Regenerative medicines: A new regulatory paradigm for South Africa.

Clinicians are increasingly using regenerative medicines to repair, replace, regenerate or rejuvenate lost, damaged or diseased genes, cells, tissues or organs. In South Africa, access to these novel gene therapies and cell and tissue-based products is limited. The human leukocyte antigen (HLA) diversity and a paucity of suitable HLA-identical unrelated donors, results in limited access to haematopoietic stem and progenitor cell transplantation (HSPCT). Cell-based products could increase this access. Genetic diversity can also manifest in local or region-specific rare congenital disorders, and in vivo gene therapies hold the promise of developing treatments and cures for these debilitating disorders. South Africa has a disproportionate mortality rate due to non-natural causes, with many surviving with permanent injuries and disabilities. Tissue-engineered cell-based products have the potential to restore many of those affected and improve quality of life and productivity. These factors create an urgency for South Africa to develop regenerative medicines to address the country's unique needs and to provide access to these new and innovative treatment modalities. Achieving this objective requires a well-coordinated effort by multiple stakeholders and role players. A critical component of a regenerative medicine ecosystem is establishing an enabling regulatory framework for these new classes of medicines. Here we provide a brief profile of South Africa, including its genetic diversity, economy, the impact of the burden of disease, health policy and the healthcare system. We address the regulation of medicines, how the existing framework can accommodate regenerative medicines, and the steps needed to establish a future regulatory framework.

Testing the Impact of the Whole-Day Good Behavior Game on Aggressive Behavior: Results of a Classroom-Based Randomized Effectiveness Trial.

Three generations of developmental epidemiologically based randomized field trials of the Good Behavior Game (GBG) have been delivered to Baltimore elementary schools. With the collaboration of family and community partners, all three trials were directed at decreasing proximal targets of aggressive behavior and improving learning in first-grade classrooms with distal mental health and substance abuse outcomes. GBG is a group-contingent classroom behavior management strategy that promotes classmate/peer concern for each child's positive behavior by rewarding teams with below-criterion levels of aggressive, disruptive behavior. GBG targets early risk factors for the above distal outcomes: aggressive, disruptive behavior, family/school relationships, and school failure. Here, we report on the third-generation randomized prevention trial of the GBG (whole-day first grade program (WD)), including 12 elementary schools. WD enhanced the standard curriculum in the areas of classroom behavior management; academic instruction, particularly reading; and family-classroom partnerships. Using a within-school classroom randomized trial design, we: 1) evaluate the effectiveness of the WD program by sex and cohort and 2) measure variation in WD impact by the quality of teachers' behavior management practices. Data from 961 first graders were used in general growth mixture modeling that accounts for classroom randomization to identify distinct developmental trajectories of aggressive, disruptive behavior and GBG impact on these trajectories. In the chronic high aggression trajectory of males, ratings of aggression after WD implementation and to the end of third grade were significantly lower in the WD condition than in controls in classrooms with a higher WD dosage (Cohort 2) and especially in classrooms with higher quality of WD implementation. For females, we found a modest but significant benefit of GBG in the low trajectory class when cohorts were combined. Regarding policy implications, embedding GBG into the curricula in teacher's colleges could better support student learning and behavior. Clinical Trials Registration number: NCT00257088.

COVID-19 in children: Should we be worried?

Reports indicate that children infected with SARS-CoV-2 have thus far presented with less severe disease than adults. Anxiety regarding a greater ability to transmit the virus is largely unfounded and has played a significant role in the decision to allow children to return to school. In some patients, however, especially in infants and in those with underlying comorbidities, severe disease must be anticipated and planned for accordingly. The most relevant severe clinical presentation in addition to the established respiratory complications, is that of a multisystem inflammatory disorder, with features resembling Kawasaki disease. The impact of the pandemic on the economic and social wellbeing of children, including food insecurity and care when parents are ill, cannot be ignored. During this pandemic, it is imperative to ensure access to routine and emergency medical services to sick children. In so doing, potentially devastating medical and socioeconomic consequences can be mitigated.

Statistical properties of four effect-size measures for mediation models.

This project examined the performance of classical and Bayesian estimators of four effect size measures for the indirect effect in a single-mediator model and a two-mediator model. Compared to the proportion and ratio mediation effect sizes, standardized mediation effect-size measures were relatively unbiased and efficient in the single-mediator model and the two-mediator model. Percentile and bias-corrected bootstrap interval estimates of ab/s Y , and ab(s X )/s Y in the single-mediator model outperformed interval estimates of the proportion and ratio effect sizes in terms of power, Type I error rate, coverage, imbalance, and interval width. For the two-mediator model, standardized effect-size measures were superior to the proportion and ratio effect-size measures. Furthermore, it was found that Bayesian point and interval summaries of posterior distributions of standardized effect-size measures reduced excessive relative bias for certain parameter combinations. The standardized effect-size measures are the best effect-size measures for quantifying mediated effects.

Estimating drug effects in the presence of placebo response: causal inference using growth mixture modeling.

Placebo-controlled randomized trials for antidepressants and other drugs often show a response for a sizeable percentage of the subjects in the placebo group. Potential placebo responders can be assumed to exist also in the drug treatment group, making it difficult to assess the drug effect. A key drug research focus should be to estimate the percentage of individuals among those who responded to the drug who would not have responded to the placebo ('Drug Only Responders'). This paper investigates a finite mixture model approach to uncover percentages of up to four potential mixture components: Never Responders, Drug Only Responders, Placebo Only Responders, and Always Responders. Two examples are used to illustrate the modeling, a 12-week antidepressant trial with a continuous outcome (Hamilton D score) and a 7-week schizophrenia trial with a binary outcome (illness level). The approach is formulated in causal modeling terms using potential outcomes and principal stratification. Growth mixture modeling (GMM) with maximum-likelihood estimation is used to uncover the different mixture components. The results point to the limitations of the conventional approach of comparing marginal response rates for drug and placebo groups. It is useful to augment such reporting with the GMM-estimated prevalences for the four classes of subjects and the Drug Only Responder drug effect estimate.

[Juvenile hyaline fibromatosis]. / Juvenile hyaline Fibromatose.

Juvenile hyaline fibromatosis is a rare autosomal recessive disease of the connective tissue. We present the case of a 6-year-old normal mental developed boy with confluent pearly papules behind the ears and in the paranasal folds, firm nodules of the scalp, the back and metaphalangs, and severe gingival hypertrophy.

Irradiation induces DNA damage and modulates epigenetic effectors in distant bystander tissue in vivo.

Irradiated cells induce chromosomal instability in unirradiated bystander cells in vitro. Although bystander effects are thought to be linked to radiation-induced secondary cancers, almost no studies have evaluated bystander effects in vivo. Furthermore, it has been proposed that epigenetic changes mediate bystander effects, but few studies have evaluated epigenetic factors in bystander tissues in vivo. Here, we describe studies in which mice were unilaterally exposed to X-irradiation and the levels of DNA damage, DNA methylation and protein expression were evaluated in irradiated and bystander cutaneous tissue. The data show that X-ray exposure to one side of the animal body induces DNA strand breaks and causes an increase in the levels of Rad51 in unexposed bystander tissue. In terms of epigenetic changes, unilateral radiation suppresses global methylation in directly irradiated tissue, but not in bystander tissue at given time-points studied. Intriguingly, however, we observed a significant reduction in the levels of the de novo DNA methyltransferases DNMT3a and 3b and a concurrent increase in the levels of the maintenance DNA methyltransferase DNMT1 in bystander tissues. Furthermore, the levels of two methyl-binding proteins known to be involved in transcriptional silencing, MeCP2 and MBD2, were also increased in bystander tissue. Together, these results show that irradiation induces DNA damage in bystander tissue more than a centimeter away from directly irradiated tissues, and suggests that epigenetic transcriptional regulation may be involved in the etiology of radiation-induced bystander effects.

Prevalence of anxiety symptoms among a sample of outpatients in an internal medicine clinic: a pilot study.

Previous studies in primary care settings indicate that Axis I anxiety disorders range in prevalence from 2.1% to 14.8%. However, the prevalence of anxiety symptoms, rather than Axis I diagnoses, has undergone limited study. In a pilot study, we surveyed 88 outpatients in an internal medicine clinic and explored the prevalence of various anxiety symptoms based on four measures of anxiety and worry. Thirty percent of participants endorsed mixed anxiety features, 33% reported generalized anxiety symptoms, nearly half acknowledged obsessive-compulsive personality symptoms, and nearly a quarter identified meaningful levels of worry. Seventeen percent of participants were positive on all four study measures. These data suggest that anxiety symptoms are probably more prevalent in primary care settings than recognized.

Anxiety symptoms and healthcare utilization among a sample of outpatients in an internal medicine clinic.

OBJECTIVE: In this study, we explored the role of anxiety symptoms (i.e., symptoms that would probably not fulfill DSM criteria) in relationship to healthcare utilization. METHOD: We surveyed 117 outpatients in an internal medicine clinic regarding four types of anxiety symptoms (i.e., mixed anxiety features, generalized anxiety, obsessive-compulsive personality features, worry), and through a retrospective review of medical records, examined healthcare utilization patterns. RESULTS: Nearly 28% of participants endorsed "positive" results on at least three of the anxiety-symptom measures. When examined for relationships to healthcare utilization, only obsessive-compulsive personality features demonstrated a significant relationship. CONCLUSIONS: While anxiety symptoms were common in this primary care sample, their impact on healthcare utilization was limited, in that only obsessive-compulsive personality features demonstrated a relationship.

The S. cerevisiae Mag1 3-methyladenine DNA glycosylase modulates susceptibility to homologous recombination.

DNA glycosylases, such as the Mag1 3-methyladenine (3MeA) DNA glycosylase, initiate the base excision repair (BER) pathway by removing damaged bases to create abasic apurinic/apyrimidinic (AP) sites that are subsequently repaired by downstream BER enzymes. Although unrepaired base damage may be mutagenic or recombinogenic, BER intermediates (e.g. AP sites and strand breaks) may also be problematic. To investigate the molecular basis for methylation-induced homologous recombination events in Saccharomyces cerevisiae, spontaneous and methylation-induced recombination were studied in strains with varied MAG1 expression levels. We show that cells lacking Mag1 have increased susceptibility to methylation-induced recombination, and that disruption of nucleotide excision repair (NER; rad4) in mag1 cells increases cellular susceptibility to these events. Furthermore, expression of Escherichia coli Tag 3MeA DNA glycosylase suppresses recombination events, providing strong evidence that unrepaired 3MeA lesions induce recombination. Disruption of REV3 (required for polymerase zeta (Pol zeta)) in mag1 rad4 cells causes increased susceptibility to methylation-induced toxicity and recombination, suggesting that Pol zeta can replicate past 3MeAs. However, at subtoxic levels of methylation damage, disruption of REV3 suppresses methylation-induced recombination, indicating that the effects of Pol zeta on recombination are highly dose-dependent. We also show that overproduction of Mag1 can increase the levels of spontaneous recombination, presumably due to increased levels of BER intermediates. However, additional APN1 endonuclease expression or disruption of REV3 does not affect MAG1-induced recombination, suggesting that downstream BER intermediates (e.g. single strand breaks) are responsible for MAG1-induced recombination, rather than uncleaved AP sites. Thus, too little Mag1 sensitizes cells to methylation-induced recombination, while too much Mag1 can put cells at risk of recombination induced by single strand breaks formed during BER.

National Institutes of Health Consensus Development Conference Statement: adjuvant therapy for breast cancer, November 1-3, 2000.

OBJECTIVE: Our goal was to provide health-care providers, patients, and the general public with an assessment of currently available data regarding the use of adjuvant therapy for breast cancer. PARTICIPANTS: The participants included a non-Federal, non-advocate, 14-member panel representing the fields of oncology, radiology, surgery, pathology, statistics, public health, and health policy as well as patient representatives. In addition, 30 experts in medical oncology, radiation oncology, biostatistics, epidemiology, surgical oncology, and clinical trials presented data to the panel and to a conference audience of 1000. EVIDENCE: The literature was searched with the use of MEDLINE(TM) for January 1995 through July 2000, and an extensive bibliography of 2230 references was provided to the panel. Experts prepared abstracts for their conference presentations with relevant citations from the literature. Evidence from randomized clinical trials and evidence from prospective studies were given precedence over clinical anecdotal experience. CONSENSUS PROCESS: The panel, answering predefined questions, developed its conclusions based on the evidence presented in open forum and the scientific literature. The panel composed a draft statement, which was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference. The draft statement was made available on the World Wide Web immediately after its release at the conference and was updated with the panel's final revisions. The statement is available at http://consensus.nih.gov. CONCLUSIONS: The panel concludes that decisions regarding adjuvant hormonal therapy should be based on the presence of hormone receptor protein in tumor tissues. Adjuvant hormonal therapy should be offered only to women whose tumors express hormone receptor protein. Because adjuvant polychemotherapy improves survival, it should be recommended to the majority of women with localized breast cancer regardless of lymph node, menopausal, or hormone receptor status. The inclusion of anthracyclines in adjuvant chemotherapy regimens produces a small but statistically significant improvement in survival over non-anthracycline-containing regimens. Available data are currently inconclusive regarding the use of taxanes in adjuvant treatment of lymph node-positive breast cancer. The use of adjuvant dose-intensive chemotherapy regimens in high-risk breast cancer and of taxanes in lymph node-negative breast cancer should be restricted to randomized trials. Ongoing studies evaluating these treatment strategies should be supported to determine if such strategies have a role in adjuvant treatment. Studies to date have included few patients older than 70 years. There is a critical need for trials to evaluate the role of adjuvant chemotherapy in these women. There is evidence that women with a high risk of locoregional tumor recurrence after mastectomy benefit from postoperative radiotherapy. This high-risk group includes women with four or more positive lymph nodes or an advanced primary cancer. Currently, the role of postmastectomy radiotherapy for patients with one to three positive lymph nodes remains uncertain and should be tested in a randomized controlled trial. Individual patients differ in the importance they place on the risks and benefits of adjuvant treatments. Quality of life needs to be evaluated in selected randomized clinical trials to examine the impact of the major acute and long-term side effects of adjuvant treatments, particularly premature menopause, weight gain, mild memory loss, and fatigue. Methods to support shared decision-making between patients and their physicians have been successful in trials; they need to be tailored for diverse populations and should be tested for broader dissemination.

Evaluating microbial indicators of environmental condition in Oregon rivers.

Traditional bacterial indicators used in public health to assess water quality and the Biolog system were evaluated to compare their response to biological, chemical, and physical habitat indicators of stream condition both within the state of Oregon and among ecoregion aggregates (Coast Range, Willamette Valley, Cascades, and eastern Oregon). Forty-three randomly selected Oregon river sites were sampled during the summer in 1997 and 1998. The public health indicators included heterotrophic plate counts (HPC), total coliforms (TC), fecal coliforms (FC) and Escherichia coli (EC). Statewide, HPC correlated strongly with physical habitat (elevation, riparian complexity, % canopy presence, and indices of agriculture, pavement, road, pasture, and total disturbance) and chemistry (pH, dissolved O2, specific conductance, acid-neutralizing capacity, dissolved organic carbon, total N, total P, SiO2, and SO4). FC and EC were significantly correlated generally with the river chemistry indicators. TC bacteria significantly correlated with riparian complexity, road disturbance, dissolved O2, and SiO2 and FC. Analyzing the sites by ecoregion, eastern Oregon was characterized by high HPC, FC, EC, nutrient loads, and indices of human disturbance, whereas the Cascades ecoregion had correspondingly low counts of these indicators. The Coast Range and Willamette Valley presented inconsistent indicator patterns that are more difficult to characterize. Attempts to distinguish between ecoregions with the Biolog system were not successful, nor did a statistical pattern emerge between the first five principle components and the other environmental indicators. Our research suggests that some traditional public health microbial indicators may be useful in measuring the environmental condition of lotic systems.

A community health promotion partnership model: the South Carolina health connection.

Over a five year period, the South Carolina Health Connection Project has evolved to multi-site, multi-organization community-base collaborative initiative. From this project over $60,000.00 in funds have been secured. However, when costing the human resources and many other in-kind contributions involved in the SCHC Projects activities, the Project can modestly be valued at nearly $200,000.00. The efforts of a few have been shared with others, who also shared the resources with others, and the health promotion empowerment cycle continues. We believe the South Carolina Health Connection is an exemplary of a Community Health Promotion Partnership Model. We hope you will agree!

Self-esteem matters: racial & gender differences among rural southern adolescents.

Self-esteem does matter! It matters so much that Oprah dedicated an entire issue of "O" magazine to address the subject. "It's a woman's most treasured possession" (Winfrey, 2000a). Self-esteem has a profound influence on adolescent health promotion behaviors. This study contributes to understanding the role self-esteem plays in the behavior of adolescents. Utilizing a secondary data analysis, race and gender self-esteem differences among adolescents were investigated. The sample of 1,237 students (46% African-American and 52% White) from rural southern areas consisted of 744 females and 493 males. Self-esteem was assessed using the Miller Self-esteem Questionnaire (SEQ). The Hendricks Perceptual Health Promoting Determinants Model (HPHD) provided the theoretical framework for the study. The results of the study revealed a statistically significant difference in various aspects of self-esteem according to race and gender. African-Americans and males had a higher self-esteem which is consistent with many prior studies.

Developing community partnerships to promote adolescent health.

The author discusses a very successful community partnership entitled the "South Carolina Health Connection Project (SCHCP) established in the state of South Carolina to curtail the high incidence of teenage pregnancies in that state. Over 18 community organizations supported the project funded by the American Association for the Advancement of Science (AAAS) in 1997 in which 2,000 youth participated.

Health promoting behaviors among rural southern early adolescents.

A central element in attaining the goals and objectives of Healthy People 2010 is promoting healthy behavior lifestyles. Health promotion continues to be sanctioned as the long term most cost effective approach to a reduction in preventable health problems. Adolescents are presently an age group in jeopardy of making the transition into adulthood with healthy lifestyles. This paper describes the use of the Health Promoting Lifestyle Profile (HPLP) (Walker, Sechrist, and Pender, 1987) as a measure of health promoting behaviors in a group of rural southern early adolescents (1036 seventh and eight graders; 81% were African American). The findings suggest that rural southern adolescents perceive themselves to be enganging in health promoting lifestyle behaviors. However, some HPLP subscales seemed to be especially difficult for adolescents.

Fostering Healthy Communities @ Hair Care Centers.

The author discusses the planning and development of a unique method of reaching African American clients by Chi Eta Phi Sorority, Inc. members in the state of South Carolina through use of beauty shops and barber shops, which is termed Hair Care Centers. Using bulletin boards which are placed in these establishments, the members of Chi Eta Phi Sorority, Inc. change the educational materials monthly based on the minority health awareness themes created by the Office of Minority Health in Washington, DC. The goal of Project F-HC is to take self-care, health promoting, disease prevention information to places where persons frequent, making it easily accessible.