Infection prevention and control in health facilities in post-Ebola Liberia: don't forget the private sector!

Setting: Recognising the importance of infection prevention and control (IPC), a minimum standards tool (MST) was developed in Liberia to guide the safe (re-) opening and provision of care in health facilities. Objectives: To analyse the implementation of specific IPC measures after the 2014 Ebola virus outbreak between June 2015 and May 2016, and to compare the relative improvements in IPC between the public and private sectors. Design: A retrospective comparative cohort study. Results: We evaluated 723 (94%) of the 769 health facilities in Liberia. Of these, 437 (60%) were public and 286 (40%) were private. There was an overall improvement in the MST scores from a median of 13 to 14 out of a maximum possible score of 16. While improvements were observed in all aspects of IPC in both public and private health facilities, IPC implementation was systematically higher in public facilities. Conclusions: We demonstrate the feasibility of monitoring IPC implementation using the MST checklist in post-Ebola Liberia. Our study shows that improvements were made in key aspects of IPC after 1 year of evaluations and tailored recommendations. We also highlight the need to increase the focus on the private sector to achieve further improvements in IPC.

Contexte : En reconnaissance de l'importance de la prévention et contrôle de l'infection (PCI), le Liberia a élaboré le « minimum standards tool ¼ (MST) afin de guider en toute sécurité l'ouverture/réouverture des structures de santé et la prestation de soins.Objectifs : Analyser la mise en œuvre des mesures spécifiques de PCI après la flambée épidémique d'Ebola en 2014, entre juin 2015 et mai 2016, et comparer les améliorations relatives de la PCI entre le secteur public et privé.Schéma : Une étude rétrospective comparative de cohorte.Résultats : Nous avons évalué 723 (94%) des 769 structures de santé au Liberia. Parmi elles, 437 (60%) étaient publiques et 286 (40%), privées. Il y a eu une amélioration générale des scores MST depuis une médiane de 13 à 14, avec un score maximal de 16. Des améliorations ont été observées dans tous les aspects de la PCI à la fois dans les structures de santé publiques et privées, mais la mise en œuvre de la PCI a été systematiquement plus élevée dans les structures publiques.Conclusions: Nous avons démontré la faisabilité du suivi de la mise en œuvre de la PCI grâce à la check-list de la MST dans le Liberia d'après Ebola. Nous avons montré des améliorations dans des aspects clés de la PCI après une année d'évaluation et adapté les recommandations de la PCI. Nous mettons également en lumière le besoin d'accorder davantage d'attention au secteur privé, de manière à faire davantage de progrès dans la PCI.

Marco de referencia: Al reconocer la importancia de las medidas de prevención y control de las infecciones (PCI), se elaboró en Liberia un instrumento de normas mínimas encaminado a orientar la apertura o reapertura y la prestación de servicios en los establecimientos de atención de salud de manera segura.Objetivos: Analizar la ejecución de medidas específicas de PCI después de la epidemia del Ébola del 2014, entre junio del 2015 y mayo del 2016, y comparar los progresos relativos en la materia entre el sector público y el sector privado.Método: Un estudio retrospectivo de cohortes comparativo.Resultados: Se evaluaron 723 de los 769 establecimientos de salud de Liberia (94%). De estos, 437 pertenecían al sector público (60%) y 286 (40%) al sector privado. Se observó una mejoría global en las puntuaciones del instrumento de normas mínimas de una mediana de 13 a 14, sobre una puntuación máxima de 16. Hubo progresos en todos los aspectos de PCI en los establecimientos del sector público y privado, pero su aplicación fue sistemáticamente más alta en los centros del sector público.Conclusiones: El presente estudio puso en evidencia la factibilidad de vigilar la ejecución de las medidas de PCI utilizando la lista de verificación del instrumento de normas mínimas, después de la epidemia del Ébola en Liberia. Los resultados revelaron progresos en aspectos primordiales, después de un año de evaluaciones y recomendaciones adaptadas en materia de PCI. Se destacó además la necesidad de aumentar la atención prestada al sector privado, con el fin de promover mayores progresos en este campo.

Apolipoprotein D--an atypical apolipoprotein.

The structure of ApoD and its sites of synthesis have been discovered. These characteristics differ from those of the other apolipoproteins. The role of ApoD in the plasma lipoprotein system remains to be discovered, but the recent, rapid increase in our knowledge of this protein suggests that it plays an important role in the homeostasis or housekeeping of probably all organs. One of its functions is likely to be the transport of a hydrophobic ligand (a lipid) in a one-to-one molar ratio with itself. This transport is likely to occur unidirectionally between neighboring cells in an organ, and between perivascular cells and the blood circulation. The chemical structure of the natural ligand, or ligands, of ApoD in normal cells in vivo or in culture is not known, but ApoD has been shown to bind some steroids and bilirubin. Remarkable upregulation of synthesis of ApoD has been observed during regeneration of injured peripheral nerves. Perhaps the physiologic role of ApoD will prove to be more interesting and of equal importance in biology to the roles of the other apolipoproteins in cardiovascular disease.

Physical characterization of the stratum corneum of an in vitro human skin equivalent produced by tissue engineering and its comparison with normal human skin by ATR-FTIR spectroscopy and thermal analysis (DSC).

An in vitro human skin equivalent may be obtained by culturing human keratinocytes on a collagen gel containing fibroblasts. The anchored skin equivalent cultured at the air-liquid interface closely resembles human skin and is acceptable for in vitro percutaneous absorption. However, it is still more permeable than human skin. Since intercellular lipids have been recognized to play an important role in skin permeability, infrared spectroscopy and differential scanning calorimetry were performed on the stratum corneum of bovine or human skin equivalents grown at different days of air-liquid culture. The symmetric and asymmetric CH(2) stretching vibrations suggested that for all days observed, the intercellular lipids were less organized than those in human skin, irrespective of whether bovine or human collagen was used. Different culture conditions were also tested and the medium without serum and no epidermal growth factor at the air-liquid culture showed results significantly more comparable to human skin. Actually, the thermal behavior of in vitro stratum corneum showed transitions at lower temperatures than human skin. The transition around 80 degrees C, in the form of a lipid-protein complex, was absent. These results showed that the structural arrangement of intercellular lipids and their thermodynamic properties hold a crucial role in the barrier function of the stratum corneum.

The utilization of recombinant prostanoid receptors to determine the affinities and selectivities of prostaglandins and related analogs.

Stable cell lines that individually express the eight known human prostanoid receptors (EP(1), EP(2), EP(3), EP(4), DP, FP, IP and TP) have been established using human embryonic kidney (HEK) 293(EBNA) cells. These recombinant cell lines have been employed in radioligand binding assays to determine the equilibrium inhibitor constants of known prostanoid receptor ligands at these eight receptors. This has allowed, for the first time, an assessment of the affinity and selectivity of several novel compounds at the individual human prostanoid receptors. This information should facilitate interpretation of pharmacological studies that employ these ligands as tools to study human tissues and cell lines and should, therefore, result in a greater understanding of prostanoid receptor biology.

Quantitative study of glutamic acid decarboxylase-immunoreactive neurons and cytochrome oxidase activity in normal and partially deafferented rat hindlimb somatosensory cortex.

Somatosensory cortex reorganizes following restricted deafferentation so that deprived neurons acquire new receptive fields. Electrophysiological data suggest that a decrease in inhibition might be one of the mechanisms contributing to these changes. This hypothesis was tested by evaluating quantitatively glutamic acid decarboxylase (GAD) immunoreactivity and cytochrome oxidase (CO) activity in normal and partially deafferented rat hindlimb somatosensory cortex. In normal animals, there were laminar differences in the frequencies of GAD+ cells that correlated with the levels of CO activity. Two weeks after transection of the sciatic nerve, CO levels were reduced in all layers of the hindlimb somatosensory cortex contralateral to the nerve transection whereas the frequencies of GAD+ cells were unchanged except in layer IV where a 16% decrease was observed. This observation is consistent with the hypothesis that the expression of GAD in layer IV is partially controlled by the amount of afferent input. The ability of novel inputs to develop stable patterns of excitation in deafferented somatosensory cortex may depend upon the reduction of GABAergic inhibition which follows deafferentation.

Cytosolic phospholipase A2, cyclo-oxygenases and arachidonate in human stomach tumours.

Human stomach tumours usually form more prostaglandins (PGs) than their associated normal mucosa/submucosa, but the mechanisms are not fully understood. The key enzymes are cytosolic phospholipase A2 (cPLA2, Mr 85,000) and the cyclo-oxygenases (COXs) which exist in constitutive (COX-1) and inducible forms (COX-2). In human stomach tumours and associated macroscopically normal tissues, we determined the fatty acid composition by gas chromatography, amounts of cPLA2, COX-1 and COX-2 by immunoblotting with specific antibodies and cPLA2 enzyme activity using a tritiated substrate. Although compared to normal mucosa there was less arachidonate in tumours (P < 0.05), the arachidonate/total fatty acid ratio was higher. Mean amounts of cPLA2 and COX-1 and cPLA2 activity were similar in tumours and normal mucosa. However, substantial amounts of COX-2 were found in the tumours but not in the mucosa, which may explain why many gastric tumours form increased amounts of PGs.

T lymphocyte responses to multiple minor histocompatibility antigens generate both self-major histocompatibility complex-restricted and cross-reactive cytotoxic T lymphocytes.

Minor histocompatibility antigens (MiHA) may represent ideal targets for cancer immunotherapy since (1) the expression of many MiHA is tissue specific and (2) they can trigger potent T lymphocyte responses. A primary objective of our research program is to characterize T cell responses to cells displaying multiple incompatible MiHA. Early in the course of this work, we observed in various stimulator/responder combinations that immunization versus multiple MiHA generated cytotoxic effectors that killed not only stimulator cells but also a large panel of MHC-identical and MHC-different targets. To characterize the cells responsible for this cytotoxic activity and their specificity, we expanded polyclonal and clonal CD3+ CD4- CD8+ LP anti-C57BL/6 effectors. LP anti-C57BL/6 polyclonal effectors (LPTc cell line) showed strong cytotoxic activity when tested against several H-2b and non-H-2b targets, but displayed, respectively, weak or absent cytotoxicity against MHC class I-deficient cells and syngeneic cells. When used as cold targets, C57BL/6 cells inhibited the lysis of all H-2b and non-H-2b cells. Some H-2b, but no H-2d or H-2k, cold targets inhibited the lysis of C57BL/6 targets. With the exception of LP and C57BL/6, all types of H-2b cells (A.BY, D1.LP and C3H.SW) showed complete reciprocal inhibition of lysis. The same observation was made for non-H-2b targets. The cytotoxicity profile of 12/14 LP anti-C57BL/6 clones was identical to that of the LPTc cell line, while 2/14 clones recognized only H-2b cells. Cytotoxicity was inhibited by incubation of effector cells with anti-CD3 or anti-CD8 antibodies and by incubation of target cells with specific anti-MHC class I antibodies. These results show that immunization against multiple MiHA in the context of self-MHC generates 2 types of CTL: some are strictly self-MHC restricted while others are strongly cross-reactive and recognized MHC-peptide complexes on allogeneic MHC-different targets. This observation has significant implications concerning the use of anti-MiHA T cells in cancer immunotherapy.

The effects of strychnine on neurons in cat somatosensory cortex and its interaction with the inhibitory amino acids, glycine, taurine and beta-alanine.

In area 3b of primary somatosensory cortex, neurons may be classified as either rapidly adapting or slowly adapting to sustained stimuli and may be differentiated further by the presence or absence of a receptive field and by their threshold of activation. It is also possible to use the rate of adaptation of the background activity to a sustained stimulus to divide the cortex into slowly adapting regions or rapidly adapting regions. By blocking GABA-mediated inhibition with iontophoretically administered bicuculline methiodide, others have observed an increase in receptive field size in rapidly adapting regions but not in slowly adapting regions. The present study was designed to look for a different inhibitory transmitter which might control receptive field size in slowly adapting regions. Iontophoretically delivered strychnine was employed as an antagonist because it interferes with glycine-like inhibitory transmitters such as glycine, taurine and beta-alanine. Pharmacological tests were performed on 157 neurons in two series of experiments. In the first series three effects were documented. (i) In rapidly adapting regions, the size of the receptive field increased in 11 out of 25 cases whereas none of the 20 receptive fields tested in slowly adapting regions enlarged. (ii) In 13 of 24 cases a receptive field was revealed for previously unresponsive neurons in rapidly adapting regions whereas only 5 of 22 unresponsive cells tested in slowly adapting regions developed a receptive field. (iii) In 15 of 25 cells with receptive fields tested in rapidly adapting zones, strychnine reduced the threshold for somatic stimuli but only 8 of 20 cells isolated in slowly adapting zones showed this effect. In a second series of experiments, the effect of beta-alanine, glycine and taurine was examined on neurons of the rapidly adapting regions. beta-Alanine and taurine reduced the excitability of all neurons tested. Glycine inhibited most neurons. However, strychnine only antagonized the inhibitory effects of beta-alanine on responses to peripheral stimuli (9 of 11 cases). When neurons could not be driven by peripheral stimuli, the inhibition of spontaneous or glutamate-induced activity could not be blocked by strychnine (0 of 18 cases). We suggest that glycine-like amino acids contribute to the control of receptive field size and the control of neuronal excitability in rapidly adapting regions but not in slowly adapting regions. Our data suggest that strychnine-sensitive synapses are limited only to a subset of cortical neurons driven by somatic inputs.

Acetylcholine permits long-term enhancement of neuronal responsiveness in cat primary somatosensory cortex.

Acetylcholine (ACh) was administered iontophoretically to single neurons in cat somatosensory cortex. Using extracellular recording techniques, neuronal responsiveness was determined at regular intervals from the number of action potentials produced either by iontophoretically applied glutamate or by tactile stimulation of the cutaneous receptive field. The responses were altered in only 21% (13/61) of the neurons following the application of ACh alone. In contrast, 75% (66/88) of the neurons displayed altered responses during administration of ACh simultaneously with either iontophoretically administered glutamate or with tactile stimulation of the receptive field. Forty-seven percent (29/62) of the responses potentiated in the presence of ACh remained enhanced for periods lasting from 8 min to over 1 h. The responsiveness of cortical neurons to afferent inputs changes during the reorganization of somatotopic maps that occurs after deafferentation, and perhaps during some forms of learning. As ACh has been implicated in some of these processes, it may be that the changes in responsiveness observed here following iontophoretically applied ACh are similar to those which facilitate the acquisition of neuronal responses to altered or novel afferent inputs.

Production of bioengineered cancer tissue constructs in vitro: epithelium-mesenchyme heterotypic interactions.

A few models have been established to study cancer cells in vitro. However, the cellular interactions have rarely been studied specifically using bioengineered cancer constructs combining human carcinoma cells and tumor-associated fibroblasts. We developed an in vitro model of tridimensional bioengineered cancer tissue constructs (bCTC) by seeding mammary epithelial cancer cells or normal keratinocytes over a mesenchymal layer containing tumor-derived fibroblastic cells or normal skin fibroblasts. After the introduction of epithelial cells, each construct was cultured for another 10 d. Histologic analyses showed that carcinoma cell lines could invade the subjacent mesenchymal layer and that the capacity to migrate was related to the invasive potential of cancer cells and the type of fibroblasts used, while noninvasive populations did not. Of the tested epithelial cells, MDA-MB-231 and, to a lesser degree, HDQ-P1 cell lines were invasive, and the invasion was deeper into the mesenchymal component containing tumor-derived fibroblasts. However, with normal skin fibroblasts, the mesenchymal layer was degraded twice faster than with tumor-derived fibroblastic cells. MDA-MB-231 cells and normal keratinocytes induced the highest level of gelatinase B, and the level was lowest with the MCF-7 cell line. The activated form of gelatinase B was, however, induced to the highest levels in the keratinocyte-seeded bCTC containing tumor-derived but not normal fibroblasts. MDA-MB-231 was the only epithelial cancer cell line whose activity of gelatinase A was reduced when cocultured with tumor-derived fibroblasts but not under normal fibroblast stimulation. Finally, a 50/48-kDa gelatinase band has been observed in bCTCs with noninvasive epithelial cells only. Our study demonstrates the selective secretion of gelatinases according to the phenotype of the cells seeded in the various bCTCs.

Multistep production of bioengineered skin substitutes: sequential modulation of culture conditions.

Many studies are being conducted to define the role of growth factors in cutaneous physiology in order to add cytokines in a timely fashion for optimal tissue engineering of skin. This study is aimed at developing a multistep approach for the production of bioengineered skin substitutes, taking into account the effects of various growth factors according to the culture time. The use of a serum-supplemented medium throughout the whole culture period of skin substitutes was compared to the sequential use of specific additives at defined culture steps. Histological analysis revealed that serum was necessary for keratinocyte proliferation and migration on dermal substitutes during the first 2 d after their seeding. However, the serum-free medium presented some advantages when supplemented with different additives at specific culture steps. Interestingly, ascorbic acid added to the dermal substitutes before and after keratinocyte seeding maintained their cuboidal morphology in the basal epidermal layer. In the absence of serum, collagen matrix degradation slowed down, and a better multilayered epidermal organization was obtained, notably with retinoic acid. Stratum corneum formation was also enhanced by fatty acids. Thus, sequential addition of exogenous factors to the medium used to produce skin substitutes can improve their structural features and functional properties in vitro.

Skin equivalent produced with human collagen.

Several studies have recently been conducted on cultured skin equivalent (SE), prepared using human keratinocytes seeded on various types of dermal equivalents (DE). We previously showed the advantages of our anchorage method in preventing the severe surface reduction of DE due to fibroblast contractile properties in vitro. A new anchored human SE was established in our laboratory in order to obtain a bioengineered tissue that would possess the appropriate histological and biological properties. In order to compare the effects of different collagen origins on the evolution of SE in vitro, human keratinocytes were seeded on three types of anchored DE. A comparative study was carried out between bovine SE (bSE), human SE (hSE), and human skin equivalent containing additional dermal matrix components (hSE+). Immunohistological analysis showed that hSE and hSE+ presented good structural organization, including the deposition of several basement membrane constituents. Higher amounts of transglutaminase, ceramides, and keratin 1 were detected in the epidermal layers of all SE when cultured at the air-liquid interface. However, a 92 kDa gelatinase activity was higher in bovine skin equivalent (bSE) compared to hSE cultures. The use of human collagens comparatively to bovine collagen as SE matricial component delayed the degradation of the dermal layer in culture.

Selective culture of epithelial cells from primary breast carcinomas using irradiated 3T3 cells as feeder layer.

The main drawback of the selective culture of human mammary epithelial cells from primary breast cancer is the overgrowth of tumor-associated stromal fibroblasts. This drawback may be overcome by using, in primary culture, lethally irradiated 3T3 cells which act as a feeder layer to maintain tumor-derived epithelial cell proliferation. These 3T3 cells, exposed to 60 Gy at confluence, form a specific cellular substrate which constitutes an obstacle to fibroblast attachment. Enzyme-disaggregated breast cells from six primary breast carcinomas were cocultured over lethally irradiated but living 3T3 cells. The method led to the purification of tumor-derived epithelial cells from all six cancer samples, and long-term culture was obtained in one. The epithelial nature of these purified tumor-derived epithelial cells was demonstrated by their general morphology and by the expression of cytokeratins and Epithelial Membrane Antigen. These results confirm the stimulatory effect of a this stromal feeder layer on breast epithelial cell growth and show that this stromal feeder layer can also control the fibroblast overgrowth. Our results provide an alternative approach in the selective culture of epithelial cells from primary breast carcinoma.

Interaction structure of husbands' and wives' disclosure of marital conflict to their respective best friend.

Husbands' and wives' conversations with their respective best friend (N = 88) were coded to assess spouses' and friends' mutual influence in regulating support and interference with regard to spouses' marriage and to assess the impact of spouses' sex and marital satisfaction on the conversation processes. Dissatisfied husbands and wives expressed fewer positive and more negative views of marriage than satisfied husbands and wives and the friends in the 2 groups. There were no group and no sex differences in interference sequences. There were group and sex differences in support sequences. Friends of satisfied wives and those of dissatisfied husbands were more likely than satisfied wives and dissatisfied husbands to get support for their positive views of marriage. The findings are discussed with reference to the specific effects of outsiders' support and interference on satisfied and dissatisfied spouses.

A prospective pilot study investigating the musculoskeletal pain in postmenopausal breast cancer patients receiving aromatase inhibitor therapy.

BACKGROUND: Although arthralgia is a known adverse effect of aromatase inhibitor (ai) treatment in postmenopausal breast cancer patients, few studies have carried out a comprehensive evaluation of the nature, onset, and incidence of musculoskeletal (msk) pain in these patients. We therefore used a pilot study to identify conditions or markers predictive of pain. METHODS: For 24 weeks, we monitored 30 eligible postmenopausal women starting ai therapy. Pre-existing and incident msk conditions and pain were assessed clinically and with ultrasonography of the hands and wrists. In addition, patient questionnaires were used to assess pain before and during ai therapy. Biochemical markers were measured at baseline and at regular intervals after anastrozole therapy began. Gene profiling studies were carried out before and 48 hours after the initial ai administration. RESULTS: Over the 24-week study period, 20 participants (67%) showed no pain symptoms; 5 (17%) experienced low or moderate pain at baseline, which did not increase with ai treatment; and during therapy, 5 (17%) showed exacerbation of pain attributable to osteoarthritis of the hand and to finger flexor tenosynovitis. Although all 30 participants had some degree of msk conditions before anastrozole therapy started, the pre-existing conditions did not necessarily predispose the women to increased pain during anastrozole treatment. Higher levels of urinary N-telopeptides of type i collagen were associated with the groups presenting pain, suggesting a higher extent of pre-existing bone resorption, without significant evolution over the 24-week treatment period. Slightly higher levels of 1,25(OH)(2) vitamin D(3) were observed at baseline in patients with pain increase, but did not significantly change during treatment; however, average levels of 25(OH) vitamin D(3) increased, likely because of supplementation. Although biochemical markers did not discriminate efficiently between pain groups, a signature of 166 genes in peripheral blood mononuclear cells was identified that could stratify patients into the various groups observed in this pilot study. The gene signature was enriched in components of inflammatory signalling and chemokine expression, of antitumoural immunity pathways, and of metabolic response to hormones and xenobiotics, although no clinically significant association could be made in the present study, considering the small number of patients. Nevertheless, the observed trend suggests the feasibility of developing surrogate predictive markers of msk pain. Patient compliance was high in this study and was not affected by pain exacerbation. CONCLUSIONS: Baseline msk assessment showed pre-existing causes for pain in most of the study patients before initiation of the ai. Exacerbation of existing osteoarthritis pain and tenosynovial symptoms was the primary cause of pain increase. Musculoskeletal pain assessment at baseline and prompt treatment of pain symptoms may help to optimize adherence to ai therapy. The value of routinely assessing inflammatory markers such as C-reactive protein and erythrocyte sedimentation rate was not supported by our pilot study. Gene expression profiles in peripheral blood mononuclear cells may be further explored in larger-scale studies as stratification markers to identify patients at risk of developing arthralgia.

Electrophysiological studies of acetylcholine and the role of the basal forebrain in the somatosensory cortex of the cat. I. Cortical neurons excited by glutamate.

1. Microelectrodes attached to iontophoretic pipettes were used to isolate 410 single neurons in the primary somatosensory cortex of halothane-anesthetized cats. Basal forebrain (BF) stimulation, when paired with pulses of iontophoretically administered glutamate, affected the responsiveness in 24 (54%) of 39 neurons; 17 were facilitated, and seven were inhibited. Five minutes after BF stimulation the average response for a sample of 20 cells was enhanced by 45% (+/- 19). All but one of the effects lasted as long as the cell was studied, often greater than 1 h. 2. When atropine was administered while the BF was stimulated during glutamate excitation, 7 of 16 cells were enhanced, but the average increase was only 16% (+/- 15) for a sample of 15 cells. After the atropine had dissipated, four cells were enhanced by the BF stimulus. In three of these the enhancement had been blocked previously by atropine. 3. BF stimulation had effects similar to iontophoretically administered acetylcholine (ACh), but the effects appeared more frequently with BF stimulation than they had with acetylcholine administration. 4. We propose that the enhanced neuronal responsiveness is due to the release of acetylcholine by cortical terminals of cholinergic neurons located in the BF. The BF stimulus may be more effective than acetylcholine administration because corticopetal cholinergic fibers may end in the immediate vicinity of receptors responsible for long-term changes in membrane permeability.