The implementation of environmental health policies in health care facilities: The case of Malawi.

Establishing and maintaining safe and sufficient environmental health (EH) conditions in health care facilities (HCFs) is important to prevent and control infections. In 2018, the Government of Malawi finalized an environmental health policy that defines specific targets and programs for EH in healthcare settings. This and other related policies have been used since 2010 as a guide for EH practice in HCFs, but the implementation of these policies has been incomplete to-date. This study qualitatively examines the successes and shortcomings of implementing these policies in Malawi's public HCFs. Thematic analysis of interviews with 53 respondents from all levels of government was used to identify the successes of the policies and the barriers to effective implementation using Contextual Interaction Theory. The greatest identified strength lies in the design of the EH department and its ability to connect individual HCFs and EH actors directly to the policy-making level of government. Identified barriers to implementation include: insufficient financial support; lack of human resources; incomplete reporting; poor stakeholder coordination; and insufficient training of EH actors. We recommend refresher trainings for all EH actors, the establishment of a directorate level EH position, and strengthened coordination to improve the collection, analysis, and reporting of monitoring data to enable EH actors to advocate for the additional funding needed to develop programs for EH personnel and to apply effective EH interventions.

A novel diagnostic algorithm for heparin-induced thrombocytopenia.

INTRODUCTION: While diagnostic algorithm using PF4-heparin enzyme-linked immunosorbent assay (ELISA) optical density (OD), and heparin neutralization assay (HNA), or 4T score have been proposed to replace serotonin-release assay (SRA) for heparin-induced thrombocytopenia (HIT), their performance against SRA is unclear. In this study, we proposed and validated the performance of a new algorithm combining PF4-heparin ELISA optical density (OD), HNA and 4T score against SRA for HIT diagnosis. METHODS: Heparin neutralization assays were performed on specimens submitted for HIT testing with positive PF4-heparin ELISA from December 2015 to September 2017, which were separated into a "training" and a "validation" data set. 4T scores were calculated for ELISA positive cases. RESULTS: A total of 123 consecutive unique patient samples had positive PF4-heparin ELISA with also HNA data, SRA data, and 4T scores available. Compared to SRA, a "laboratory criteria" (ELISA OD ≥ 1.4 and HNA ≥ 70%) had a sensitivity of 88% (14/16) and specificity of 91% (42/46), and a "combined criteria" (4T score = 8, or 4T score = 6 or 7 and ELISA OD ≥ 1.0, or 4T score = 4 or 5 and ELISA OD ≥ 2.0) had a sensitivity of 75% (12/16) and specificity of 98% (45/46) in the training data set. Laboratory and combined criteria had 90% (56/62) concordance rate. Importantly, for these concordant cases, the diagnostic specificity is 100% (46/46). Based on the data, a novel diagnostic algorithm combining these 2 criteria was proposed and validated prospectively. CONCLUSION: A novel algorithm has high diagnostic accuracy and potentially could eliminate the need for SRA testing in at least 90% patients with suspected HIT.

Anti-CD22 and anti-CD79B antibody drug conjugates are active in different molecular diffuse large B-cell lymphoma subtypes.

Antibody drug conjugates (ADCs), in which cytotoxic drugs are linked to antibodies targeting antigens on tumor cells, represent promising novel agents for the treatment of malignant lymphomas. Pinatuzumab vedotin is an anti-CD22 ADC and polatuzumab vedotin an anti-CD79B ADC that are both linked to the microtubule-disrupting agent monomethyl auristatin E (MMAE). In the present study, we analyzed the activity of these agents in different molecular subtypes of diffuse large B-cell lymphoma (DLBCL) both in vitro and in early clinical trials. Both anti-CD22-MMAE and anti-CD79B-MMAE were highly active and induced cell death in the vast majority of activated B-cell-like (ABC) and germinal center B-cell-like (GCB) DLBCL cell lines. Similarly, both agents induced cytotoxicity in models with and without mutations in the signaling molecule CD79B. In line with these observations, relapsed and refractory DLBCL patients of both subtypes responded to these agents. Importantly, a strong correlation between CD22 and CD79B expression in vitro and in vivo was not detectable, indicating that patients should not be excluded from anti-CD22-MMAE or anti-CD79B-MMAE treatment because of low target expression. In summary, these studies suggest that pinatuzumab vedotin and polatuzumab vedotin are active agents for the treatment of patients with different subtypes of DLBCL.

Telomeric chromatin: roles in aging, cancer and hereditary disease.

Over the last several years there has been an explosion in our understanding of the organization of telomeric chromatin in mammals. As in other regions of the genome, chromatin composition at the telomere regulates structure, which defines function. Mammalian telomeres, similar to what has been demonstrated for telomeres of other eukaryotes, carry marks of heterochromatin and alteration in this underlying epigenetic code has effects on telomere replication and recombination. Experiments aimed at determining links between changes in telomeric chromatin and possible roles in aging and disease are beginning to emerge. The rapid refinement of our knowledge of the structure and alterations in telomeric chromatin over the last several years makes it likely that we are just seeing the tip of the iceberg.

Identification of target sites of the alpha2-Mcm1 repressor complex in the yeast genome.

The alpha2 and Mcm1 proteins bind DNA as a heterotetramer to repress transcription of cell-type-specific genes in the yeast Saccharomyces cerevisiae. Based on the DNA sequence requirements for binding by the alpha2-Mcm1 complex, we have searched the yeast genome for all potential alpha2-Mcm1 binding sites. Genes adjacent to the sites were examined for expression in the different cell mating types. These sites were further analyzed by cloning the sequences into a heterologous promoter and assaying for alpha2-Mcm1-dependent repression in vivo and DNA-binding affinity in vitro. Fifty-nine potential binding sites were identified in the search. Thirty-seven sites are located within or downstream of coding region of the gene. None of the sites assayed from this group are functional repressor sites in vivo or bound by the alpha2-Mcm1 complex in vitro. Among the remaining 22 sites, six are in the promoters of known alpha-specific genes and two other sites have an alpha2-Mcm1-dependent role in determining the direction of mating type switching. Among the remaining sequences, we have identified a functional site located in the promoter region of a previously uncharacterized gene, SCYJL170C. This site functions to repress transcription of a heterologous promoter and the alpha2-Mcm1 complex binds to the site in vitro. SCYJL170C is repressed by alpha2-Mcm1 in vivo and therefore using this method we have identified a new a-specific gene, which we call ASG7.

Retinal protein kinase C.

The protein kinase C (PKC) family of serine/threonine kinase isoenzymes are universally expressed in vertebrate tissues where they control vital cellular functioning. PKC comprises twelve currently identified mammalian isoenzymes, described in three distinct groups according to their need for different effector stimulation. Immunological localisation studies in various vertebrate retinas have indicated the presence, so far, of eight of the PKC subspecies, each with a unique cellular distribution in this tissue. Use of these immunological probing techniques with antibodies raised to the individual PKC family members by immunohistochemistry and western blotting, along with biochemical tools such as the potent activators, the tumour-promoting phorbol esters can hopefully lead to elucidation of the roles of these enzymes in the neural retina. Research work to date has pinpointed a number of roles for PKC in this tissue including control of dopamine release, modulation of glutamate receptor function (probably by a process of direct receptor phosphorylation), phosphorylatory modulation of GABAC-receptor function, an involvement in the retinal ischaemic cascade process (the relevance of which is unknown as yet), involvement in control of cytoskeletal interactions by cytoskeletal element-kinase action and feedback control of enzymes involved in the process of inositol phosphate signalling. PKC has been shown to have an important regulatory role in the process of phototransduction: many of the enzymes and proteins making up the phototransduction cascade act as in vitro and in vivo substrates for PKC-dependent phosphorylation and can have their normal function modified in this way. Also, PKC has been implicated in the control of spinule formation in the retina, a process involved in retinal synaptic plasticity and functioning. All of this work has been described, herein. Collation and utilisation of knowledge of all of the work described here may help us to determine the exact roles for individual isoenzymes in the retina. This in turn may help us to understand and further to prevent pathological conditions leading to inappropriate retinal functioning and possible blindness. Furthermore, understanding the roles of PKC in the neural retina may lead us to vital clues in the understanding of the functioning of this important group of enzymes in the nervous system as a whole and eventually to the prevention of many major neuropathological disorders.

The occurrence of protein kinase C theta and lambda isoforms in retina of different species.

The localization and immunochemical identification of the novel protein kinase C theta (nPKC theta) and the atypical protein kinase C lambda (aPKC lambda) isoforms in retinas of different species were analyzed by immunohistochemistry and SDS-PAGE/Western blotting. nPKC theta immunoreactivity is associated with bipolar cells of mammalian (rabbit, rat and guinea pig) retinas but not the non-mammalian goldfish retina which has a lower concentration of nPKC theta. However, SDS-PAGE and Western blotting data indicate the antigen recognized by the nPKC theta monoclonal antibody in the retina is of a lower molecular weight than that expected for nPKC theta. This would suggest nPKC theta is more susceptible to degradation/breakdown than other PKC isoforms found in the retina or that the nPKC theta antibody may be recognizing an unknown retinal antigen. A comparison of nPKC theta and cPKC alpha immunoreactivities in bipolar cells shows unique distributions exist for the two isoforms. nPKC theta is present in the developing retina at an earlier stage than cPKC alpha. The typical 'transport' of cPKC alpha toward axonal terminals by phorbol-12,13-dibutyrate does not occur for nPKC theta yet both are translocated from the cytosolic to membrane compartments. The inner plexiform layer and the inner nuclear layer (putative horizontal cells) of all species examined (rabbit, rat, guinea pig and goldfish) exhibited positive immunoreactivity for aPKC lambda as confirmed by SDS-PAGE/Western blotting.

The effect of kainate on protein kinase C, GABA, and the uptake of serotonin in the rabbit retina in vivo.

The purpose of this study was to investigate the effect of kainate on protein kinase C (PKC), gamma-aminobutyrate (GABA) and serotonin uptake in the rabbit retina. Kainate when injected into the vitreous humour produces a change in the GABA immunoreactivity within 6 hours. After 3 days, remnants of the normal GABA immunoreactivity still persist and additionally astrocyte and microglia-like elements "stain" positively for GABA. After 7 days exposure to kainate none of the normal GABA immunoreactivity is apparent, instead a number of round-shaped elements which may be reactive astrocytes and/or microglia stain positively for GABA. During these stages kainate does not affect the alpha PKC immunoreactivity associated with the on-bipolar cells. Six hours following kainate treatment the ability of certain GABA amacrine cells to take up exogenous serotonin is unaffected. After three days only a few of these cells can still take up exogenous serotonin and then not avidly. After seven days the GABA/serotonin amacrine cells cannot take up exogenous serotonin suggesting that all of these neurons are irreversibly damaged. One hour after treatment with kainate both calcium-dependent and -independent PKC species are translocated from the cytosolic to membrane compartments. After 5 hours and 7 days there was also evidence from the enzyme assay experiments that kainate caused the calcium-dependent and -independent PKC enzymes to be translocated but because the total enzyme activity was reduced due perhaps to down-regulation of the enzyme this was difficult to assess precisely.(ABSTRACT TRUNCATED AT 250 WORDS)

Defining a generalist education: an idea whose time is still coming.

Generalist education is different from the traditional medical curriculum as it has developed over the past 40 years. For example, in their training doctors must develop the appropriate skills, knowledge, and attitudes to understand patients' specific expectations, address wellness rather than illness only, be familiar with concepts of clinical epidemiology, concentrate on interpersonal communication, and strive to control costs. The University of Illinois College of Medicine at Rockford was established to provide community-based medical education. Beginning in their second year, all Rockford students have extensive clinical training in one of three community health centers operated by the Department of Family and Community Medicine. Several kinds of evaluation have been conducted to assess the reaction to and impact of this clinical training on the students and faculty, and follow-up studies have tracked the students after graduation. The Rockford experience has shown that the entire curriculum must give uncompromising support for generalist education, all primary care faculty must have a common knowledge base in the theory and practice of generalist medicine, and the shift to generalist education will require shifts in attitude and behavior throughout the academic medicine community at the institution.

Interlaboratory variability in serum lipid measurements.

Identification of elevated blood cholesterol has become a priority in the effort to reduce coronary heart disease. Previous data indicate that considerable laboratory variability in lipid testing exists in the United States. To determine the interlaboratory variability of serum lipid measurements in the Little Rock area, split serum samples from three subjects were sent to ten area laboratories. The average coefficient of variation among the ten local laboratories was 3.20% for total cholesterol, 9.46% for HDL-cholesterol, 7.73% for triglycerides, and 5.95% for calculated LDL-cholesterol. The results indicate that clinicians cannot assume that adequate standardization for lipid determinations exists for all laboratories. Without accuracy and precision data for the specific laboratory, caution should be used in the strict application of guidelines for classification and treatment of patients with abnormal serum-lipid measurements.

Prostate-specific antigen levels from completely sectioned, clinically benign, whole prostates.

Clinically benign whole, untrimmed prostates and pelvic lymph nodes were obtained from 105 patients at autopsy. All 105 patients had premortem serum from which prostate-specific antigen (PSA) levels were obtained. Sixty-eight did not have carcinoma of the prostate (CAP), 28 had CAP less than 1 ml and 9 had CAP larger than 1 ml. Eleven untrimmed prostates weighed 80 g or more and eight had elevated PSA levels (more than 4.0 ng/ml): five of eight without CAP, two of two with CAP less than 1 ml, and one of one with CAP larger than 1 ml. Ninety-four whole untrimmed prostates weighed less than 80 g and 20 had elevated PSA levels: ten of 60 without CAP, two of 26 with CAP less than 1 ml, and eight of eight with CAP larger than 1 ml. This study suggests that PSA levels from patients with untrimmed prostates weighing 80 g or more (equivalent to a 60-g trimmed prostate) are usually elevated regardless whether CAP is present. However, CAP less than 1 ml, in untrimmed prostates less than 80 g, usually does not elevate PSA levels whereas CAP larger than 1 ml usually does (P less than 0.0001). The likelihood that elevated PSA levels, from patients with untrimmed prostates less than 80 g, are due to CAP larger than 1 ml increases as the PSA level increases.

Prenatal protocol usage.

A review was conducted of 825 obstetrics cases on active computer file at the Department of Family and Community Medicine in Little Rock, Arkansas. Independent raters evaluated faculty and resident usage of a prenatal protocol which was routinely used as a teaching tool in the department's residency program since 1972. Significant differences were found to exist with regard to usage of the tool by physician status. Faculty were more consistent and thorough in their usage of the teaching tool when compared to residents. Differences were explained in terms of a practice effect, research bias of faculty, levels of practice, and potential weaknesses in the educational program.

Stage D1 prostate carcinoma. The histologic appearance of nodal metastases and its relationship to survival.

Eighty-two of 307 consecutive staging lymphadenectomies had nodal metastases (Stage D1 prostate carcinoma). Seventy-seven of the 82 cases had at least a 5-year follow-up and 50 had at least a 10-year follow-up. Three of these 77 cases had Grade 1 (well-differentiated) metastases, 59 (77%) had Grade 2-3 (moderately differentiated) metastases, and 15 (19%) had Grade 4 (poorly differentiated) metastases (M. D. Anderson Hospital [MDAH] grading system). The patients with moderately differentiated metastases had 5-year and 10-year survival rates of 79% and 34%, respectively, whereas the patients with poorly differentiated metastases had 5-year and 10-year survival rates of 13% and 0%, respectively (P less than 0.0001). This study demonstrates a statistically significant difference between the prognosis of Stage D1 patients with moderately differentiated metastases and Stage D1 patients with poorly differentiated metastases. Consequently, the evaluation of the histologic appearance of Stage D1 metastases may be of clinical importance.

Oat bran supplementation for elevated serum cholesterol.

The National Heart, Lung, and Blood Institute (NHLBI) has recommended intensive dietary treatment as first-line therapy for patients with high cholesterol levels. The NHLBI has also encouraged research into the effectiveness and safety of alternative diets and further study of human behavior as it relates to adherence to diets. Based on these recommendations and previous studies suggesting a hypocholesterolemic effect of oat bran dietary supplementation, 16 family practice outpatients with elevated cholesterol levels were enrolled in a 12 week study designed to assess the practicality and effectiveness of adding four oat bran muffins per day to the diet. Subjects were randomized into immediate intervention and delayed intervention groups. The combined group had a significant decrease in total cholesterol of 7.9 percent (p less than .03) and in LDL-cholesterol of 10.1 percent (p less than .03) but there was no significant difference with respect to lipid changes between the immediate group and the delay group when the delay group was serving as a control for the immediate group. The results taken in conjunction with evidence in the literature indicate that the simple addition of oat bran muffins to the diet of certain family practice outpatients is well tolerated and probably effective in lowering serum total and low density lipoprotein cholesterol.

Physicians' attitudes on advance directives.

Advance directives provide means for competent individuals to influence treatment decisions in the event of serious illness and subsequent loss of competence, the "living will" being the best known example. Physicians in Arkansas who were identified to be currently engaged in general practice, family medicine, or internal medicine, including its subspecialities (N = 1293), were surveyed to assess attitudes toward and experiences with advance directives. Almost 80% of all respondents expressed a positive attitude and fewer than 2% expressed a negative attitude toward such documents. A majority (55.9%) had actual experience with the instruments in their practices, and 83.5% of these physicians said that their attitude had become more positive as a result of their experience. More frequent employment of advance directives in critical situations was associated with more positive attitudes and experiences. Most of the benefits claimed for advance directives--improved communication and trust, easier and more confident treatment decision, less stress and guilt, and promotion of patient autonomy--were substantiated by the results.

KIE: Physicians practicing in Arkansas, one of the first states to pass legislation authorizing patients to refuse life-sustaining treatment in advance, were surveyed to determine their attitudes toward advance directives. Questionnaires were sent to 1,293 practitioners in general practice, family practice, and internal medicine and its subspecialties. Among other items, respondents were asked their opinions of the standard arguments for and against advance directives, and the extent of and results of their own experiences with these documents. Almost 80% of the 790 respondents reported a positive attitude toward advance directives, with 1.5% reporting a negative attitude. A majority of physicians responding to the survey had actual experience with advance directives, and over 80% of these doctors reported that their attitude had become more favorable as a result of their experience. Respondents strongly supported arguments for advance directives that concerned patient autonomy.

Corneal surface ablation by 193 nm excimer laser and wound healing in rabbits.

The 193 nm argon fluoride excimer laser was used to ablate a 6 mm diameter area of the central rabbit cornea under various conditions of power, beam configuration and exposure time. High repetition rates or prolonged exposures produced charring and prevented rapid epithelial wound closure. Endothelial vacuolization, reduction in density, and displacement of cell material into Descemet's layer resulted in these experiments. A beam of low and uniform power intensity (40 pulses per second, 100 seconds at 23 mJ/cm2) reduced stromal damage, cellular infiltration, and epithelial irregularities including punctate staining and cell exfoliation. Epithelial rehealing occurred within two days. Basal lamina and hemidesmosomes were reformed by one week. Endothelial damage was not detected. Excimer laser ablation may allow removal of superficial dystrophies or scars, followed by rapid healing from normal corneal reparative processes.

Alterations in cholinergic muscarinic and somatostatin binding sites in a patient with idiopathic intestinal pseudo-obstruction.

We present a comparative study of cholinergic muscarinic and somatostatin binding sites on isolated membranes from mucosa and tunica muscularis of normal and dilated parts of the proximal jejunum obtained at surgery from a patient with idiopathic intestinal pseudo-obstruction (IIP) syndrome. We found a statistically significant diminution of cholinergic muscarinic and somatostatin binding sites in mucosa taken from the dilated part of the jejunum, compared with those taken from the normal part. Tunica muscularis of the dilated part of the jejunum contained a significantly higher concentration of peripheral cholinergic muscarinic binding sites (M2) than the normal part did, whereas concentration of M1 cholinergic muscarinic and somatostatin binding sites was similar in both examined parts. These results indicate that IIP-syndrome may be related to alterations in cholinergic muscarinic binding sites in the tunica muscularis of the intestine.