Improving cause of death certification in the Philippines: implementation of an electronic verbal autopsy decision support tool (SmartVA auto-analyse) to aid physician diagnoses of out-of-facility deaths.

BACKGROUND: The majority of deaths in the Philippines occur out-of-facility and require a medical certificate of cause of death by Municipal Health Officers (MHOs) for burial. MHOs lack a standardised certification process for out-of-facility deaths and when no medical records are available, certify a high proportion of ill-defined causes of death. We aimed to develop and introduce SmartVA Auto-Analyse, a verbal autopsy (VA) based electronic decision support tool in order to assist the MHOs in certifying out-of-facility deaths. METHOD: We conducted a stakeholder consultation, process mapping and a pre-test to assess feasibility and acceptability of SmartVA Auto-Analyse. MHOs were first asked to conduct an open-ended interview from the family members of the deceased, and if they were not able to arrive at a diagnosis, continue the interview using the standardised SmartVA questionnaire. Auto-Analyse then presented the MHO with the three most likely causes of death. For the pilot, the intervention was scaled-up to 91 municipalities. We performed a mixed-methods evaluation using the cause of death data and group discussions with the MHOs. RESULTS: Of the 5649 deaths registered, Auto-Analyse was used to certify 4586 (81%). For the remaining 19%, doctors believed they could assign a cause of death based on the availability of medical records and the VA open narrative. When used, physicians used the Auto-Analyse diagnosis in 85% of cases to certify the cause of death. Only 13% of the deaths under the intervention had an undetermined cause of death. Group discussions identified two themes: Auto-Analyse standardized the certification of home deaths and assisted the MHOs to improve the quality of death certification. CONCLUSION: Standardized VA combined with physician diagnosis using the SmartVA Auto-Analyse support tool was readily used by MHOs in the Philippines and can improve the quality of death certification of home deaths.

Impact of seed-applied pesticides on rhizobial survival and legume nodulation.

AIMS: Compatibility of seed-applied pesticides and rhizobial inoculants is an important consideration for farmers when sowing legumes. Some of the seed-applied pesticides may influence rhizobial growth and nodulation, but there is currently little available information on the potential inhibitory effects. Therefore, common seed fungicidal and insecticidal treatments were assessed to determine adverse impacts on rhizobial inoculants both in vitro, on treated seed, and in the field. METHODS AND RESULTS: Initially, the in vitro toxicity of the seed-applied fungicides Thiram 600, P-Pickel T (PPT), their active ingredients (thiram and thiabendazole) and the insecticide Gaucho to rhizobia was measured with filter discs containing varying concentrations of the pesticides. Pea and chickpea seed was then coated with the same pesticides and inoculated with rhizobia in different inoculant substrates to determine bacterial survival and nodulation. Finally, a field trial using the fungicide PPT and commercial inoculants was conducted. Some seed fungicide treatments were found to be inhibitory to rhizobia and reduce nodulation under monoxenic conditions and in the field. SIGNIFICANCE AND IMPACT OF THE STUDY: These data provide more detailed information on the compatibility of specific rhizobial inoculants with common seed-applied pesticides. This research will provide information on the compatibility of rhizobia and seed-applied pesticides, and assist farmers to select sowing practices which reduce the risk of crop nodulation failures.

Islands as Laboratories: Indigenous Knowledge and Gene Drives in the Pacific.

This article argues that the genetic engineering technology known as gene drive must be evaluated in the context of the historic and ongoing impacts of settler colonialism and military experimentation on indigenous lands and peoples. After defining gene drive and previewing some of the key ethical issues related to its use, the author compares the language used to justify Cold War-era nuclear testing in the Pacific with contemporary scholarship framing islands as ideal test sites for gene drive-modified organisms. In both cases, perceptions of islands as remote and isolated are mobilized to warrant their treatment as sites of experimentation for emerging technologies. Though gene drive may offer valuable interventions into issues affecting island communities (e.g., vector-borne disease and invasive species management), proposals to conduct the first open trials of gene drive on islands are complicit in a long history of injustice that has treated islands (and their residents) as dispensable to the risks and unintended consequences associated with experimentation. This article contends that ethical gene drive research cannot be achieved without the inclusion of indigenous peoples as key stakeholders and provides three recommendations to guide community engagement involving indigenous communities: centering indigenous self-determination, replacing the deficit model of engagement with a truly participatory model, and integrating indigenous knowledge and values in the research and decision-making processes related to gene drive.

Wheat gluten structure and (non-)covalent network formation during deep-fat frying.

The aim of this work was to investigate wheat gluten protein network structure throughout the deep-frying process and evaluate its contribution to frying-induced micro- and macrostructure development. Gluten polymerization, gluten-water interactions, and molecular mobility were assessed as a function of the deep-frying time (0 - 180 s) for gluten-water model systems of differing hydration levels (40 - 60 % moisture content). Results showed that gluten protein extractability decreased considerably upon deep frying (5 s) mainly due to glutenin polymerization by disulfide covalent cross-linking. Stronger gliadin and glutenin protein-protein interactions were attributed to the formation of covalent linkages and evaporation of water interacting with protein chains. Longer deep-frying (> 60 s) resulted in progressively lower protein extractabilities, mainly due to the loss in gliadin protein extractability, which was associated with gliadin co-polymerization with glutenin by thiol-disulfide exchange reactions. The mobility of gluten polymers was substantially reduced during deep-frying (based on the lower T2 relaxation time of the proton fraction representing the non-exchanging protons of gluten) and gluten proteins gradually transitioned from the rubbery to the glassy state (based on the increased area of said protons). The sample volume during deep-frying was strongly correlated to the reduced protein extractability (r = -0.792, p < 0.001) and T2 relaxation time of non-exchanging protons of gluten proteins (r = -0.866, p < 0.001) thus demonstrating that the extent of gluten structural expansion as a result of deep-frying is dictated both by the polymerization of proteins and the reduction in their molecular mobility.

First-in-Human Assessment of Gut Permeability in Crohn's Disease Patients Using Fluorophore Technology.

Background and Aims: The dual sugar absorption test as a classic measure of human intestinal permeability has limited clinical utility due to lengthy and cumbersome urine collection, assay variability, and long turnaround. We aimed to determine if the orally administered fluorophore MB-102 (relmapirazin) (molecular weight [MW] = 372) compares to lactulose (L) (MW = 342) and rhamnose (R) (MW = 164)-based dual sugar absorption test as a measure of gut permeability in people with a spectrum of permeability including those with Crohn's disease (CD). Methods: We performed a single-center, randomized, open-label, crossover study comparing orally administered MB-102 (1.5 or 3.0 mg/kg) to L (1000 mg) and R (200 mg). Adults with active small bowel CD on magnetic resonance enterography (cases) and healthy adults (controls) were randomized to receive either MB-102 or L and R on study day 1, and the other tracer 3 to 7 days later. Urine was collected at baseline and 1, 2, 4, 6, 8, 10, and 12 hours after tracer ingestion to calculate the cumulative urinary percent excretion of MB-102 and L and R. Results: Nine cases and 10 controls completed the study without serious adverse events. Urinary recovery of administered MB-102 correlated with recovery of lactulose (r-squared = 0.83) for all participants. MB-102 urine recovery was also tracked with the L:R ratio urine recovery (r-squared = 0.57). In controls, the percentages of L and MB-102 recovered were similar within a narrow range, unlike in CD patients. Conclusion: This first-in-human study of an orally administered fluorophore to quantify gastrointestinal permeability in adults with CD demonstrates that MB-102 is well tolerated, and its recovery in urine mirrors that of percent L and the L:R ratio.

Transdermal Detection of MB-102 and Correlation to Meropenem Pharmacokinetics During Continuous Renal Replacement Therapy: In Vivo Results.

Critically ill patients undergoing continuous renal replacement therapy (CRRT) have medical conditions requiring extensive pharmacotherapy. Continuous renal replacement therapy impacts drug disposition. Few data exist regarding drug dosing requirements with contemporary CRRT modalities and effluent rates. The practical limitations of pharmacokinetic studies requiring numerous plasma and effluent samples, and lack of generalizability of observations from specific CRRT prescriptions, highlight gaps in bedside assessment of CRRT drug elimination and individualized dosing needs. We employed a porcine model using transdermal fluorescence detection of the glomerular filtration rate fluorescent tracer agent MB-102, with the aim to assess the relationship between systemic exposure of MB-102 and meropenem during CRRT. Animals underwent bilateral nephrectomies and received intravenous bolus doses of MB-102 and meropenem. Once MB-102 equilibrated in the animal, CRRT was initiated. Continuous renal replacement therapy prescriptions comprised four combinations of blood pump (low versus high) and effluent (low versus high) flow rates. Changes in transdermal detected MB-102 clearance occurred immediately with a change in CRRT rates. Blood side meropenem clearance mirrored transdermal MB-102 clearance ( r2 : 0.95-0.97, p value all <0.001). We suggest transdermal MB-102 clearance provides real-time personalized assessment of drug elimination and could optimize prescription of drugs for critically ill patients requiring CRRT.

Codesigning a community-based participatory research project to assess tribal perspectives on privacy and health data sharing: A report from the Strong Heart Study.

Broad health data sharing raises myriad ethical issues related to data protection and privacy. These issues are of particular relevance to Native Americans, who reserve distinct individual and collective rights to control data about their communities. We sought to gather input from tribal community leaders on how best to understand health data privacy and sharing preferences in this population. We conducted a workshop with 14 tribal leaders connected to the Strong Heart Study to codesign a research study to assess preferences concerning health data privacy for biomedical research. Workshop participants provided specific recommendations regarding who should be consulted, what questions should be posed, and what methods should be used, underscoring the importance of relationship-building between researchers and tribal communities. Biomedical researchers and informaticians who collect and analyze health information from Native communities have a unique responsibility to safeguard these data in ways that align to the preferences of specific communities.

Characterization of MB-102, a New Fluorescent Tracer Agent for Point-of-Care Renal Function Monitoring.

MB-102 is a fluorescent tracer agent designed for measurement of point-of-care glomerular filtration rate (GFR) and is currently in clinical studies. MB-102 possesses a strong UV absorbance at 266 nm and 435 nm, and broad fluorescent emission at ~560 nm when excited at ~440 nm. The MB-102 formulation is stable at 2°C-8°C for >3 years. The pKa's of the 2 acid groups are 2.71 and 3.40. Both X-ray crystallography and HPLC confirmed the D, D chirality of MB-102 in solid, in solution, and in the drug formulation. Initial safety and toxicity was published previously [Bugaj and Dorshow, 2015], which enabled the commencement of clinical studies. In vitro studies showed that 4.1% of MB-102 is bound to human plasma proteins, compared to 6.0% for the accepted standard GFR agent iohexol. The blood-to-plasma ratio for MB-102 was 0.590, illustrating minimal distribution of MB-102 into red blood cells. The manufacture of MB-102 under good manufacturing practice yields the designed molecular structure at high purity (>95% wt/wt).

Transdermal fluorescence detection of a dual fluorophore system for noninvasive point-of-care gastrointestinal permeability measurement.

The intestinal mucosal barrier prevents macromolecules and pathogens from entering the circulatory stream. Tight junctions in this barrier are compromised in inflammatory bowel diseases, environmental enteropathy, and enteric dysfunction. Dual sugar absorption tests are a standard method for measuring gastrointestinal integrity, however, these are not clinically amenable. Herein, we report on a dual fluorophore system and fluorescence detection instrumentation for which gastrointestinal permeability is determined in a rat small bowel disease model from the longitudinal measured transdermal fluorescence of each fluorophore. This fluorophore technology enables a specimen-free, noninvasive, point-of-care gastrointestinal permeability measurement which should be translatable to human clinical studies.

Genetic Characterization and Diversity of Rathayibacter toxicus.

ABSTRACT Rathayibacter toxicus is a nematode-vectored gram-positive bacterium responsible for a gumming disease of grasses and production of a highly potent animal and human toxin that is often fatal to livestock and has a history of occurring in unexpected circumstances. DNA of 22 strains of R. toxicus from Australia were characterized using amplified fragment length polymorphism (AFLP) and pulsed-field gel electrophoresis (PFGE). AFLP analysis grouped the 22 strains into three genetic clusters that correspond to their geographic origin. The mean similarity between the three clusters was 85 to 86%. PFGE analysis generated three different banding patterns that enabled typing the strains into three genotypic groups corresponding to the same AFLP clusters. The similarity coefficient was 63 to 81% for XbaI and 79 to 84% for SpeI. AFLP and PFGE analyses exhibited an analogous level of discriminatory power and produced congruent results. PFGE analysis indicated that the R. toxicus genome was represented by a single linear chromosome, estimated to be 2.214 to 2.301 Mb. No plasmids were detected.

"Whenever they cry, I cry with them": Reciprocal relationships and the role of ethics in a verbal autopsy study in Papua New Guinea.

Verbal autopsy (VA) methods usually involve an interview with a recently bereaved individual to ascertain the most probable cause of death when a person dies outside of a hospital and/or did not receive a reliable death certificate. A number of concerns have arisen around the ethical and social implications of the use of these methods. In this paper we examine these concerns, looking specifically at the cultural factors surrounding death and mourning in Papua New Guinea, and the potential for VA interviews to cause emotional distress in both the bereaved respondent and the VA fieldworker. Thirty one semi-structured interviews with VA respondents, the VA team and community relations officers as well as observations in the field and team discussions were conducted between June 2013 and August 2014. While our findings reveal that VA participants were often moved to cry and feel sad, they also expressed a number of ways they benefited from the process, and indeed welcomed longer transactions with the VA interviewers. Significantly, this paper highlights the ways in which VA interviewers, who have hitherto been largely neglected in the literature, navigate transactions with the participants and make everyday decisions about their relationships with them in order to ensure that they and VA interviews are accepted by the community. The role of the VA fieldworker should be more carefully considered, as should the implications for training and institutional support that follow.

Multiplex PCB-based electrochemical detection of cancer biomarkers using MLPA-barcode approach.

Asymmetric multiplex ligation-dependent probe amplification (MLPA) was developed for the amplification of seven breast cancer related mRNA markers and the MLPA products were electrochemically detected via hybridization. Seven breast cancer genetic markers were amplified by means of the MLPA reaction, which allows for multiplex amplification of multiple targets with a single primer pair. Novel synthetic MLPA probes were designed to include a unique barcode sequence in each amplified gene. Capture probes complementary to each of the barcode sequences were immobilized on each electrode of a low-cost electrode microarray manufactured on standard printed circuit board (PCB) substrates. The functionalised electrodes were exposed to the single-stranded MLPA products and following hybridization, a horseradish peroxidase (HRP)-labelled DNA secondary probe complementary to the amplified strand completed the genocomplex, which was electrochemically detected following substrate addition. The electrode arrays fabricated using PCB technology exhibited an excellent electrochemical performance, equivalent to planar photolithographically-fabricated gold electrodes, but at a vastly reduced cost (>50 times lower per array). The optimised system was demonstrated to be highly specific with negligible cross-reactivity allowing the simultaneous detection of the seven mRNA markers, with limits of detections as low as 25pM. This approach provides a novel strategy for the genetic profiling of tumour cells via integrated "amplification-to-detection".

Identifying competencies for Australian health professionals working in international health.

A profile of the roles performed by Australian health professionals working in international health was constructed to identify the core competencies they require, and the implications for education and training of international health practitioners. The methods used included: literature review and document analysis of available training and education; an analysis of competencies required in job descriptions for international health positions; and consultations with key informants. The international health roles identified were classified in four main groups: Program Directors, Program Managers, Team Leaders and Health Specialists. Thirteen 'core' competencies were identified from the job analysis and key informant/group interviews. Contributing to international health development in resource poor countries requires high level cultural, interpersonal and teamwork competencies. Technical expertise in health disciplines is required, with flexibility to adapt to new situations. International health professionals need to combine public health competencies with high level personal maturity to respond to emerging challenges.

Etiology of acute lower respiratory tract infection in Central Australian Aboriginal children.

BACKGROUND: Aboriginal children in central Australia have attack rates for acute lower respiratory tract infection (ALRI) that are similar to those in developing countries. Although mortality rates are much lower than in developing countries, morbidity is high and ALRI is still the leading cause of hospitalization. However, there are no data on the etiology of ALRI in this population. METHODS: We prospectively studied 322 cases of ALRI in 280 Aboriginal children admitted to the hospital. Blood, urine and nasopharyngeal aspirate samples were examined for evidence of bacterial, viral and chlamydial infection. RESULTS: The combination of blood culture, viral studies and chlamydial serology provided at least 1 etiologic agent in 170 of 322 (52.5%) cases. Assays for pneumolysin immune complex and pneumolysin antibody increased etiologic diagnosis to 219 (68.0%). Blood cultures were positive in 6% but pneumolysin immune complex and pneumolysin antibody studies were positive in one-third of cases. Evidence of viral infection was present in 155 (48%) of cases compared with 12% in controls (P < 001). There were only 7 possible cases and 2 definite cases of Chlamydia trachomatis and 3 cases of Chlamydia pneumoniae. Coinfection was common in these children. CONCLUSION: These findings have implications for both standard treatment protocols and vaccine strategies. The high rate of coinfection may make it difficult to develop simple clinical predictors of bacterial infection. In the setting of a developed country with efficient patient evacuation services, management algorithms that focus on disease severity and need for hospital referral will be most useful to health staff in remote communities. Pneumococcal conjugate vaccines will be required to reduce the high attack rate of pneumococcal disease.

Responding to cough: Boholano illness classification and resort to care in response to childhood ARI.

A qualitative study into the health seeking behaviour of caretakers in response to ARI in children under five years of age was conducted in the province of Bohol, the Philippines. The study was designed to compliment survey data generated from a long running ARI intervention project, specifically to explain behaviours identified as problematic by the project. Results indicate the importance of folk diagnosis as a basis for selection of first resort for care in the management of childhood ARI. A cultural category, piang, was identified as a major factor influencing health seeking behaviour and delay in consulting the biomedical system where serious ARI exists. In addition, caretakers' financial situation and social contacts are important in their decision to seek biomedical assistance and are often implicated in delay in presentation and acting upon referral to hospital.

Inducible Flavone in Oats (Avena sativa) Is a Novel Defense Against Plant-Parasitic Nematodes.

ABSTRACT The induction of defense compounds in oats (Avena sativa) in response to invasion by parasitic nematodes and to application of the wound hormone methyl jasmonate was examined. Oats cv. Quoll seedlings were challenged with Pratylenchus neglectus, Heterodera avenae, and Ditylenchus dipsaci and treated with 1 x 10(-4) M methyl jasmonate. Three compounds, isolated in methanolic root and shoot extracts of oats, exhibiting an absorbance spectrum typical of flavone glycosides, were induced by nematode invasion and methyl jasmonate. These were identified as flavone-C-glycosides by mass spectrometry. The effect of the flavone-C-glycosides on the invasion by and development of cereal cyst nematode H. avenae was assessed using methanolic extracts of shoots and roots from methyl jasmonate-treated plants. Both extracts impaired nematode invasion and development. When the extracts were fractionated by high voltage paper electrophoresis, only one flavone-C-glycoside, O-methyl-apigenin-C-deoxyhexoside-O-hexoside, inhibited nematode invasion. The protective effect of the induction of flavone-C-glycosides in oats by methyl jasmonate was evaluated against H. avenae and P. neglectus. Treatment with methyl jasmonate reduced invasion of both nematodes and increased plant mass, compensating for damage caused by the nematodes, and is attributed to the active flavone-C-glycoside. The active compound, O-methyl-apigenin-C-deoxyhexoside-O-hexoside, has not been implicated previously in plant defense against any pest or pathogen, and appears to provide protection against the major cereal nematodes Heterodera and Pratylenchus.

First Report of Grapevine Downy Mildew (Plasmopara viticola) in Commercial Viticulture in Western Australia.

Despite the suitability of climate, Western Australia was one of the few grape (Vitis vinifera L.) growing areas free of grapevine downy mildew (Plasmopara viticola (Berk. & M. A. Curtis) Berl. & De Toni in Sacc.). Area freedom had been maintained by restricting the movement of host material and machinery from outside the state and fungicide use in Western Australia vineyards had been considerably less. P. viticola was detected in 1997 in 14 of 15 vines growing at Kalumburu, a remote community in the semi-arid tropics of Western Australia, and was eradicated. In October 1998, grape leaves with oilspots typical of downy mildew were received from a grower in the Swan Valley near Perth, one of the main production areas of Western Australia. Sporangia were hyaline and ellipsoid (14 × 11 µm), were borne on treelike sporangiophores, and were consistent with those described for P. viticola (1). This is the first record of P. viticola in commercial viticulture in Western Australia. A response plan for exotic diseases was activated and after 2 weeks of surveillance the disease was found in 45 of 70 vineyards surveyed of the 280 vineyards in the Swan Valley. Given the extent of spread, eradication of downy mildew was not considered possible. Weather data for August to October 1998 indicated the likelihood of several infection periods from budburst to flowering when the disease was first detected. Crop loss will be considerable in many vineyards. P. viticola was also found in bench-grafted cuttings in pots in leaf consigned from the Swan Valley to several other areas in August 1998. Downy mildew was found in other areas only in association with these consigned vines. An industry code of practice, including hygiene, is being developed to slow the rate of spread of P. viticola in Western Australia. Reference: (1) Anon. C.M.I. Descriptions of Pathogenic Fungi and Bacteria No. 980, 1989.

Upper airway carriage by Haemophilus influenzae and Streptococcus pneumoniae in Australian aboriginal children hospitalised with acute lower respiratory infection.

When nasopharyngeal secretions from 171 Australian Aboriginal children hospitalized with acute lower respiratory tract infections (ALRI) were cultured selectively for Streptococcus pneumoniae and Haemophilus influenzae, 136 (79.5%) and 151 (88.3%) children yielded 166 and 254 isolates of S. pneumoniae and H. influenzae, respectively. In colonized subjects multiple populations of S. pneumoniae (20% of carriage-positive patients) and H. influenzae (55%) were common. Pneumococci belonging to 27 types or groups were identified. H. influenzae serotype b colonized 16.4% of all children studied. More than one half of 152 children tested were excreting antibiotics at the time of admission to hospital. Significantly fewer children with serum antibiotic residues were colonized with S. pneumoniae than were antibiotic free children. Antibiotic usage had no measurable impact on the isolation rate of H. influenzae.

Sampling ryegrass to assess the risk of annual ryegrass toxicity.

Most stock losses caused by annual ryegrass toxicity occur because stockowners unknowingly allow their stock to graze annual ryegrass (Lolium rigidum) infected with the bacterium Clavibacter toxicus. To help stockowners avoid losses we have developed criteria for a testing service to determine the risk of poisoning before the pasture is grazed. Low, medium and high risk categories were selected using samples of dry, mature ryegrass seedheads collected by stockowners from untreated, infected pastures in South Australia. The proportion of toxic paddocks in each risk category over all the seasons tested was 11%, 32% and 76%, respectively, and these accounted for 7%, 14% and 79% of total stock losses. The proportion of paddocks in which stock were poisoned did not vary significantly between years, was not affected by variation in sample weight, and did not vary between South Australia and Western Australia.