Coping with access barriers to non-communicable disease medicines: qualitative patient interviews in eight counties in Kenya.

BACKGROUND: There is rich literature on barriers to medicines access for the treatment of non-communicable diseases (NCDs) in high-income countries. Less is known about low- and middle-income countries, in particular the differences in coping with medicines access barrier by household wealth and disease. The aim of this study was to compare the coping mechanisms of patients with the lack of availability and affordability of cardio-vascular diseases, diabetes and asthma medicines in Kenya. METHODS: This qualitative study was part of a larger mixed methods evaluation study conducted in eight counties of Kenya from 2016 to 2019. Forty-nine patient interviews at study end line explored their NCD journey, perceptions of availability, stockouts and affordability of NCD medicines, their enrollment in health insurance, and their relationship with the private chemists. Transcribed interviews were coded using Nvivo software. A two-step thematic approach was used, first conducting a priority coding which was followed by coding emerging and divergent themes. RESULTS: Overall, we found that patients across all disease types and wealth level faced frequent medicine stock-outs at health facilities. In the absence of NCD medicines at health facilities, patients coped by purchasing medicines from local chemists, switching health facilities, requesting a different prescription, admitting oneself to an inpatient facility, establishing connections with local staff to receive notifications of medicine stock, stocking up on medicines, utilizing social capital to retrieve medicines from larger cities and obtaining funds from a network of friends and family. Categorizing by disease revealed patterns in coping choices that were based on the course of the disease, severity of the symptoms and the direct and indirect costs incurred as a result of stockouts of NCD medicines. Categorizing by wealth highlight differences in households' capacity to cope with the unavailability and unaffordability of NCD medicines. CONCLUSIONS: The type of coping strategies to access barriers differ by NCD and wealth group. Although Kenya has made important strides to address NCD medicines access challenges, prioritizing enrollment of low wealth households in county health insurance programs and ensuring continuous availability of essential NCD medicines at public health facilities close to the patient homes could improve access.

Protein alterations associated with temozolomide resistance in subclones of human glioblastoma cell lines.

Temozolomide (TMZ) is the standard chemotherapeutic agent for human malignant glioma, but intrinsic or acquired chemoresistance represents a major obstacle to successful treatment of this highly lethal group of tumours. Obtaining better understanding of the molecular mechanisms underlying TMZ resistance in malignant glioma is important for the development of better treatment strategies. We have successfully established a passage control line (D54-C10) and resistant variants (D54-P5 and D54-P10) from the parental TMZ-sensitive malignant glioma cell line D54-C0. The resistant sub-cell lines showed alterations in cell morphology, enhanced cell adhesion, increased migration capacities, and cell cycle arrests. Proteomic analysis identified a set of proteins that showed gradual changes in expression according to their 50% inhibitory concentration (IC(50)). Successful validation was provided by transcript profiling in another malignant glioma cell line U87-MG and its resistant counterparts. Moreover, three of the identified proteins (vimentin, cathepsin D and prolyl 4-hydroxylase, beta polypeptide) were confirmed to be upregulated in high-grade glioma. Our data suggest that acquired TMZ resistance in human malignant glioma is associated with promotion of malignant phenotypes, and our reported molecular candidates may serve not only as markers of chemoresistance but also as potential therapeutic targets in the treatment of TMZ-resistant human malignant glioma, providing a platform for future investigations.

Self-assembling peptide nanofiber scaffold promotes the reconstruction of acutely injured brain.

Traumatic brain injury (TBI) or brain surgery may cause extensive loss of cerebral parenchyma. However, no strategy for reconstruction has been clinically effective. Our previous study had shown that self-assembling peptide nanofiber scaffold (SAPNS) can bridge the injured spinal cord, elicit axon regeneration, and eventually promote locomotor functional recovery. In the present study we investigated the effect of SAPNS for the reconstruction of acutely injured brain. The lesion cavity of the injured cortex was filled with SAPNS or saline immediately after surgically induced TBI, and the rats were killed 2 days, 2 weeks, or 6 weeks after the surgery for histology, immunohistochemistry, and TUNEL studies. Saline treatment in the control animals resulted in a large cavity in the injured brain, whereas no cavity of any significant size was found in the SAPNS-treated animals. Around the lesion site in control animals were many macrophages (ED1 positive) but few TUNEL-positive cells, indicating that the TBI caused secondary tissue loss mainly by means of necrosis, not apoptosis. In the SAPNS-treated animals the graft of SAPNS integrated well with the host tissue with no obvious gaps. Moreover, there were fewer astrocytes (GFAP positive) and macrophages (ED1 positive) around the lesion site in the SAPNS-treated animals than were found in the controls. Thus, SAPNS may help to reconstruct the acutely injured brain and reduce the glial reaction and inflammation in the surrounding brain tissue. FROM THE CLINICAL EDITOR: Self-assembling peptide nanofiber scaffold (SAPNS) was reported earlier to bridge the injured spinal cord, elicit axon regeneration, and promote locomotor recovery. In this study the effect of SAPNS for the reconstruction of acutely injured brain was investigated. In SAPNS-treated animals the graft integrated well with the host tissue with no obvious gaps. SAPNS may help to reconstruct the acutely injured brain and reduced the glial reaction and inflammation in the surrounding brain tissue.

Impact of a multidisciplinary trauma team on the outcome of acute subdural haematoma.

INTRODUCTION: To review the outcome of patients with post-traumatic acute subdural haematoma (ASDH) before and after the establishment of a hospital trauma team at a designated trauma centre. METHOD: A retrospective analysis was conducted on 82 consecutive patients who underwent surgery for post-traumatic ASDH. The 'PRE' and 'POST' groups included patients admitted before and after the establishment of a hospital trauma team, respectively. Injury severity was assessed by the admission Glasgow coma score, imaging findings, and the revised trauma score. Clinical outcome measures were the hospital length of stay and the Glasgow outcome score (GOS) upon hospital discharge. RESULTS: The overall mortality rate was 53.7%. No significant difference was found between the PRE and POST groups. The mean length of hospital stay was also comparable between the two groups. The functional status of those who survived acute hospital care was significantly better in the POST group. Good outcome (GOS of 4 or 5) was achieved in 66.7% of the survivors in the POST group, compared with 25.0% in the PRE group (p=0.024). CONCLUSION: Post-traumatic ASDH carried a poor prognosis. The mortality rate and hospital length of stay of patients were not found to be reduced after the establishment of a hospital trauma team. The latter, however, was associated with significantly better functional outcome amongst survivors. Although causality cannot be established due to the multitude of factors which may have affected patient outcome, our findings nonetheless provide further support for the introduction of a multidisciplinary hospital trauma team for the optimal care of trauma patients.

Concomitant use of Western and Chinese medicine treatments in neurosurgical patients in Hong Kong.

OBJECTIVE: To investigate the profile of concomitant use of Chinese medicine (CM) and Western medical treatment in neurosurgical patients. METHODS: A guided questionnaire survey was conducted on 309 Chinese patients under neurosurgical care in a teaching hospital in Hong Kong from June to July 2006. RESULTS: Concomitant use of CM was reported by 25.9% of patients. Age was identified to be associated with the use of CM. Half of the CM-users were unaware of there being potential risks of adverse interactions between neurosurgical and CM treatments. Among the CM-users 85% would continue to receive both treatments but only 52.0% would inform neurosurgeons on their CM use. Patients' perceived lack of benefit from CM was the main reason for not using it although 47.0% indicated their willingness to try CM given better access to information. CONCLUSIONS: Informal source was the major channel of CM use amongst patients with neurosurgical conditions. A need for improved patient education and service provision was identified and should become an important consideration for healthcare systems which anticipate an increased use of CM amongst patients. Strategies to enhance doctor-patient communications in mainstream care such as pre-operative checklists for herbal medications and post-operative advice may facilitate the safe and complementary use of both treatment systems.