-Stage Liver Disease (MELD) exception points. However, there are no data evaluating the current POPH exception policy and its implementation. We used Organ Procurement and Transplantation Network (OPTN) data to compare outcomes of patients with approved POPH MELD exceptions from 2006 to 2012 to all nonexception waitlist candidates during this period. Since 2006, 155 waitlist candidates had approved POPH MELD exceptions, with only 73 (47.1%) meeting the formal OPTN exception criteria. Furthermore, over one-third of those with approved POPH exceptions either did not fulfill hemodynamic criteria consistent with POPH or had missing data, with 80% of such patients receiving a transplant based on receiving exception points. In multivariable multistate survival models, waitlist candidates with POPH MELD exceptions had an increased risk of death compared to nonexception waitlist candidates, regardless of whether they did (hazard ratio [HR]: 2.46, 95% confidence interval [CI]: 1.73-3.52; n = 100) or did not (HR: 1.60, 95% CI: 1.04-2.47; n = 55) have hemodynamic criteria consistent with POPH. These data highlight the need for OPTN/UNOS to reconsider not only the policy for POPH MELD exceptions, but also the process by which such points are awarded.

Loss of the xeroderma pigmentosum group B protein binding site impairs p210 BCR/ABL1 leukemogenic activity

Previous studies have demonstrated that p210 BCR/ABL1 interacts directly with the xeroderma pigmentosum group B (XPB) protein, and that XPB is phosphorylated on tyrosine in cells that express p210 BCR/ABL1. In the current study, we have constructed a p210 BCR/ABL1 mutant that can no longer bind to XPB. The mutant has normal kinase activity and interacts with GRB2, but can no longer phosphorylate XPB. Loss of XPB binding is associated with reduced expression of c-MYC and reduced transforming potential in ex-vivo clonogenicity assays, but does not affect nucleotide excision repair in lymphoid or myeloid cells. When examined in a bone marrow transplantation (BMT) model for chronic myelogenous leukemia, mice that express the mutant exhibit attenuated myeloproliferation and lymphoproliferation when compared with mice that express unmodified p210 BCR/ABL1. Thus, the mutant-transplanted mice show predominantly neutrophilic expansion and altered progenitor expansion, and have significantly extended lifespans. This was confirmed in a BMT model for B-cell acute lymphoblastic leukemia, wherein the majority of the mutant-transplanted mice remain disease free. These results suggest that the interaction between p210 BCR/ABL1 and XPB can contribute to disease progression by influencing the lineage commitment of lymphoid and myeloid progenitors.

Evaluation of pectinolytic activities for oenological uses from psychrotrophic yeasts

Of the twenty-three morphotypes of yeasts isolated from soil capable of utilizing pectin as sole carbon source at 6°C, two yeast isolates, one psychrotolerant (PT1) and one psychrophilic (SPY11), were selected according to their ability to secrete pectinolytic enzymes under some oenological conditions (temperature 6 and 12°C and pH 3.5) and ability or inability to grow above 20°C, respectively. As compared to their optimal activity, the three pectinolytic enzymes viz., pectin methyl esterase (PME), endopolygalacturonase (endo-PG) and exopolygalacturonase (exo-PG) isolated and assayed at pH 3.5 from PT1 were found to retain 39, 60 and 60% activity at 12°C and 40, 79 and 74% activity at 28°C, respectively. Likewise, the enzymes PME and endo-PG at pH 3.5 from SPY11 displayed 46 and 86% activity at 12°C and 50 and 60% activity at 28°C, respectively. All these enzymes showed 20-90% of residual activity at pH 3.5 and 6°C. The yeast isolates PT1 and SPY11 were identified as Rhodotorula mucilaginosa and Cystofilobasidium capitatum, respectively, on the basis of morphological, physiological and molecular characteristics. This study presents the first report on pectinolytic activities under major oenological conditions from psychrotolerant isolate R. mucilaginosa PT1 and psychrophilic isolate C. capitatum SPY11.

SIGNIFICANCE AND IMPACT OF THE STUDY

The cold-active pectinolytic enzymes (PME, endo-PG and exo-PG) from the newly isolated and identified psychrophilic yeast Cystofilobasidium capitatum SPY11 and psychrotolerant yeast Rhodotorula mucilaginosa PT1that exhibited 50-80% of their optimum activity under some major oenological conditions pH (3.5) and temperatures (6 and 12°C) could be applied to wine production and juice clarification at low temperature. The psychrotrophic yeasts themselves could be applied to cold process for the production of enzymes thus saving cost of energy and protecting process from contamination.

Improving quality and use of data through data-use workshops: Zanzibar, United Republic of Tanzania

PROBLEM

In Zanzibar, United Republic of Tanzania, as in many developing countries, health managers lack faith in the national Health Management Information System (HMIS). The establishment of parallel data collection systems generates a vicious cycle: national health data are used little because they are of poor quality, and their relative lack of use, in turn, makes their quality remain poor.

APPROACH

An action research approach was applied to strengthen the use of information and improve data quality in Zanzibar. The underlying premise was that encouraging use in small incremental steps could help to break the vicious cycle and improve the HMIS.

LOCAL SETTING

To test the hypothesis at the national and district levels a project to strengthen the HMIS was established in Zanzibar. The project included quarterly data-use workshops during which district staff assessed their own routine data and critiqued their colleagues' data.

RELEVANT CHANGES

The data-use workshops generated inputs that were used by District Health Information Software developers to improve the tool. The HMIS, which initially covered only primary care outpatients and antenatal care, eventually grew to encompass all major health programmes and district and referral hospitals. The workshops directly contributed to improvements in data coverage, data set quality and rationalization, and local use of target indicators.

LESSONS LEARNT

Data-use workshops with active engagement of data users themselves can improve health information systems overall and enhance staff capacity for information use, presentation and analysis for decision-making.

Barriers to ART adherence & follow ups among patients attending ART centres in Maharashtra, India

Background & objectives:

Adherence to ART is a patient specific issue influenced by a variety of situations that a patient may encounter, especially in resource-limited settings. A study was conducted to understand factors and influencers of adherence to ART and their follow ups among patients attending ART centres in Maharashtra, India.

Methods:

Between January and March 2009, barriers to ART adherence among 32 patients at three selected ART centres functioning under national ART roll-out programme in Maharashtra, India, were studied using qualitative methods. Consenting patients were interviewed to assess barriers to ART adherence. Constant comparison method was used to identify grounded codes.

Results:

Patients reported multiple barriers to ART adherence and follow up as (i) Financial barriers where the contributing factors were unemployment, economic dependency, and debt, (ii) social norm of attending family rituals, and fulfilling social obligations emerged as socio-cultural barriers, (iii) patients’ belief, attitude and behaviour towards medication and self-perceived stigma were the reasons for sub-optimal adherence, and (iv) long waiting period, doctor-patient relationship and less time devoted in counselling at the center contributed to missed visits.

Interpretation & conclusions:

Mainstreaming ART can facilitate access and address ‘missed doses’ due to travel and migration. A ‘morning’ and ‘evening’ ART centre/s hours may reduce work absenteeism and help in time management. Proactive ‘adherence probing’ and probing on internalized stigma might optimize adherence. Adherence probing to prevent transitioning to suboptimal adherence among patients stable on ART is recommended.

Community perspectives on care options for HIV prevention trial participants

There is on-going global debate and policy-setting concerning researchers' obligations to meet the health needs of people participating in HIV prevention trials in resource-poor settings. The perspectives of local community stakeholders on this issue are poorly understood as most of what is presented on behalf of communities where research takes place is anecdotal commentary. Using qualitative methods (130 in-depth interviews and 20 focus groups) we assessed perceived fairness of different strategies to meet the health needs of women who become HIV-infected during a hypothetical vaginal microbicide trial. Respondents included HIV prevention research participants, community stakeholders and health-care service providers in ten sites in seven countries (South Africa, Malawi, Tanzania, Zimbabwe, Zambia, India, US). Many respondents perceived referrals to be a potentially fair way to address care and treatment needs but concerns were also voiced about the adequacy of local health-care options and the ability of trial participants to access options. Most respondents viewed the provision of antiretroviral treatment by researchers to HIV-infected trial participants as unfair if treatment was not sustained beyond the end of the trial. The results underscore the importance of effectively linking trial participants to sustainable, community-based treatment and care.

Low HIV-1 incidence among married serodiscordant couples in Pune, India

Unlike commercial sex workers and patients attending sexually transmitted infection (STI) clinics, married couples are not typically targeted for HIV risk reduction programs in India. Thus, married partners of HIV-infected persons are at particularly high risk for HIV infection. Between September 2002 and November 2004, 457 HIV-1 sero-discordant, married couples were enrolled in a one-year prospective study of HIV transmission in Pune, India. The HIV incidence among uninfected partners was 1.22 per 100 person-years (95% CI 0.45-2.66), which is much lower than what has been previously reported among discordant couples in Africa. This may be due to higher rates of condom use, lower rates of STIs and higher CD4 T lymphocyte counts, among the Indian HIV sero-discordant couples.

Assessment of routine surveillance data as a tool to investigate measles outbreaks in Mozambique

BACKGROUND

Measles remains a major public health problem in Mozambique despite significant efforts to control the disease. Currently, health authorities base their outbreak control on data from the routine surveillance system while vaccine coverage and efficacy are calculated based on mathematical projections of the target population. The aim of this work was to assess the quality of the measles reporting system during two outbreaks that occurred in Maputo City (1998) and in Manica Province (2002).

METHODS

Retrospectively, we collected data from the routine surveillance system, i.e. register books at health facilities and weekly provincial and national epidemiological reports. To test whether the provinces registered an outbreak, the distribution of measles cases was compared to an endemic level established based on cases reported in previous years.

RESULTS

There was a significant under-notification of measles cases from the health facilities to the province and national level. Register books, the primary sources of information for the measles surveillance system, were found to be incomplete for two main variables: "age" and "vaccination status".

CONCLUSION

The Mozambican surveillance system is based on poor quality records, receives the notification of only a fraction of the total number of measles in the country and may result in failures do detect epidemics. The measles reporting system does not provide the data needed by Expanded Program on Immunisation managers to make evidence-based decisions, nor does it allow in-depth analysis to monitor measles epidemiology in the country. The progress of Mozambique to the next stage of measles elimination will require an improvement of the routine surveillance system and a stronger Health Information System.