Contribution of a bonded scholarship scheme to staffing rural health facilities.

BACKGROUND: Local and international research has identified rural origin as an important reason why healthcare professionals (HCPs) work in rural areas, and in South Africa (SA) considerable effort has gone into recruiting and training rural-origin students. However, there is little information in the SA literature on where graduates supported by these initiatives work, and whether they contribute to the rural workforce long term. OBJECTIVE: To determine the number of years that rural-origin Umthombo Youth Development Foundation (UYDF)-supported graduates of different disciplines worked at rural public healthcare facilities (PHCFs). METHODS: A retrospective descriptive study reviewed work record data of 405 UYDF graduates, to calculate the number of years they worked at a rural PHCF. Data were analysed descriptively and presented in tables with totals and percentages. RESULTS: Ninety percent (363/405) of UYDF-supported graduates returned to work at a rural PHCF. High percentages of social workers (85%), optometrists (80%), speech therapists, nurses (72%) and dental therapists (70%) worked for ≥5 years at a rural PHCF, while only 13% of audiologists, 14% of doctors, 29% of pharmacists, and 28% of dentists and occupational therapists worked at a rural PHCF for ≥5 years. Ten percent (42/405) of graduates did not work at a rural PHCF at all. A total of 110/124 (89%) of doctors supported by UYDF had worked at a rural PHCF, with 32% (40/124) working at a rural PHCF for ≥3 years. Overall, 54% of UYDF-supported graduates (219/405) worked for ≥3 years at a rural PHCF, and 38.5% (157/405) worked for ≥5 years at rural PHCFs. The majority of UYDF graduates had contributed towards long-term staffing of rural PHCFs. Lack of professional development opportunities at rural PHCFs as well as the reduced number of funded posts at rural PHCFs reduced the effectiveness of the UYDF initiative. CONCLUSION: The UYDF Scholarship Scheme has shown that investment in rural students through a bonded scholarship can contribute to staffing rural PHCFs, as >90% of graduates worked at rural PHCFs, and for some disciplines >70% of graduates worked for ≥5 years at a rural PHCF. Allied HCPs worked on average for longer periods at rural PHCFs than doctors.

Association between chorionicity and preterm birth in twin pregnancies: a systematic review involving 29 864 twin pregnancies.

BACKGROUND: The perinatal mortality and morbidity among twins vary by chorionicity. Although it is considered that monochorionicity is associated with an increased risk of preterm birth in twin pregnancies, no systematic review exists evaluating this association. OBJECTIVES: This systematic review was undertaken to assess the association between preterm birth and chorionicity in twin pregnancies. SEARCH STRATEGY: We searched the electronic databases from January 1990 to July 2019 without language restrictions. SELECTION CRITERIA: All studies on twin pregnancies where chorionicity and preterm birth were evaluated were included. DATA COLLECTION AND ANALYSIS: Findings are reported as odds ratios with 95% confidence intervals. The estimates are pooled using random-effects meta-analysis. MAIN RESULTS: From 13 156 citations, we included 39 studies (29 864 pregnancies). Monochorionicity was significantly associated with increased risk of preterm birth at ≤28, ≤32, ≤34 and <37 weeks in women asymptomatic and symptomatic for preterm labour (odds ratio [OR] 2.14, 95% CI 1.52-3.02, I2  = 46%, OR 1.55, 95% CI 1.27-1.89 I2  = 68%, OR 1.47, 95% CI 1.27-1.69, I2  = 60%, OR 1.66, 95% CI 1.43-1.93, I2  = 65%, respectively). Among those asymptomatic for preterm labour, significantly increased odds of preterm birth were seen for monochorionicity at gestations ≤34 weeks (OR 1.85, 95% CI 1.42-2.40, I2  = 25%) and <37 weeks (OR 1.75, 95% CI 1.22-2.53, I2  = 61%). Sensitivity analysis showed significantly increased odds of spontaneous preterm birth at ≤34 and <37 weeks for monochorionicity (OR 1.25, 95% CI 1.01-1.55, I2  = 0% and OR 1.41, 95% CI 1.13-1.78, I2  = 0%). CONCLUSIONS: Monochorionicity is significantly associated with preterm birth at all gestations. TWEETABLE ABSTRACT: In twin pregnancies, monochorionicity is associated with an increased risk of preterm birth at all gestations.

The training of healthcare professionals: An expense or an investment?

BACKGROUND: There is little information on the financial return of investment when funding the tertiary education of healthcare professionals (HCPs) in South Africa (SA). OBJECTIVES: To assess the cost-benefit of the Umthombo Youth Development Foundation (UYDF) scholarship scheme, which has supported the training of HCPs from rural areas in KwaZulu-Natal Province, SA, for the past 19 years, and to establish whether it is a worthwhile investment. METHODS: This was an economic analysis to estimate the costs and economic value of UYDF's investment in the training of HCPs, using a deterministic model developed in Excel 2010 (Microsoft, USA) to analyse the UYDF's historical, numerical and economic data. Costs were measured in monetary terms, and a rate of return on investment was calculated over the working life of HCPs who had been supported by the UYDF. RESULTS: With a >90% pass rate, the total cost of training the 254 graduates supported by the UYDF from 2009 to 2015 was estimated to be ZAR186 million. Graduates are expected to generate an estimated ZAR15 billion in lifetime earnings, which is equal to ZAR4 billion at 2015 prices, and represents an internal rate of return of 63%. Income tax paid on future earnings will be ~ZAR4 billion, assuming a 20 - 30% tax rate. CONCLUSIONS: The analysis has shown that the cost of HCPs' education, where the annual pass rate is >90%, and >98% of graduates are employed, is an excellent investment. Consideration should be given to finding ways of improving the pass rate at institutions of higher learning and ensuring that graduates obtain meaningful employment if such returns on investment are to be seen on a national level.

Stemmed DNA nanostructure for the selective delivery of therapeutics.

DNA has emerged as a biocompatible biomaterial that may be considered for various applications. Here, we report tumor cell-specific aptamer-modified DNA nanostructures for the specific recognition and delivery of therapeutic chemicals to cancer cells. Protein tyrosine kinase (PTK)7-specific DNA aptamer sequences were linked to 15 consecutive guanines. The resulting aptamer-modified product, AptG15, self-assembled into a Y-shaped structure. The presence of a G-quadruplex at AptG15 was confirmed by circular dichroism and Raman spectroscopy. The utility of AptG15 as a nanocarrier of therapeutics was tested by loading the photosensitizer, methylene blue (MB), to the G-quadruplex as a model drug. The generated MB-loaded AptG15 (MB/AptG15) showed specific and enhanced uptake to CCRF-CEM cells, which overexpress PTK7, compared with Ramos cells, which lack PTK7, or CCRF-CEM cells treated with a PTK7-specific siRNA. The therapeutic activity of MB/AptG15 was tested by triggering its photodynamic effects. Upon 660 nm light irradiation, MB/AptG15 showed greater reactive oxygen species generation and anticancer activity in PTK7-overexpressing cells compared to cells treated with MB alone, those treated with AptG15, and other comparison groups. AptG15 stemmed DNA nanostructures have significant potential for the cell-type-specific delivery of therapeutics, and possibly for the molecular imaging of target cells.

Screening for pulmonary tuberculosis in HIV-infected individuals: AIDS Clinical Trials Group Protocol A5253.

BACKGROUND: Improved tuberculosis (TB) screening is urgently needed for human immunodeficiency virus (HIV) infected patients. METHODS: An observational, multi-country, cross-sectional study of HIV-infected patients to compare a standardized diagnostic evaluation (SDE) for TB with standard of care (SOC). SOC evaluations included TB symptom review (current cough, fever, night sweats and/or weight loss), sputum Ziehl-Neelsen staining and chest radiography. SDE screening added extended clinical signs and symptoms and fluorescent microscopy (FM). All participants underwent all evaluations. Mycobacterium tuberculosis on sputum culture was the primary outcome. RESULTS: A total of 801 participants were enrolled from Botswana, Malawi, South Africa, Zimbabwe, India, Peru and Brazil. The median age was 33 years; 37% were male, and median CD4 count was 275 cells/mm(3). Thirty-one participants (4%) had a positive culture on Löwenstein-Jensen media and 54 (8%) on MGIT. All but one positive culture came from sub-Saharan Africa, where the prevalence of TB was 54/445 (12%). SOC screening had 54% sensitivity (95%CI 40-67) and 76% specificity (95%CI 72-80). Positive and negative predictive values were respectively 24% and 92%. No elements of the SDE improved the predictive values of SOC. CONCLUSIONS: Symptom-based screening with smear microscopy was insufficiently sensitive. More sensitive diagnostic testing is required for HIV-infected patients.

Impact of the human immunodeficiency virus on early multidrug-resistant tuberculosis treatment outcomes in Botswana.

SETTING: The impact of the human immunodeficiency virus (HIV) on multidrug-resistant tuberculosis (MDR-TB) treatment outcomes in sub-Saharan Africa, where extensive rollout of highly active antiretroviral therapy (HAART) has occurred, remains unclear. OBJECTIVE: To compare the time to initial culture conversion among patients with and those without HIV infection in a setting of individualized MDR-TB care in Botswana. DESIGN: Prospective cohort study of MDR-TB patients receiving ambulatory, integrated TB-HIV care at two public clinics in Botswana. The time to culture conversion was compared by HIV status using Cox proportional hazard ratios (HRs). RESULTS: A total of 40 HIV-infected and 30 non-HIV-infected patients with MDR-TB and follow-up cultures were identified. The median time to initial culture conversion was 78 days (interquartile range [IQR] 42-186) for HIV-infected and 95 days (IQR 70-133) for non-HIV-infected individuals (log rank P > 0.5; unadjusted HR 0.9, 95%CI 0.5-1.5). Adjusting for age, sex, treatment history and number of active anti-tuberculosis drugs did not change this result (adjusted HR 0.8, 95%CI 0.4-1.4). CONCLUSION: We found no difference in the proportion of or time to initial sputum culture conversion between an HIV-infected and a non-infected cohort of MDR-TB patients in Botswana, suggesting that outcomes may be comparable in similar settings with access to individualized anti-tuberculosis treatment and HAART.

Induced sputum improves the diagnosis of pulmonary tuberculosis in hospitalized patients in Gaborone, Botswana.

SETTING: Low sensitivity of acid-fast bacilli (AFB) sputum smears and absence of productive cough are obstacles to the diagnosis of pulmonary tuberculosis (PTB) in hospitals that lack access to bronchoscopy. OBJECTIVES: To evaluate induced sputum, gastric content, blood and urine specimens to improve PTB diagnosis in patients not diagnosed by expectorated sputum AFB smears. DESIGN: Patients admitted to the medical wards of a large public hospital in Gaborone, Botswana, were prospectively enrolled if they had symptoms consistent with PTB, an abnormal chest radiograph, were treated empirically with anti-tuberculosis chemotherapy or had no improvement on antibiotics, and had a non-productive cough or AFB smear-negative sputum. Induced sputum was stained for AFB and Mycobacterium tuberculosis cultures were performed on induced sputum, gastric contents, urine and blood. RESULTS: Of 140 patients meeting the enrollment criteria, 113 (81%) were human immunodeficiency virus (HIV) positive. Fifty-seven (41%) had PTB based on positive cultures from one or more sites, including 48 (84%) from induced sputum, 17 (30%) urine, 13 (23%) gastric contents and 7 (12%) blood. AFB smears were positive in only 18 (32%) culture-proven PTB cases. CONCLUSION: Induced sputum cultures greatly enhanced M. tuberculosis detection in patients with a high prevalence of HIV/AIDS in a hospital without access to bronchoscopy.

Waves in interplanetary shocks: a wind/WAVES study.

We describe results from the first statistical study of waveform capture data during 67 interplanetary (IP) shocks with Mach numbers ranging from approximately 1-6. Most of the waveform captures and nearly 100% of the large amplitude waves were in the ramp region. Although solitary waves, Langmuir waves, and ion acoustic waves (IAWs) are all observed in the ramp region of the IP shocks, large amplitude IAWs dominate. The wave amplitude is correlated with the fast mode Mach number and with the shock strength. The observed waves produced anomalous resistivities from approximately 1-856 Omega.m (approximately 10(7) times greater than classical estimates.) The results are consistent with theory suggesting IAWs provide the primary dissipation for low Mach number shocks.

Effects of oestrogen on trigeminal ganglia in culture: implications for hormonal effects on migraine.

Although migraine is more common in women than men and often linked to the menstrual cycle, few studies have investigated the biological basis of hormonal influences on the trigeminovascular system. In the present study we investigated the effect of physiological levels (10(-9) m) oestrogen on female rat trigeminal ganglia in vitro. Immunocytochemical analysis demonstrated the presence of oestrogen receptor-alpha in a predominantly cytoplasmic location and in neurites. Microarray analysis demonstrated that oestrogen treatment regulates several genes with potential relevance to menstrual migraine. The genes that were upregulated included synapsin-2, endothelin receptor type B, activity and neurotransmitter-induced early gene 7 (ania-7), phosphoserine aminotransferase, MHC-1b, and ERK-1. Down-regulated genes included IL-R1, bradykinin B2 receptor, N-tropomodulin, CCL20, GABA transporter protein, fetal intestinal lactase-phlorizin hydrolase, carcinoembryonic antigen-related protein, zinc finger protein 36, epsin 1 and cysteine string protein. Protein activity assays demonstrated that exposure of the cultured neurons to oestrogen leads to activation of ERK, which has been linked to inflammatory pain. Immunocytochemistry demonstrated that activated ERK was present in neurons containing peripherin, a marker of nociceptive neurons. Several of the genes in the present study may provide potential targets for understanding the association of oestrogen with migraine and other hormone-related orofacial pain.

Small rat islets are superior to large islets in in vitro function and in transplantation outcomes.

Barriers to the use of islet transplantation as a practical treatment for diabetes include the limited number of available donor pancreata. This project was designed to determine whether the size of the islet could influence the success rate of islet transplantations in rats. Islets from adult rats were divided into two groups containing small (diameter <125 microm) or large (diameter >150 microm) islets. An average pancreas yielded three times more small islets than large. Smaller islets were approximately 20% more viable, with large islets containing a scattered pattern of necrotic and apoptotic cells or central core cell death. Small islets in culture consumed twice as much oxygen as large islets when normalized for the same islet equivalents. In static incubation, small islets released three times more insulin under basal conditions than did large islets. During exposure to high glucose conditions, the small islets released four times more insulin than the same islet equivalencies of large islets, and five times more insulin was released by the small islets in response to glucose and depolarization with K+. Most importantly, the small islets were far superior to large islets when transplanted into diabetic animals. When marginal islet equivalencies were used for renal subcapsular transplantation, large islets failed to produce euglycemia in any recipient rats, whereas small islets were successful 80% of the time. The results indicate that small islets are superior to large islets in in vitro testing and for transplantation into the kidney capsule of diabetic rats.

Cellular uptake and metabolism of DNA frayed wires.

DNA frayed wires are a novel, multistranded form of DNA that arises from interactions between single-stranded oligodeoxyribonucleotides with the general sequence d(N(x)G(y)) or d(G(y)N(x)), where y > 10 and x > 5. Frayed wires exhibit greater stability with respect to thermal and chemical denaturation than single- or double-stranded DNA molecules and, thus, may have potential usefulness for DNA drug delivery. However, the stability and uptake of frayed wires have not been investigated in biological systems. Our objective was to examine the cellular uptake and stability of frayed wires in cultured hepatic cells. In these studies, the parent oligonucleotide d(A(15)G(15)) was used to form DNA frayed wires (DNA(FW)) while a random 30-mer oligonucleotide was used as the control nonaggregated DNA (DNA(SS)). Uptake and metabolism studies of DNA(FW) were performed in cultured human hepatoma, HepG2 cells and compared to DNA(SS). Our results indicate that DNA(FW) are not cytotoxic and that their intracellular uptake in HepG2 cells is 2-3.5-fold greater than that of DNA(SS) within the first 2 h (p < 0.05). Similarly, nuclear localization of DNA(FW) is 10-13-fold higher than that of DNA(SS) (p < 0.05). As both internalized and extracellular DNA(FW) appear to be more stable in vitro than DNA(SS), the enhanced uptake may be due to either increased stability or enhanced intracellular transport. These studies also indicate that uptake of DNA(FW) likely occurs via active processes such as receptor-mediated endocytosis similar to mechanisms which have been proposed for DNA(SS). The internalization pathways of DNA(FW) may differ somewhat from that of DNA(SS) insofar as chloroquine does not appear to alter DNA(FW) uptake and degradation, as is the case with DNA(SS).

Clinical protocol. A phase 1 open-label clinical trial of the safety and tolerability of single escalating doses of autologous CD4 T cells transduced with VRX496 in HIV-positive subjects.

The proposed study is a Phase I trial to evaluate a HIV-based lentiviral vector carrying an antisense sequence targeted to HIV in the treatment of HIV infection. The primary objective of this Phase I study is to determine the safety and tolerability of treatment with autologous CD4+ T cells modified (transduced) ex vivo with VRX496 when administered to HIV-infected patients. VRX496 is a completely gutted lentiviral vector and does not code for any viral proteins. The viral vector contains an antisense sequence targeted to the HIV envelope (env) gene. VRX496 directly interferes with wild-type HIV (wt-HIV) expression via anti-env antisense expression in vector transduced CD4 cells that become infected with wt-HIV. Expression of the anti-HIV antisense env from a HIV vector transcript would target wt-HIV RNA and destroy it, and hence, decrease productive HIV replication from CD4 T cells. The clinical goal for this treatment approach is to decrease viral loads and promote CD4 T cell survival in vivo. Data from in vitro studies suggest that HIV vectors such as VRX496 could potentially reduce viral loads in HIV-infected individuals and thus could delay the onset to AIDS while promoting CD4 T cell survival and providing the immune system with a better chance to control the infection. Additionally, preliminary results from experiments in SCID mice (mice with transplanted human immune cells) indicate that the human cells transduced with VRX496 and implanted into the SCID mice do not elicit any overt adverse effects. HIV-infected patients (CD4 T cell count of >200/mm3, discontinued from HAART therapy) will undergo leukoapheresis with subsequent CD4 T cell isolation. Patient CD4 T cells will be transduced ex vivo with the vector, expanded for 8-11 days, and then the modified cells will be reintroduced into the patient. Each subject will receive a single intravenous injection infused over 30 minutes; subjects will be examined 24, 48, and 72 hours post-injection and weekly for 4 weeks. Patients will receive one of four different ascending doses (1 x 10(9), 3 x 10(9), 1 x 10(10), and 3 X 10(10) cells/patient). Doses will be administered to four independent, sequential subject cohorts of 3 patients. Groups will be administered escalating doses at 6-week intervals after safety has been demonstrated in the previous group. Follow-up examinations will be conducted 1, 3, and 6 months post-injection. Long term follow-up including RCR testing will be performed.

Species differences in [11C]clorgyline binding in brain.

[11C]Clorgyline selectively binds to MAO A in the human brain. This contrasts with a recent report that [11C]clorgyline (in contrast to other labeled MAO A inhibitors) is not retained in the rhesus monkey brain [4]. To explore this difference, we compared [11C]clorgyline in the baboon brain before and after clorgyline pretreatment and we also synthesized deuterium substituted [11C]clorgyline (and its nor-precursor) for comparison. [11C]Clorgyline was not retained in the baboon brain nor was it influenced by clorgyline pretreatment or by deuterium substitution, contrasting to results in humans. This suggests a species difference in the susceptibility of MAO A to inhibition by clorgyline and represents an unusual example of where the behavior of a radiotracer in the baboon brain does not predict its behavior in the human brain.

On the stability of double stranded nucleic acids.

We present the first pressure-versus-temperature phase diagram for the helix-to-coil transition of double stranded nucleic acids. The thermodynamic stability of a nucleic acid duplex is a complex function of temperature and pressure and strongly depends on the denaturation temperature, T(M), of the duplex at atmospheric pressure. Depending upon T(M), pressure, and temperature, the phase diagram shows that pressure may stabilize, destabilize, or have no effect on the conformational state of DNA. To verify the phase diagram, we have conducted high-pressure UV melting experiments on poly(dIdC)poly(dIdC), a DNA duplex, poly(rA)poly(rU), an RNA duplex, and poly(dA)poly(rU), a DNA/RNA hybrid duplex. The T(M) values of these duplexes have been modulated by altering the solution ionic strength. Significantly, at low salt, these three duplexes have helix-to-coil transition temperatures of 50 degrees C or less. In agreement with the derived phase diagram, we found that the polymeric duplexes were destabilized by pressure if the T(M) is < approximately 50 degrees C. However, these duplexes were stabilized by pressure if the T(M) is > approximately 50 degrees C. The DNA/RNA hybrid duplex, poly(dA)poly(rU), with a T(M) of 31 degrees C in 20 mM NaCl undergoes a pressure-induced helix-to-coil transition at room temperature. This is the first report of pressure-induced denaturation of a nucleic acid duplex and provides new insights into the molecular forces stabilizing these structures.

Increased plasma tryptophan in HIV-infected patients treated with pharmacologic doses of nicotinamide.

OBJECTIVE: Decreased plasma tryptophan in persons infected with human immunodeficiency virus (HIV) was first reported over a decade ago, and this observation has since been confirmed by many groups. Before this study, only zidovudine (an antiviral medication) had been reported to reverse plasma tryptophan depletion in HIV-infected persons. Starting with the hypothesis that HIV induces a pellagra-like state and that plasma tryptophan in HIV-infected patients is decreased as a known biochemical correlate of pellagra, we predicted that niacin therapy would reverse plasma tryptophan depletion as it does in pellagra. METHODS: After receiving approval from the institutional review board, we treated HIV-infected patients for 2 mo with high-dose niacin in the form of oral nicotinamide. RESULTS: There was an average 40% increase in plasma tryptophan (P = 0.01) in the four HIV-infected individuals who completed the 2-mo protocol. This finding was specific in that four other amino acids, which have been shown to have significant plasma concentration alterations during HIV infection (i.e., cystine, methionine, taurine, and lysine), showed no significant change with nicotinamide therapy. CONCLUSIONS: There were no adverse side effects attributable to this treatment. The effects of high-dose nicotinamide treatment on morbidity or mortality in HIV-infected persons are yet to be determined. This report marks the first successful use of a vitamin to reverse this HIV-induced metabolic abnormality.

Evidence that L-deprenyl treatment for one week does not inhibit MAO A or the dopamine transporter in the human brain.

In this study, we investigated whether treatment with L-deprenyl, a selective monoamine oxidase B (MAO B) inhibitor, also inhibits MAO A or the dopamine transporter in the human brain. Six normal volunteers (age 46+/-6 yrs) had two PET sessions, one at baseline and one following L-deprenyl (10 mg/day) for 1 week. Each session included one scan with [11C]clorgyline (to assess MAO A) and one scan 2 hours later with [11C]cocaine (to assess dopamine transporter availability). A 3-compartment model was used to compare the plasma-to-brain transfer constant, K1 (a function of blood flow) and lambdak3 (a kinetic term proportional to brain MAO A) before and after treatment. Dopamine transporter availability was measured as the ratio of distribution volumes of the striatum to cerebellum (DVR) which is equal to Bmax/KD +1. L-Deprenyl treatment for 1 week did not affect either brain MAO A activity or dopamine transporter availability. There was a non-significant trend for an increase in K1 after L-deprenyl. These results confirm that L-deprenyl after one week of treatment at doses typically used clinically is selective for MAO B and that it does not produce a measurable affect on the dopamine transporter, suggesting that MAO A inhibition and dopamine transporter blockade do not contribute to its pharmacological effects.