Reasons for implementation success despite health system constraints: qualitative insights on 'what worked' for cotrimoxazole preventive therapy.

BACKGROUND: Although Cotrimoxazole preventive therapy (CPT) has shown to be highly efficacious in reducing morbidity and mortality among people living with Human immunodeficiency virus (HIV) under 'ideal world' study conditions, operational challenges are limiting its effectiveness when implementing in countries most affected by the HIV epidemic. The fact that Mozambican authorities reported high coverage of CPT among patients with HIV, has led to this qualitative case study aimed at exploring possible factors responsible for the successful implementation of CPT in the Province of Maputo. METHODS: Between February and April 2019, we individually interviewed nine governmental stakeholders, including the person responsible for the HIV Program, the person responsible for the TB Program and the person responsible for Pharmaceutical management at three administrative levels (central, provincial and district level). Interviews were recorded, transcribed, and analysed thematically using MAXQDA Analytics Pro. Findings were translated from Portuguese into English. RESULTS: Five themes iteratively emerged: (a) Role of governance & leadership, (b) Pharmaceutical strategies, (c) Service delivery modifications, (d) Health care provider factors, and (e) Patients' perspectives. Interviews revealed that continuous supply of cotrimoxazole (CTZ) had been facilitated through multiple-source procurement and a push-pull strategy. One part of CTZ arrived in kits that were imported from overseas and distributed to public health facilities based on their number of outpatient consultations (push strategy). Another part of CTZ was locally produced and distributed as per health facility demand (pull strategy). Strong district level accountability also contributed to the public availability of CTZ. Interviewees praised models of differentiated care, the integrated HIV service delivery and drug delivery strategies for reducing long queues at the health facility, better accommodating patients' needs and reducing their financial and organisational burden. CONCLUSIONS: This study presents aspects that governmental experts believed to be key for the implementation of CPT in the Province of Maputo, Mozambique. Enhancing the implementation outcomes - drug availability and feasibility of the health facility-based service delivery - seemed crucial for the implementation progress. Reasons for the remarkable patient acceptability of CPT in our study setting should be further investigated.

MOF-based heterogeneous catalysis in continuous flow via incorporation onto polymer-based spherical activated carbon supports.

We present an approach to harnessing the tuneable catalytic properties of complex nanomaterials for continuous flow heterogeneous catalysis by combining them with the scalable and industrially implementable properties of carbon pelleted supports. This approach, in turn, will enable these catalytic materials, which largely currently exist in forms unsuitable for this application (e.g. powders), to be fully integrated into large scale, chemical processes. A composite heterogeneous catalyst consisting of a metal-organic framework-based Lewis acid, MIL-100(Sc), immobilised onto polymer-based spherical activated carbon (PBSAC) support has been developed. The material was characterised by focused ion beam-scanning electron microscopy-energy dispersive X-ray analysis, powder X-ray diffraction, N2 adsorption, thermogravimetric analysis, atomic absorption spectroscopy, light scattering and crush testing with the catalytic activity studied in continuous flow. The mechanically robust spherical geometry makes the composite material ideal for application in packed-bed reactors. The catalyst was observed to operate without any loss in activity at steady state for 9 hours when utilised as a Lewis acid catalyst for the intramolecular cyclisation of (±)-citronellal as a model reaction. This work paves the way for further development into the exploitation of MOF-based continuous flow heterogeneous catalysis.

HIV infection increases the risk of acquiring Plasmodium vivax malaria: a 4-year cohort study in the Brazilian Amazon HIV and risk of vivax malaria.

Globally, malaria and human immunodeficiency virus (HIV) are both independently associated with a massive burden of disease and death. While their co-infection has been well studied for Plasmodium falciparum, scarce data exist regarding the association of P. vivax and HIV. In this cohort study, we assessed the effect of HIV on the risk of vivax malaria infection and recurrence during a 4-year follow-up period in an endemic area of the Brazilian Amazon. For the purpose of this study, we obtained clinical information from January 2012 to December 2016 from two databases. HIV screening data were acquired from the clinical information system at the tropical hospital Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD). The National Malaria Surveillance database (SIVEP malaria) was utilized to identify malaria infections during a 4-year follow-up period after diagnosis of HIV. Both datasets were combined via data linkage. Between 2012 and 2016, a total of 42,121 people were screened for HIV, with 1569 testing positive (3.7%). Out of all the patients diagnosed with HIV, 198 had at least one episode of P. vivax malaria in the follow-up. In the HIV-negative group, 711 participants had at least one P. vivax malaria episode. When comparing both groups, HIV patients had a 6.48 [(5.37-7.83); P < 0.0001] (adjusted relative risk) greater chance of acquiring P. vivax malaria. Moreover, being of the male gender [ARR = 1.41 (1.17-1.71); P < 0.0001], Amerindian ethnicity [ARR = 2.77 (1.46-5.28); P < 0.0001], and a resident in a municipality of the Metropolitan region of Manaus [ARR = 1.48 (1.02-2.15); P = 0.038] were independent risk factors associated with an increased risk of clinical malaria. Education ≥ 8 years [ARR = 0.41 (0.26-0.64); P < 0.0001] and living in the urban area [ARR = 0.44 (0.24-0.80); P = 0.007] were associated to a lower risk of P. vivax malaria. A total of 28 (14.1%) and 180 (25.3%) recurrences (at least a second clinical malaria episode) were reported in the HIV-positive and HIV-negative groups, respectively. After adjusting for sex and education, HIV-positive status was associated with a tendency towards protection from P. vivax malaria recurrences [ARR = 0.55 (0.27-1.10); P = 0.090]. HIV status was not associated with hospitalizations due to P. vivax malaria. CD4 + counts and viral load were not associated with recurrences of P. vivax malaria. No significant differences were found in the distribution of parasitemia between HIV-negative and HIV-positive P. vivax malaria patients. Our results suggest that HIV-positive status is a risk factor for vivax malaria infection, which represents an additional challenge that should be addressed during elimination efforts.

Mixed methods systematic review and metasummary about barriers and facilitators for the implementation of cotrimoxazole and isoniazid-Preventive therapies for people living with HIV.

BACKGROUND: Cotrimoxazole and isoniazid preventive therapy (CPT, IPT) have been shown to be efficacious therapies for the prevention of opportunistic infections and tuberculosis (TB) among people living with human immunodeficiency virus (HIV). Despite governments' efforts to translate World Health Organization recommendations into practice, implementation remains challenging. This review aimed to explore and compare CPT and IPT with respect to similarities and differences of barriers identified across high TB/HIV burden countries. A secondary objective was to identify facilitators for implementing both preventive therapies. METHODS: We searched MEDLINE, Web of Science and SCOPUS databases for peer-reviewed literature published before September 2020. We extracted and synthesized our findings using Maxqda software. We applied framework synthesis in conjunction with metasummary to compare both therapies with respect to similarities and differences of barriers identified across seven health system components (in line with the modified WHO's Framework for action). Protocol registration: PROSPERO (CRD42019137778). FINDINGS: We identified four hundred and eighty-two papers, of which we included forty for review. Although most barrier themes were identical for both preventive therapies, we identified seven intervention-specific themes. Like for CPT, barriers identified for IPT were most frequently classified as 'service delivery-related barriers' and 'patient & community-related barriers'. 'Health provider-related barriers' played an important role for implementing IPT. Most facilitators identified referred to health system strengthening activities. CONCLUSIONS: For researchers with limited working experience in high TB/HIV burden countries, this review can provide valuable insights about barriers that may arise at different levels of the health system. For policymakers in high TB/HIV burden countries, this review offers strategies for improving the delivery of IPT (or any newer therapy regimen) for the prevention of TB. Based on our findings, we suggest initial and continuous stakeholder involvement, focusing on the efficient use and reinforcement of existing resources for health.

The importance of gender of patients and general practitioners in relation to treatment practices for overweight.

BACKGROUND: Several studies suggest that men and women are treated differently for similar disease including diabetes and cardiovascular disease. Differences in attitudes and treatment practices towards men and women with obesity are not well recognized. OBJECTIVE: To investigate the attitudes and treatment practices among Danish general practitioners (GPs), in relation to treatment of overweight, while taking gender of both the patients and practitioners into account. DESIGN: Questionnaire inventory covertly examining attitudes and practices among Danish general practitioners towards treatment of overweight. All 3.637 general practitioners from the Danish Medical Association register were invited to participate in the survey. In total 1.136 participated. RESULTS: The GPs found weight loss to be more important for overweight male than overweight female patients. They also treated complications to overweight more rigorously among male than female patients, and recommended lipid lowering medicine more often to male than female overweight patients. In addition, the younger female GPs and older male GPs more often said that they would treat an overweight patient with lipid lowering medicine. CONCLUSION: Among general practitioners in Denmark, treatment for weight loss is more often practiced for overweight male than overweight female patients presenting with same symptoms. In addition, hyperlipidemia among overweight males is also more often treated with lipid lowering medicine than hyperlipidemia among overweight females.

Protein tyrosine phosphatase SHP2/PTPN11 mistargeting as a consequence of SH2-domain point mutations associated with Noonan Syndrome and leukemia.

SHP2/PTPN11 is a key regulator of cytokine, growth factor and integrin signaling. SHP2 influences cell survival, proliferation and differentiation by regulating major signaling pathways. Mutations in PTPN11 cause severe diseases like Noonan, LEOPARD syndrome or leukemia. Whereas several of these mutations result in altered enzymatic activity due to impaired auto-inhibition, not all disease patterns can be explained by this mechanism. In this study we analyzed altered binding properties of disease-related SHP2-mutants bearing point mutations within the SH2-domain (T42A, E139D, and R138Q). Mutants were chosen according to SPR assays, which revealed different binding properties of mutated SH2 towards phosphorylated receptor peptides. To analyze global changes in mutant binding properties we applied quantitative mass spectrometry (SILAC). Using an in vitro approach we identified overall more than 1000 protein candidates, which specifically bind to the SH2-domain of SHP2. We discovered that mutations in the SH2-domain selectively affected protein enrichment by altering the binding capacity of the SH2-domain. Mutation-dependent, enhanced or reduced exposure of SHP2 to its binding partners could have an impact on the dynamics of signaling networks. Thus, disease-associated mutants of SHP2 should not only be discussed in the context of deregulated auto-inhibition but also with respect to deregulated protein targeting of the SHP2 mutants. BIOLOGICAL SIGNIFICANCE: Using quantitative mass spectrometry based proteomics we provided evidence that disease related mutations in SHP2 domains of SHP2 are able to influence SHP2 recruitment to its targets in mutation dependent manner. We discovered that mutations in the SH2-domain selectively affected protein enrichment ratios suggesting altered binding properties of the SH2-domain. We demonstrated that mutations within SHP2, which had been attributed to affect the enzymatic activity (i.e. affect the open/close status of SHP2), also differ in respect to binding properties. Our study indicates that SHP2 mutations need to be discussed not only in terms of deregulated auto-inhibition but also with respect to deregulated protein targeting properties of the SHP2 mutants. Discovery of the new binding partners for disease-related SHP2 mutants might provide a fruitful foundation for developing strategies targeting Noonan-associated leukemia.

Interleukin-6 signalling: more than Jaks and STATs.

The hallmark of signalling by many cytokines is the activation of the Janus kinase (Jak)/signal transducer and activator of transcription (STAT) pathway. However, cytokines additionally activate other pathways. In past years we realised that these pathways significantly contribute to the physiological functions of IL-6 and pathophysiological functions in the context of many inflammatory and proliferative diseases. Whereas other articles in this issue of the European Journal of Cell Biology focus on STAT activation and its regulation we here aim to summarise our knowledge and some remaining questions on interleukin-6 (IL-6)-induced STAT-independent pathways as well as the cross-talk with the Jak/STAT pathway. In the early stages of studying cytokine signalling we were used to analysing individual signalling pathways. These days we know about the importance of both, the crosstalk between pathways initiated by combinations of cytokines as well as the crosstalk between individual pathways initiated by a single cytokine. Whereas the inter-cytokine crosstalk can be studied relatively easily, more sophisticated experimental approaches are required to elucidate the intra-cytokine crosstalk.

Biphasic mini-reactor for characterization of biocatalyst performance.

Biphasic reaction media are extending the scope of technical biocatalysis. Thorough investigation of the factors affecting catalyst performance under these conditions is of key importance for the successful implementation of catalytic processes. Here, we present a reactor setup suitable for comprehensive systematic characterization and optimization of biocatalyzed reactions in biphasic systems with distinct phases. It is distinguished by small volumes allowing reproducible experimentation with minimum amounts of solvent and catalyst. The interfacial area is kept constant and independent stirring of both phases is allowed in order to minimize superimposing effects. Evaporation of low-volatile organic solvents is prevented by use of airtight construction. The broad applicability of this mini-reactor is demonstrated with regard to determination of mass transfer, enzyme productivity, and enzyme stability in both batch and continuous mode.

Ionic liquids in biotechnology: applications and perspectives for biotransformations.

Ionic liquids are considered as an alternative to organic solvents for catalysis. The literature in this field is reviewed with focus on advantageous use of ionic liquids in biocatalysis and biotransformations. The overview reveals that the exploration and mapping of ionic liquids with respect to biocatalysis is still sketchy. It is apparent that advantages can be gained in view of activity, stability and selectivity. Furthermore, integration of reaction and separation has a high potential in the field. The review presents quantitative data on the productivities, space-time yields, as well as stability as far as they can be extracted from the literature.

SHPS-1/SIRP1alpha contributes to interleukin-6 signalling.

The transmembrane glycoprotein signal regulatory protein/SHP2-substrate (SIRP1alpha/SHPS-1) has been implicated in growth factor- and cell adhesion-induced signalling. Here we report on the contribution of SIRP1alpha to IL-6 type cytokine signalling. SIRP1alpha binds the protein tyrosine phosphatase SHP2 upon treatment with interleukin-6 in a stimulation-dependent manner. Mouse embryonic fibroblasts expressing a SIRP1alpha protein which lacks the intracellular part show enhanced SHP2 phosphorylation and ERK1/2 activation in response to IL-6, suggesting that SIRP1alpha affects IL-6-signalling through SHP2. Whereas SHP2 phosphorylation is enhanced in SIRP1alpha-deficient cells STAT3 activation is delayed and STAT3-dependent gene induction is reduced which correlates with reduced STAT3 serine phosphorylation. Our results indicate that SIRP1alpha contributes to IL-6 signalling by counteracting SHP2 phosphorylation which consequently affects ERK-activation and STAT3-dependent transactivation as well as target gene expression. Our observations will help to understand the tight balance of MAPK- and STAT3-activation in response to IL-6 which was found to be misbalanced in many autoimmune diseases, inflammatory proliferative diseases and cancer.

[Monitoring the prevalence of obesity]. / Monitorering af forekomsten af fedme.

The Danish Fitness and Nutrition Council has proposed a model to monitor the prevalence of overweight and obesity in Denmark. The model should make it possible to assess whether different initiatives reduce the prevalence of obesity and to gain knowledge on how to prevent obesity. The prevalence of obesity should be estimated in a non-biased randomly selected sample of the population once yearly, using all available data from routine measurements and encouraging new measurements conducted in professional settings where routine data are not available.

Prostaglandin E1 inhibits IL-6-induced MCP-1 expression by interfering specifically in IL-6-dependent ERK1/2, but not STAT3, activation.

IL (interleukin)-6 exerts pro- as well as anti-inflammatory activities. Beside many other activities, IL-6 is the major inducer of acute phase proteins in the liver, acts as a differentiation factor for blood cells, as migration factor for T-cells and is a potent inducer of the chemokine MCP-1 (monocyte chemoattractant protein-1). Recent studies have focused on the negative regulation of IL-6 signal transduction through the IL-6-induced feedback inhibitors SOCS (suppressor of cytokine signalling) 1 and SOCS3 or the protein tyrosine phosphatases SHP-2 (Src homology 2 domain-containing protein tyrosine phosphatase 2) and TcPTP (T-cell protein tyrosine phosphatase). Studies on the cross-talk between pro-inflammatory mediators (IL-1, tumour necrosis factor, lipopolysaccharide) and IL-6 elucidated further regulatory mechanisms. Less is known about the regulation of IL-6 signal transduction by hormone/cytokine signalling through G-protein-coupled receptors. This is particularly surprising since many of these hormones (such as prostaglandins and chemokines) play an important role in inflammatory processes. In the present study, we have investigated the inhibitory activity of PGE(1) (prostaglandin E(1)) on IL-6-induced MCP-1 expression and have elucidated the underlying molecular mechanism. Surprisingly, PGE(1) does not affect IL-6-induced STAT (signal transducer and activator of transcription) 3 activation, but does affect ERK (extracellular-signal-regulated kinase) 1/2 activation which is crucial for IL-6-dependent expression of MCP-1. In summary, we have discovered a specific cross-talk between the adenylate cyclase cascade and the IL-6-induced MAPK (mitogen-activated protein kinase) cascade and have investigated its impact on IL-6-dependent gene expression.

Lateral ligand-receptor interactions on membranes probed by simultaneous fluorescence-interference detection.

We describe an experimental approach for studying ligand-receptor interactions in the plane of the membrane. The extracellular domains of the type I interferon receptor subunits ifnar1-EC and ifnar2-EC were tethered in an oriented fashion onto solid-supported, fluid lipid bilayers, thus mimicking membrane anchoring and lateral diffusion of the receptor. Ligand-induced receptor assembling was investigated by simultaneous total internal reflection fluorescence spectroscopy and reflectance interferometry (RIf). Based on a rigorous characterization of the interactions of fluorescence-labeled IFNalpha2 with each of the receptor subunits, the dynamics of the ternary complex formation on the fluid lipid bilayer was addressed in further detail making use of the features of the simultaneous detection. All these measurements supported the formation of a ternary complex in two steps, i.e., association of the ligand to ifnar2-EC and subsequent recruitment of ifnar1-EC on the surface of the membrane. Based on the ability to control and quantify the receptor surface concentrations, equilibrium, and rate constants of the interaction in the plane of the membrane were determined by monitoring ligand dissociation at different receptor surface concentrations. Using mutants of IFNalpha2 binding to ifnar2-EC with different association rate constants, the key role of the association rate constants for the assembling mechanism was demonstrated.