Engineering Escherichia coli for increased Und-P availability leads to material improvements in glycan expression technology

BACKGROUND

Bacterial surface glycans are assembled by glycosyltransferases (GTs) that transfer sugar monomers to long-chained lipid carriers. Most bacteria employ the 55-carbon chain undecaprenyl phosphate (Und-P) to scaffold glycan assembly. The amount of Und-P available for glycan synthesis is thought to be limited by the rate of Und-P synthesis and by competition for Und-P between phosphoglycosyl transferases (PGTs) and GTs that prime glycan assembly (which we collectively refer to as PGT/GTs). While decreasing Und-P availability disrupts glycan synthesis and promotes cell death, less is known about the effects of increased Und-P availability.

RESULTS

To determine if cells can maintain higher Und-P levels, we first reduced intracellular competition for Und-P by deleting all known non-essential PGT/GTs in the Gram-negative bacterium Escherichia coli (hereafter called ΔPGT/GT cells). We then increased the rate of Und-P synthesis in ΔPGT/GT cells by overexpressing the Und-P(P) synthase uppS from a plasmid (puppS). Und-P quantitation revealed that ΔPGT/GT/puppS cells can be induced to maintain 3-fold more Und-P than wild type cells. Next, we determined how increasing Und-P availability affects glycan expression. Interestingly, increasing Und-P availability increased endogenous and recombinant glycan expression. In particular, ΔPGT/GT/puppS cells could be induced to express 7-fold more capsule from Streptococcus pneumoniae serotype 4 than traditional E. coli cells used to express recombinant glycans.

CONCLUSIONS

We demonstrate that the biotechnology standard bacterium E. coli can be engineered to maintain higher levels of Und-P. The results also strongly suggest that Und-P pathways can be engineered to increase the expression of potentially any Und-P-dependent polymer. Given that many bacterial glycans are central to the production of vaccines, diagnostics, and therapeutics, increasing Und-P availability should be a foremost consideration when designing bacterial glycan expression systems.

Lipopolysaccharide Is a 4-Aminoarabinose Donor to Exogenous Polyisoprenyl Phosphates through the Reverse Reaction of the Enzyme ArnT

Modification of the lipid A portion of LPS with cationic monosaccharides provides resistance to polymyxins, which are often employed as a last resort to treat multidrug-resistant bacterial infections. Here, we describe the use of fluorescent polyisoprenoids, liquid chromatography-mass spectrometry, and bacterial genetics to probe the activity of membrane-localized proteins that utilize the 55-carbon lipid carrier bactoprenyl phosphate (BP). We have discovered that a substantial background reaction occurs when B-strain E. coli cell membrane fractions are supplemented with exogenous BP. This reaction involves proteins associated with the arn operon, which is necessary for the covalent modification of lipid A with the cationic 4-aminoarabinose (Ara4N). Using a series of arn operon gene deletion mutants, we identified that the modification was dependent on ArnC, which is responsible for forming BP-linked Ara4N, or ArnT, which transfers Ara4N to lipid A. Surprisingly, we found that the majority of the Ara4N-modified isoprenoid was due to the reverse reaction catalyzed by ArnT and demonstrate this using heat-inactivated membrane fractions, isolated lipopolysaccharide fractions, and analyses of a purified ArnT. This work provides methods that will facilitate thorough and rapid investigation of bacterial outer membrane remodeling and the evaluation of polyisoprenoid precursors required for covalent glycan modifications.

Impact of traumatic perinatal events on burnout rates among midwives

BACKGROUND

Little is known about the prevalence of burnout among Irish midwives and how traumatic perinatal events in work contributes to this.

AIMS

To establish the prevalence of burnout among midwives in Ireland and whether exposure to traumatic perinatal events in work contributes to this.

METHODS

A cross-sectional study utilizing a designed questionnaire was carried out in a tertiary-referral maternity hospital involving all clinical midwives (n = 248). Demographic details and frequency of perinatal events deemed traumatic were recorded. The extent of distress was documented on two visual analogues read in combination to reflect the impact of the distressing events. Burnout severity was assessed using the Copenhagen Burnout Inventory.

RESULTS

The response rate was 55% (n = 137). Mean scores for personal, work-related and patient-related burnout were 56.0, 55.9 and 34.3, respectively. Over 90% of respondents experienced exposure to a traumatic event in work in the previous year, with 58% reporting a frequency of monthly or greater. No significant relationship was demonstrated between frequency of trauma and burnout; however, the extent of distress experienced was positively related to burnout in each domain (R2 = 0.18, 0.15 and 0.09, respectively, P < 0.01). A modest negative linear relationship exists between personal and work-related burnout and increasing age (ρ = -0.25 and -0.27, P < 0.01). A significant difference in work-related burnout score was evident between midwives with less experience and more experienced colleagues (P < 0.01).

CONCLUSIONS

Burnout is common among midwives. Exposure to discrete traumatic perinatal events experienced by women under their care contributes to this.

Tracking Colanic Acid Repeat Unit Formation from Stepwise Biosynthesis Inactivation in Escherichia coli

Colanic acid is a glycopolymer loosely associated with the outer membrane of Escherichia coli that plays a role in pathogen survival. For nearly six decades since its discovery, the functional identities of the enzymes necessary to synthesize colanic acid have yet to be assessed in full. Herein, we developed a method for detecting the lipid-linked intermediates from each step of colanic acid biosynthesis in E. coli. The accumulation of each enzyme product was made possible by inactivating sequential genes involved in colanic acid biosynthesis and upregulating the colanic acid operon by inducing rcsA transcription. LC-MS analysis revealed that these accumulated materials were consistent with the well-documented composition analysis. Recapitulating the native bioassembly of colanic acid enabled us to identify the functional roles of the last two enzymes, WcaL and WcaK, associated with the formation of the lipid-linked oligosaccharide repeating unit of colanic acid. Importantly, biochemical evidence is provided for the formation of the final glycosylation hexasaccharide product formed by WcaL and the addition of a pyruvate moiety to form a pyruvylated hexasaccharide by WcaK. These findings provide insight into the development of methods for the identification of enzyme functions during cell envelope synthesis.

Making the Enterobacterial Common Antigen Glycan and Measuring Its Substrate Sequestration

The enterobacterial common antigen (ECA), a three-sugar repeat unit polysaccharide produced by Enterobacteriaceae family members, impacts bacterial outer membrane permeability, and its biosynthesis affects the glycan landscape of the organism. ECA synthesis impacts the production of other polysaccharides by reducing the availability of shared substrates, the most notable of which is the 55-carbon polyisoprenoid bactoprenyl phosphate (BP), which serves as a carrier for the production of numerous bacterial glycans including ECA, peptidoglycan, O-antigen, and more. Here, using a combination of in vitro enzymatic synthesis and liquid chromatography-mass spectrometry (LC-MS) analysis of bacterial lysates, we provide biochemical evidence for the effect on endogenous polyisoprenoid pools from cell culture that arises from glycan pathway disruption. In this work, we have cloned and expressed each gene involved in ECA repeat unit biosynthesis and reconstituted the pathway in vitro, providing LC-MS characterized standards for the investigation of cellular glycan-linked intermediates and BP. We then generated ECA deficient mutants in genes associated with production of the polysaccharide, which we suspected would accumulate materials identical to our standards. We found that indeed accumulated products from these cells were indistinguishable from our enzymatically prepared standards, and moreover we observed a concomitant decrease in cellular BP levels with each mutant. This work provides the first direct biochemical evidence for the sequestration of BP upon the genetic disruption of glycan biosynthesis pathways in bacteria. This work also provides methods for the direct assessment of both the ECA glycan, and a new understanding of the dynamic interdependence of the bacterial polysaccharide repertoire.

General Utilization of Fluorescent Polyisoprenoids with Sugar Selective Phosphoglycosyltransferases

The protective surfaces of bacteria are comprised of polysaccharides and are involved in host invasion and colonization, host immune system evasion, and antibacterial resistance. A major barrier to our fundamental understanding of these complex surface polysaccharides lies in the tremendous diversity in glycan composition among bacterial species. The polyisoprenoid bactoprenyl phosphate (or undecaprenyl phosphate) is an essential lipid carrier necessary for early stages of glycopolymer assembly. Because of the ubiquity of bactoprenyl phosphate in these critical processes, molecular probes appended to this lipid carrier simplify identification of enzymatic roles during polysaccharide bioassembly. A limited number of these probes exist in the literature or have been assessed with such pathways, and the limits of their use are not currently known. Herein, we devise an efficient method for producing fluorescently modified bactoprenyl probes. We further expand our previous efforts utilizing 2-nitrileaniline and additionally prepare nitrobenzoxadizol-tagged bactoprenyl phosphate for the first time. We then assess the enzyme promiscuity of these two probes utilizing four well-characterized initiating phosphoglycosyltransferases: CPS2E (Streptococcus pneumoniae), WbaP (Salmonella enterica), WecA (Escherichia coli), and WecP (Aeromonas hydrophilia). Both probes serve as substrates for these enzymes and could be readily used to investigate a wide range of bacterial glycoassembly pathways. Interestingly, we have also identified unique solubility requirements for the nitrobenzoxadizol moiety for efficient enzymatic utilization that was not observed for the 2-nitrileaniline.

Ebola, fragile health systems and tuberculosis care: a call for pre-emptive action and operational research

The Ebola outbreak that started in late 2013 is by far the largest and most sustained in history. It occurred in a part of the world where pre-existing health systems were already fragile, and these deteriorated further during the epidemic due to a large number of health worker deaths; temporary or permanent closure of health facilities; non-payment of health workers; intrinsic fear of contracting or being stigmatised by Ebola among the population, which negatively influenced health-seeking behaviour; enforced quarantine of Ebola-affected communities, restricting the access of vulnerable individuals to health facilities; and late response by the international community. There are also reports of drug and consumable stockouts due to deficiencies in the procurement and supply chain as a result of overriding Ebola-related priorities. Providing tuberculosis (TB) care and achieving favourable treatment outcomes require a fully functioning health system, accurate patient tracking and high patient adherence to treatment. Furthermore, as Ebola is easily transmitted through body fluids, the use of needles-essential for TB diagnosis and treatment-needs to be avoided during an outbreak. We highlight ways in which a sustained Ebola outbreak could jeopardise TB activities and suggest pre-emptive preventive measures while awaiting operational research evidence.

Outcomes of antiretroviral therapy among younger versus older adolescents and adults in an urban clinic, Zimbabwe

SETTING

A non-governmental organisation-supported clinic offering health services including antiretroviral therapy (ART).

OBJECTIVE

To compare ART retention between younger (age 10-14 years) vs. older (age 15-19 years) adolescents and younger (age 20-29 years) vs. older (age ⩾30 years) adults and determine adolescent- and adult-specific attrition-associated factors among those initiated on ART between 2010 and 2011.

DESIGN

Retrospective cohort study.

RESULTS

Of 110 (7%) adolescents and 1484 (93%) adults included in the study, no differences in retention were observed between younger vs. older adolescents at 6, 12 and 24 months. More younger adolescents were initiated with body mass index <16 kg/m(2) compared with older adolescents (64% vs. 47%; P = 0.04). There were more females (74% vs. 52%, P < 0.001) and fewer patients initiating ART with CD4 count ⩽350 cells/mm(3) (77% vs. 81%, P = 0.007) among younger vs. older adults. Younger adults demonstrated more attrition than older adults at all time-points. No attrition risk factors were observed among adolescents. Attrition-associated factors among adults included being younger, having a lower CD4 count and advanced human immunodeficiency virus disease at initiation, and initiation on a stavudine-based regimen.

CONCLUSION

Younger adults demonstrated greater attrition and may require more attention. We were unable to demonstrate differences in attrition among younger vs. older adolescents. Loss to follow-up was the main reason for attrition across all age groups. Overall, earlier presentation for ART care appears important for improved ART retention among adults.

Novel oral anticoagulants in plastic surgery

Novel oral anticoagulants (NOACs) have emerged as a good alternative to warfarin in the prevention of stroke for patients with atrial fibrillation. NOAC use is increasing rapidly; therefore, greater understanding of their use in the perioperative period is important for optimal care. Studies and reviews that reported on the use of NOACs were identified, with particular focus on the perioperative period. PubMed was searched for relevant articles published between January 2000 and August 2015. The inevitable rise in the use of NOACs such as rivaroxaban (Xarelto™), apixaban (Eliquis™), edoxaban (Lixiana™) and dabigatran (Pradaxa™) may present a simplified approach to perioperative anticoagulant management due to fewer drug interactions, rapidity of onset of action and relatively short half-lives. Coagulation status, however, cannot reliably be monitored and no antidotes are currently available. When planning for discontinuation of NOACs, special consideration of renal function is required. Advice regarding the management of bleeding complications is provided for consideration in emergency surgery. In extreme circumstances, haemodialysis may be considered for bleeding with the use of dabigatran. NOACs will increasingly affect operative planning in plastic surgery. In order to reduce the incidence of complications associated with anticoagulation, the management of NOACs in the perioperative period requires knowledge of the time of last dose, renal function and the bleeding risk of the planned procedure. Consideration of these factors will allow appropriate interpretation of the current guidelines.

Does research through Structured Operational Research and Training (SORT IT) courses impact policy and practice?

SETTING

Structured Operational Research and Training Initiative (SORT IT) courses are well known for their output, with nearly 90% of participants completing the course and publishing in scientific journals.

OBJECTIVE

We assessed the impact of research papers on policy and practice that resulted from six SORT IT courses initiated between July 2012 and March 2013.

DESIGN

This was a cross-sectional study involving e-mail-based, self-administered questionnaires and telephone/skype/in-person responses from first and/or senior co-authors of course papers. A descriptive content analysis of the responses was performed and categorised into themes.

RESULTS

Of 72 participants, 63 (88%) completed the course. Course output included 81 submitted papers, of which 76 (94%) were published. Of the 81 papers assessed, 45 (55%) contributed to a change in policy and/or practice: 29 contributed to government policy/practice change (20 at national, 4 at subnational and 5 at hospital level), 11 to non-government organisational policy change and 5 to reinforcing existing policy. The changes ranged from modifications of monitoring and evaluation tools, to redrafting of national guidelines, to scaling up existing policies.

CONCLUSION

More than half of the SORT IT course papers contributed to a change in policy and/or practice. Future assessments should include more robust and independent verification of the reported change(s) with all stakeholders.

Effect of increased ART-CPT uptake on tuberculosis outcomes and associated factors, Burundi, 2009-2013

We retrospectively examined 3579 records of human immunodeficiency virus infected tuberculosis (TB) patients diagnosed from January 2009 to June 2013 in 55 TB treatment facilities in Burundi, to demonstrate whether improvement of combined cotrimoxazole preventive therapy and antiretroviral therapy (ART) uptake was accompanied by improvement of treatment outcomes, and to describe associated factors. Treatment success rates increased from 71% to 80% (P < 0.001). While loss to follow-up and transfer-out rates declined significantly, death rates decreased modestly, and remained high, at 14%. ART uptake was worse in suburban areas and private for-profit institutions. World Health Organization targets could be achieved if peripheral health facilities were prioritised.

Research output after participants complete a Structured Operational Research and Training (SORT IT) course

Eighteen months after successfully completing one of six Structured Operational Research and Training Initiative (SORT IT) courses, e-mail questionnaires assessing post-course research output were returned by 63 participants (100% response rate). Thirty-two (51%) participants had completed new research projects, 24 (38%) had published papers, 28 (44%) had presented abstracts at conferences, 15 (24%) had facilitated at further OR courses, and 21 (33%) had reviewed scientific papers. Seven (11%) had secured further research funding and 22 (35%) stated that their institutions were involved in implementation or capacity building in operational research. Significant research output continues beyond course completion, further endorsing the value of the SORT IT model.

Mentorship for operational research capacity building: hands-on or hands-off?

Mentorship is a key feature of operational research training courses run by the International Union Against Tuberculosis and Lung Disease and Médecins Sans Frontières. During the recent South Pacific paper writing module, the faculty discussed 'hands-on' mentorship (direct technical assistance) vs. 'hands-off' mentorship (technical advice). This article explores the advantages and disadvantages of each approach. Our collective experience indicates that 'hands-on' mentorship is a valuable learning experience for the participant and a rewarding experience for the mentor. This approach increases the likelihood of successful course completion, including publishing a well written paper. However, mentors must allow participants to lead and take ownership of the paper, in keeping with a first author position.

Do non-monetary incentives for pregnant women increase antenatal attendance among Ethiopian pastoralists?

In a pastoralist setting in Ethiopia, we assessed changes in attendance between the first and subsequent antenatal care (ANC) visits following the implementation of non-monetary incentives in a primary health care centre over a 3-year period from October 2009 to September 2012. Incentives included the provision of a bar of soap, a bucket, a mosquito net, sugar, cooking oil, a jerrycan and a delivery kit. The first ANC visits increased by 48% in the first year to 60% in the second. Subsequent visits did not show a similar pattern due to ruptures in incentive stocks. Incentives appear to increase ANC attendance; however, ruptures in stock should be avoided to sustain the effect.

What happens after participants complete a Union-MSF structured operational research training course?

SETTING

Eight operational research (OR) courses run by the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins Sans Frontières (MSF) for participants from low- and middle-income countries. There is a knowledge gap about whether participants continue OR after course completion.

OBJECTIVES

To determine 1) the research output of participants and their institutions after course completion; 2) the influence of OR fellowships on output; and 3) the output of non-OR fellows stratified by sex, region and staff position.

DESIGN

A self-administered e-mail questionnaire survey.

RESULTS

Of 83 participants who completed a course, 76 (92%) responded to the questionnaire. Following course completion, 47 (62%) participants completed new research projects, 38 (50%) published papers (vs. 25 [33%] who had published before the course), 42 (55%) presented posters or oral abstracts at conferences, 33 (43%) facilitated at further OR courses, 29 (38%) reviewed scientific papers, 25 (33%) secured further OR funding and 55 (72%) said their institutions were involved in OR implementation or capacity building. OR fellows performed better than non-OR fellows. Among the latter, males and participants from Asia had better output than females and participants from Africa (P < 0.05).

CONCLUSION

The significant proportion of participants continuing to engage in OR after course completion provides encouraging evidence of the long-term value of this capacity building model.

The Structured Operational Research and Training Initiative for public health programmes

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins sans Frontières Brussels-Luxembourg (MSF) began developing an outcome-oriented model for operational research training. In January 2013, The Union and MSF joined with the Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) to form an initiative called the Structured Operational Research and Training Initiative (SORT IT). This integrates the training of public health programme staff with the conduct of operational research prioritised by their programme. SORT IT programmes consist of three one-week workshops over 9 months, with clearly-defined milestones and expected output. This paper describes the vision, objectives and structure of SORT IT programmes, including selection criteria for applicants, the research projects that can be undertaken within the time frame, the programme structure and milestones, mentorship, the monitoring and evaluation of the programmes and what happens beyond the programme in terms of further research, publications and the setting up of additional training programmes. There is a growing national and international need for operational research and related capacity building in public health. SORT IT aims to meet this need by advocating for the output-based model of operational research training for public health programme staff described here. It also aims to secure sustainable funding to expand training at a global and national level. Finally, it could act as an observatory to monitor and evaluate operational research in public health. Criteria for prospective partners wishing to join SORT IT have been drawn up.

Antibiotic use in a district hospital in Kabul, Afghanistan: are we overprescribing?

SETTING

A district hospital in Kabul, Afghanistan, supported by Médecins Sans Frontières (MSF).

OBJECTIVES

To assess antibiotic prescribing practices in the out-patient department in summer (August 2013) and winter (January 2014).

DESIGN

Cross-sectional study, using routinely collected hospital data and using World Health Organization (WHO) defined daily dose (DDD) methodology.

RESULTS

An analysis of 4857 prescriptions (summer) and 4821 prescriptions (winter) showed that respectively 62% and 50% of all out-patients were prescribed at least one antibiotic. Prescriptions without a recorded diagnosis represented a sizeable proportion of all antibiotics prescribed. For upper respiratory tract infections (URTI), dental indications, urinary tract infections (UTI) and diarrhoea, good adherence to dosages recommended in the MSF standard treatment guidelines was observed when measured by DDD. However, certain drugs not indicated in the guidelines were prescribed, such as amoxicillin and metronidazole for UTI and azithromycin for URTI.

CONCLUSION

Rates of antibiotic prescriptions for out-patients in a district hospital in Afghanistan were high, double the WHO recommendation of 30%. While systematic non-adherence to recommended dosages was not observed, inappropriate prescriptions for specific conditions may have occurred. This study suggests that knowledge about context-specific determinants of antibiotic prescribing is a first step towards promoting rational prescribing practices in such settings.

Open access for operational research publications from low- and middle-income countries: who pays?

Open-access journal publications aim to ensure that new knowledge is widely disseminated and made freely accessible in a timely manner so that it can be used to improve people's health, particularly those in low- and middle-income countries. In this paper, we briefly explain the differences between closed- and open-access journals, including the evolving idea of the 'open-access spectrum'. We highlight the potential benefits of supporting open access for operational research, and discuss the conundrum and ways forward as regards who pays for open access.

Causes of pediatric mortality and case-fatality rates in eight Médecins Sans Frontières-supported hospitals in Africa

SETTING

Eight pediatric hospital in-patient wards in remote, rural and/or insecure areas in Africa.

OBJECTIVES

To describe, in children aged <5 years, 1) overall and individual mortality rates, 2) the 10 most common causes of mortality, and 3) their case-fatality rates.

DESIGN

Retrospective analysis of routinely collected standardized program data for 2010.

RESULTS

During 2010, 21 357 children aged <5 years were admitted and 1520 died, resulting in an overall in-patient mortality rate among under-fives of 7%. This remained the same after considering the three most common causes of mortality per hospital. One hospital with a neonatal unit showed a mortality rate of 14%. Of the 10 most common causes of mortality in the eight hospitals, severe malaria, acute lower respiratory tract infection and neonatal infection counted for about 77% of total deaths. Ranking the 10 most common causes of mortality according to case-fatality rates, septicemia, meningitis, low birth weight with pathology, neonatal infection and neonatal asphyxia were the most common (case-fatality rates 15-40%).

CONCLUSION

Despite widely different contexts, mortality rates for pediatric in-patients were consistently under 10%. To further reduce mortality, emphasis should be placed on treating sepsis and introducing implementable and/or adapted care packages for neonatal-related pathologies.

Notified tuberculosis among Singapore residents by ethnicity, 2002-2011

SETTING

The National Tuberculosis Programme in Singapore where, among resident cases, higher tuberculosis (TB) rates have been reported in ethnic Malays.

OBJECTIVE

To describe the socio-demographic and clinical characteristics of resident TB cases by ethnicity, and to assess whether Malays differ from other groups in terms of the above parameters.

DESIGN

Cross-sectional review of records from the tuberculosis registry's electronic database.

RESULTS

Among 15 622 resident cases notified, 72.2% were Chinese, 18.7% Malay, 5.8% Indian and 2.9% were from other minorities. Compared to other ethnicities, Malays were more likely to be incarcerated at the time of notification (odds ratio [OR] 3.70, 95%CI 3.03-4.52) and clustered at the same residential address (OR 1.65, 95%CI 1.44-1.89), but were less likely to be aged ≥65 years (OR 0.61, 95%CI 0.54-0.70) or to reside in high-cost housing (OR 0.11, 95%CI 0.07-0.17). In terms of disease characteristics, more Malays had diabetes mellitus (OR 1.54, 1.37-1.73), a highly-positive acid-fast bacilli smear (OR 1.64, 95%CI 1.47-1.83) and cavitary disease on chest X-ray (OR 1.41, 95%CI 1.28-1.55).

CONCLUSION

Compared to other ethnicities, reported TB cases among Malays were more severe and were likely to be more infectious. Increased vigilance in case management and contact investigations, as well as an improvement in the socio-economic conditions of this community, are required to reduce TB rates in this ethnic group.

High quit rate among smokers with tuberculosis in a modified smoking cessation programme in Dhaka, Bangladesh

SETTING

BRAC, a non-governmental organisation, implemented a modified smoking cessation programme for tuberculosis (TB) patients based on International Union Against Tuberculosis and Lung Disease (The Union) guidelines in 17 peri-urban centres of Dhaka, Bangladesh.

OBJECTIVE

To determine whether a modified version of The Union's smoking cessation intervention was effective in promoting cessation among TB patients and determinants associated with quitting smoking.

DESIGN

Cohort study of routinely collected data.

RESULTS

A total of 3134 TB patients were registered from May 2011 to April 2012. Of these, 615 (20%) were current smokers, with a mean age of 38 years (±13.8). On treatment completion, 562 patients were analysed, with 53 (9%) lost to follow-up or dead, while 82% of smokers had quit. Patients with extra-pulmonary TB were less likely to quit than those with pulmonary TB. Patients with high-intensity dependence were less likely to quit than those with low-intensity dependence.

CONCLUSION

This study suggests that a simplified smoking cessation intervention can be effective in promoting smoking cessation among TB patients in Bangladesh. This is encouraging for other low-resource settings; the Bangladesh National Tuberculosis Control Programme should consider nationwide scaling up and integration of this smoking cessation plan.

References for scientific papers: why not standardise to one global style?

The different reference styles demanded by journals, both for in-text citations and manuscript bibliographies, require that significant time and attention be paid to minute detail that constitute a tedious obstacle on the road to publication for all authors, but especially for those from resource-limited countries and/or writing in a second language. To illustrate this, we highlight different reference styles requested by five popular journals to which operational research papers are often submitted. We call for a simpler, standardised format for in-text and bibliography reference citations, so that researchers can concentrate on the science and its interpretation rather than fonts and punctuation.

Characteristics and mortality of neonates in an emergency obstetric and neonatal care facility, rural Burundi

SETTING

A Médecins Sans Frontières emergency obstetric and neonatal care facility specialising as a referral centre for three districts for women with complications during pregnancy or delivery in rural Burundi.

OBJECTIVE

To describe the characteristics and in-facility mortality rates of neonates born in 2011.

DESIGN

Descriptive study involving a retrospective review of routinely collected facility data.

RESULTS

Of 2285 women who delivered, the main complications were prolonged labour 331 (14%), arrested labour 238 (10%), previous uterine intervention 203 (9%), breech 171 (8%) and multiple gestations 150 (7%). There were 175 stillbirths and 2110 live neonates, of whom 515 (24%) were of low birth weight, 963 (46%) were delivered through caesarean section and 267 (13%) required active birth resuscitation. Overall, there were 102 (5%) neonatal deaths. A total of 453 (21%) neonates were admitted to dedicated neonatal special services for sick and low birth weight babies. A high proportion of these neonates were delivered by caesarean section and needed active birth resuscitation. Of 67 (15%) neonatal deaths in special services, 85% were due to conditions linked to low birth weight and birth asphyxia.

CONCLUSION

Among neonates born to women with complications during pregnancy or delivery, in-facility deaths due to low birth weight and birth asphyxia were considerable. Sustained attention is needed to reduce these mortality rates.

Screening for tuberculosis in pregnancy: do we need more than a symptom screen? Experience from western Kenya

OBJECTIVES

1) To explore the utility of tuberculosis (TB) symptom screening for symptoms of ≥2 weeks' duration in a routine setting, and 2) to compare differences in TB diagnosis between human immunodeficiency virus (HIV) infected and non-HIV-infected pregnant women in western Kenya.

DESIGN

Comparative cross-sectional study among pregnant women with known HIV status screened for TB from 2010 to 2012, in Eldoret, western Kenya.

RESULTS

Of 2983 participants, respectively 34 (1%), 1488 (50.5%) and 1461 (49.5%) had unknown, positive and negative HIV status. The median age was respectively 30 years (interquartile range [IQR] 26-35) and 26 years (IQR 24-31) in HIV-infected and non-infected participants. A positive symptom screen was found in respectively 8% (119/1488) and 5% (67/1461) of the HIV-infected and non-infected women. The median CD4 count at enrolment was 377 cells/μl (IQR 244-530) for HIV-infected women. One non-HIV-infected patient was sputum-positive. For HIV-infected women, TB was presumptively treated in 1% (16/1488) based on clinical symptoms and chest X-ray. Cumulatively, anti-tuberculosis treatment was offered to 0.6% (17/2949) of the participants.

CONCLUSION

This study does not seem to demonstrate the utility of TB symptom screening questionnaires in a routine setting among pregnant women, either HIV-infected or non-infected, in western Kenya.

Operational research training: the course and beyond

Insufficient operational research (OR) is generated within programmes and health systems in low- and middle-income countries, partly due to limited capacity and skills to undertake and publish OR in peer-reviewed journals. To address this, a three-module course was piloted by the International Union Against Tuberculosis and Lung Disease and Médecins Sans Frontières in 2009-2010, with 12 participants. Five received mentorship and financial support as OR Fellows. Eleven of 12 participants submitted a paper to a peer-reviewed journal within 4 weeks of the end of the course. Evaluation shows that participants continued OR activities beyond the course. During the subsequent year, they submitted and/or published 19 papers, made 10 posters and/or presentations, and many participated in training, mentoring and/or paper reviewing. Some described changes in policy and practice influenced by their research, and changes in their organisation's approach to OR. They provided recommendations for improving and expanding OR. We conclude that participants can, with certain enabling conditions, take research questions through to publication, use skills gained to undertake and promote OR thereafter and contribute to improvement in policy and practice. An internet-based network will provide participants and graduates with a platform for collection of course outcomes and ongoing mentor- and peer-based support, resources and incentives.

Characteristics and treatment outcomes of tuberculosis retreatment cases in three regional hospitals, Uganda

SETTING

Three regional referral hospitals in Uganda with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) cases.

OBJECTIVE

To determine the treatment outcomes of TB retreatment cases and factors influencing these outcomes.

DESIGN

A retrospective cohort study of routinely collected National Tuberculosis Programme data between 1 January 2009 and 31 December 2010.

RESULTS

The study included 331 retreatment patients (68% males), with a median age of 36 years, 93 (28%) of whom were relapse smear-positive, 21 (6%) treatment after failure, 159 (48%) return after loss to follow-up, 26 (8%) relapse smear-negative and 32 (10%) relapse cases with no smear performed. Treatment success rates for all categories of retreatment cases ranged between 28% and 54%. Relapse smear-positive (P = 0.002) and treatment after failure (P = 0.038) cases were less likely to have a successful treatment outcome. Only 32% of the retreatment cases received a Category II treatment regimen; there was no difference in treatment success among patients who received Category II or Category I treatment regimens (P = 0.73).

CONCLUSION

Management of TB retreatment cases and treatment success for all categories in three referral hospitals in Uganda was poor. Relapse smear-positive or treatment after failure cases were less likely to have a successful treatment outcome.

How effective is the integration of facility and community-based management of severe acute malnutrition in India?

SETTING

All children admitted to two nutritional rehabilitation centres (NRCs) during 2011-2012 in Madhya Pradesh, India.

OBJECTIVE

To determine 1) adherence to in-patient care and follow-up visits, 2) attainment and maintenance of target weight gain, and 3) association with the children's demographic characteristics.

DESIGN

A retrospective record review. The 74-day programme included 14 days of in-patient care, with subsequent home-based care and four follow-up visits to the NRC at 15-day intervals. The first three visits were part of the treatment, while the fourth was for assessment of sustained weight gain.

RESULTS

Of the 1027 children admitted, 900 (88%) completed in-patient care. Of these, 685 (76%) attended the first three follow-up visits, 482 (70%) of whom gained >15% of their admission weight. Of these, 409 (85%) completed four visits, 314 (77%) of whom were able to sustain their weight gain. Those unable to gain >15% weight by the third visit had a significantly lower proportion of sustained weight gain at the fourth visit. Children aged ⩾6 months had significantly higher odds (OR 4.5, 95%CI 3.1-6.2, P < 0.05) of completing in-patient care.

CONCLUSION

In-patient care combined with community-based follow-up was effective in adherence to follow-up visits; however, there is still room for improvement in attaining and sustaining the target weight.

Double trouble: tuberculosis and substance abuse in Nagaland, India

The diagnosis and treatment of tuberculosis (TB) in people who use and/or inject illicit drugs (PWUIDs) remains a barrier to achieving universal coverage for TB in India and globally. This report describes treatment outcomes in PWUIDs who received treatment for drug-susceptible TB at the Mon District Hospital in Nagaland, India, during 2012-2013. The median age of the patients was 39 years, and most (92%) were male. Two thirds (33/49) of the patients had a successful TB treatment outcome. A previous TB episode and residence in a semi-urban area were associated with unsuccessful treatment outcomes. Separate diagnostic and treatment algorithms, including regular adherence counselling and opioid substitution therapies, should be considered for PWUIDs.

'I'm fed up': experiences of prior anti-tuberculosis treatment in patients with drug-resistant tuberculosis and HIV

OBJECTIVES

To understand the impact of past experiences of anti-tuberculosis treatment among patients co-infected with the human immunodeficiency virus and multidrug-resistant tuberculosis (MDR-TB) on perceptions and attitudes towards treatment.

METHODS

Qualitative study using in-depth interviews with 12 HIV-MDR-TB co-infected patients in Mumbai, India.

RESULTS

Patients reported unnecessarily long pathways to care and fatigue with diagnostic and treatment procedures. In particular, they expressed concerns over the lack of efficacy of their current treatment regimen based on their experiences with anti-tuberculosis treatment regimens in the past.

CONCLUSION

Patients reported negative experiences with previous HIV and anti-tuberculosis treatment. Access to early diagnosis and rapid initiation of integrated care for HIV-MDR-TB co-infected patients, with a strong, patient-centered support system, could help to combat the low morale and lack of faith in treatment described in this group of patients.

Prevalence and incidence of cervical intra-epithelial neoplasia among female sex workers in Korogocho, Kenya

SETTING

Sex Workers Outreach Programme Clinic, Korogocho, Nairobi, Kenya.

OBJECTIVE

In a cohort of sex workers, to determine 1) the prevalence of cervical intra-epithelial neoplasia (CIN) and its association with human immunodeficiency virus-1 (HIV-1) infection, and 2) the incidence rate of CIN during the 3-year follow-up from December 2009 to December 2012.

DESIGN

Prospective nested cohort study.

RESULTS

Of the 350 women enrolled, the median age was 29 years (range 18-49); 84 (24%) were HIV-1-infected. At enrollment, 54 (15%) had an abnormal cytology, 39 (11%) had low-grade intra-epithelial lesions (LSIL) and 15 (4%) high-grade intraepithelial lesions (HSIL). HIV-1-infected women were 2.7 times (95%CI 1.7-4.4) more likely to have CIN than non-HIV-1-infected women. Among HIV-1-infected women, the prevalence of LSIL and HSIL was 2.5 times (95%CI 1.2-5.1) and seven times (95%CI 2.3-23.3) greater than among non-HIV-infected women. During the follow-up period, 39 (11%) women had incident CIN (6.6/100 person years [py]), with no difference by HIV status, i.e., respectively 7.9/100 py and 6.3/100 py in HIV-1-infected and non-HIV-1-infected women.

CONCLUSION

The prevalence and incidence of CIN among HIV-1-infected sex workers was high; early, regular screening and follow-up of this life-threatening condition is therefore recommended.

Important co-morbidity in patients with diabetes mellitus in three clinics in Western Kenya

SETTING

Diabetes clinics in three hospitals in Western Kenya: Moi Teaching and Referral Hospital and two associated district hospitals.

OBJECTIVE

To determine the proportion of diabetes patients with a history of tuberculosis (  TB), human immunodeficiency virus (HIV  ) infection and tobacco smoking.

DESIGN

A descriptive study using routinely collected data from patient records in the three diabetes clinics.

RESULTS

Of 1376 patients analyzed, 750 (55%) were female. The mean age of the patients in the clinics was 53.5 years (95%CI 52.2-54.8), with an average duration of diabetes of 8.1 years (95%CI 7.6-8.7). Of all patients, 5.6% reported a history of TB, similar to the frequency about 20 years earlier (1990) in Tanzania. Only 30% of the patients reported knowing their HIV status; 6% were HIV-positive. A history of tobacco smoking was reported by 3.8% of the patients.

CONCLUSION

The HIV epidemic does not seem to have significantly changed the relationship between TB and diabetes mellitus (DM) in this cohort of diabetes patients. The frequency of HIV and TB in this special population was comparable to that in the general population, and only a small proportion of patients reported a history of tobacco smoking.

Nerve repair with adipose-derived stem cells protects dorsal root ganglia neurons from apoptosis

Novel approaches are required in the clinical management of peripheral nerve injuries because current surgical techniques result in deficient sensory recovery. Microsurgery alone fails to address extensive cell death in the dorsal root ganglia (DRG), in addition to poor axonal regeneration. Incorporation of cultured cells into nerve conduits may offer a novel approach in which to combine nerve repair and enhance axonal regeneration with neuroprotective therapies. We examined apoptotic mediator expression in rat DRG neurons following repair of a 10-mm sciatic nerve gap using a novel synthetic conduit made of poly ε-caprolactone (PCL) and primed with adipose-derived stem cells (ADSC) differentiated towards a Schwann cell phenotype or with primary adult Schwann cells. Differentiated ADSC expressed a range of neurotrophic factors including nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), glial-derived neurotrophic factor (GDNF), and neurotrophin-4 (NT4). Incorporation of either differentiated ADSC or Schwann cells significantly increased anti-apoptotic Bcl-2 mRNA expression (P<0.001) in the DRG, while significantly decreasing pro-apoptotic Bax (P<0.001) and caspase-3 mRNA (P<0.01) expression. Cleaved caspase-3 protein was observed in the DRG following nerve injury which was attenuated when nerve repair was performed using conduits seeded with cells. Cell incorporation into conduit repair of peripheral nerves demonstrates experimental promise as a novel intervention to prevent DRG neuronal loss.

In vitro and in vivo testing of novel ultrathin PCL and PCL/PLA blend films as peripheral nerve conduit

In an attempt to obviate the drawbacks of nerve autograft, ultrathin microporous biodegradable PCL and PCL/PLA films were tested for their compatibility with motor neuron-like NG108-15 cells and primary Schwann cells. Data obtained from MTS colorimetric and DNA fluorimetric assays showed that both cell lines readily attached and proliferated on these materials. Images taken using scanning electron microscope and fluorescence microscope confirmed these observations. Enhanced cell-surface interaction was achieved by pretreating the films in NaOH solution. Importantly, NG108-15 cells could be induced into differentiated phenotype with long, un-branched neurites growing across the surface of the materials. The bipolar spindle-shaped phenotype of Schwann cells was also retained on these scaffolds. Positive immunochemical staining using antibodies against neurofilament for NG108-15 cells and S100 for Schwann cells indicated the expression of these marker proteins. In a small-scaled pilot testing, the performance of PCL conduits in bridging up a 10 mm gap in rat sciatic nerve model was assessed. Immunohistochemical staining showed that regenerated nerve tissue and penetrated Schwann cells have the potential to span the whole length of the conduit in 2 weeks.

Elastic Behavior of Porcine Coronary Artery Tissue Under Uniaxial and Equibiaxial Tension

The aim of this study was to characterize the nonlinear anisotropic elastic behavior of healthy porcine coronary arteries under uniaxial and equibiaxial tension. Porcine coronary tissue was chosen for its availability and similarity to human arterial tissue. A biaxial test device previously used to test human femoral arterial tissue samples (Prendergast, P. J., C. Lally, S. Daly, A. J. Reid, T. C. Lee, D. Quinn, and F. Dolan. ASME J. Biomech. Eng., Vol. 125, pp. 692-699, 2003) was further developed to test porcine coronary tissue specimens. The device applies an equal force to the four sides of a square specimen and therefore creates a biaxial stretch that demonstrates the anisotropy of arterial tissue. The nonlinear elastic behavior was marked in both uniaxial and biaxial tests. The tissue demonstrated higher stiffness in the circumferential direction in four out of eight cases subjected to biaxial tension. Even though anisotropy is demonstrated it is proposed that an isotropic hyperelastic model may adequately represent the properties of an artery, provided that an axial stretch is applied to the vessel to simulate the in vivo longitudinal tethering on the vessel. Isotropic hyperelastic models based on the Mooney-Rivlin constitutive equation were derived from the test data by averaging the longitudinal and circumferential equibiaxial data. Three different hyperelastic models were established to represent the test specimens that exhibited a high stiffness, an average stiffness, and a low stiffness response; these three models allow the analyst to account for the variability in the arterial tissue mechanical properties. These models, which take account of the nonlinear elastic behavior of coronary tissue, may be implemented in finite element models and used to carry out preclinical tests of intravascular devices. The errors associated with the hyperelastic models when fitting to both the uniaxial and equibiaxial data for the low stiffness, average stiffness, and high stiffness models were found to be 0.836, 5.206, and 2.980, respectively.

Endothelial cell alignment on cyclically-stretched silicone surfaces

Endothelial cells at the interface between the bloodstream and the vessel wall are continuously subjected to mechanical stimulation in vivo, and it widely recognised that such stimulation plays an important role in cardiovascular physiology. Cell deformation is induced by mechanical forces such as cyclic stretch, fluid shear stress, and transmural pressure. Although much of the work in this field has dealt with the effect of fluid shear stress, very little is known about how cyclic forces modulate and alter the morphology of single endothelial cells, and thereafter, how they effect the confluent layer of endothelial cells lining the vessel wall. The aim of this study is to investigate the response of endothelial cells when subjected to substrate deformation of similar magnitude to those experienced in vivo. Human umbilical vein endothelial cells (HUVEC) were cultured on plasma-treated silicone strips and uni-axially cyclically stretched using a custom made mechanical device. Results showed that endothelial cells subject to 10% deformation for as little as 4 h reoriented perpendicular to the stretch direction. In addition, although no integrin coating was applied to the substrate, it was found that plasma-treated silicone provided a cell adhesion substrate comparable to the commonly used collagen type I. Thus the results show that the stretch stimulus alone affects the morphology of endothelial cells. Further studies are required to establish the relative importance of substrate strain vs. fluid flow stimuli.

Analysis of Prolapse in Cardiovascular Stents: A Constitutive Equation for Vascular Tissue and Finite-Element Modelling

The effectiveness of a cardiovascular stent depends on many factors, such as its ability to sustain the compression applied by the vessel wall, minimal longitudinal contraction when it is expanded, and its ability to flex when navigating tortuous blood vessels. The long-term reaction of the tissue to the stent is also device dependant; in particular some designs provoke in-stent restenosis (i.e., regrowth of the occlusion around the stent). The mechanism of restenosis is thought to involve injury or damage to the vessel wall due to the high stresses generated around the stent when it expands. Because of this, the deflection of the tissue between the struts of the stent (called prolapse or “draping”) has been used as a measure of the potential of a stent to cause restenosis. In this paper, uniaxial and biaxial experiments on human femoral artery and porcine aortic vascular tissue are used to develop a hyperelastic constitutive model of vascular tissue suitable for implementation in finite-element analysis. To analyze prolapse, four stent designs (BeStent 2, Medtronic AVE; NIROYAL, Boston Scientific; VELOCITY, Cordis; TETRA, Guidant) were expanded in vitro to determine their repeating-unit dimensions. This geometric data was used to generate a finite element model of the vascular tissue supported within a repeating-unit of the stent. Under a pressure of 450 mm Hg (representing the radial compression of the vessel wall), maximum radial deflection of 0.253 mm, 0.279 mm, 0.348 mm and 0.48 mm were calculated for each of the four stents. Stresses in the vascular wall were highest for the VELOCITY stent. The method is proposed as a way to compare stents relative to their potential for restenosis and as a basis for a biomechanical design of a stent repeating-unit that would minimize restenosis.

Structure of the histone-core octamer in KCl/phosphate crystals at 2.15 A resolution

The structure of the native chicken histone octamer, crystallized in 2 M KCl, 1.35 M potassium phosphate pH 6.9, has been refined at 2.15 A resolution to a final R factor of 21.4% and an R(free) of 25.2%. Unique crystal-packing interactions between histone-core octamers are strong and one of them (area 4000 A(2)) involves two chloride ions and direct interactions between six acidic amino-acid residues on one octamer and the equivalent number of basic residues on the next. These interactions are on the structured part of the octamer (not involving tails). Five phosphate ions, 23 chloride ions and 437 water molecules have been identified in the structure. The phosphate and some chloride ions bind to basic amino-acid residues that interact with DNA in the nucleosome. The binding of most of the anions and the packing interactions are unique to these crystals. In other respects, and including the positions of four chloride ions, the octamer structure is very close to that of octamers in nucleosome-core particle crystals, particularly with respect to 'docking' sequences of the histone H2As and H4s. These sequences together with the H2B-H4 four-helix bundles stabilize the histone structure in the nucleosome and prevent the dissociation of the (H2A-H2B) dimers from the (H3-H4)(2) tetramer. Possible reasons why this happens at high salt in the absence of DNA are given.

The diagnosis of leprosy is delayed in the United Kingdom

Diagnostic delay in leprosy can have serious neurological consequences for the patient. We studied the presentation of leprosy patients, focusing on delays in diagnosis, in a retrospective case-note review of 28 patients referred to The Hospital for Tropical Diseases during 1995-1998. The median ages at onset of symptoms and at diagnosis were 25.1 years (range 9-77.7) and 30.1 years (range 9-78.3), respectively. The median time from symptom onset to diagnosis was 1.8 years (0.2-15.2). Prior to referral to a leprologist, patients had seen a dermatologist (20), neurologist (9), orthopaedic surgeon (5) and rheumatologist (2). Delay in diagnosis occurred in 82% of cases. Misdiagnoses as dermatological and neurological conditions were important causes of delay, and 68% of patients had nerve damage resulting in disability. Leprosy can be difficult to diagnose outside endemic areas. Increased awareness amongst general practitioners and hospital specialists would lead to more rapid diagnosis, thus minimizing damage and disability.

Rapid plastic embedding is compatible with colorimetric detection following whole mount in situ hybridization in plant specimens

In performing in situ hybridizations, nonisotopic nucleic acid labeling coupled with colorimetric detection offers a safer, easier and more rapid alternative to using radioactively labeled nucleic acid probes and microscopic autoradiography. Whole mount in situ hybridization is also advantageous, because many samples can be processed identically and the reduced handling of specimens greatly reduces the risk of exposing tissues to RNase(s). The thickness of whole mount specimens, however, often prevents accurate determination of sites of expression within specific tissues. Although post-hybridization embedding and sectioning is a solution to this problem, the precipitate formed following the common colorimetric detection procedure is soluble in the organic solvents used for dehydration prior to embedding. We have developed a dehydration and embedding procedure that takes advantage of the compatibility of L.R. White resin containing 10% (v/v) polyethylene glycol 400, and heat polymerized. The addition of the plasticizer allows L.R. White embedded tissues to be sectioned at 10 microm providing excellent signal contrast.

Congenital lobar emphysema occurring in twins

Twins born with congenital lobar emphysema are reported. This has not previously been described. Diagnosis, surgical management and subsequent course is high-lighted. These twins may well be the smallest to have operative treatment.

Pleural effusions in patients with AIDS

OBJECTIVE

To describe the range of pathology causing pleural effusions in HIV infected patients with acute respiratory episodes and to attempt to identify whether any associated radiological abnormalities enabled aetiological discrimination.

METHODS

Prospective study of chest radiographs of 58 consecutive HIV infected patients with pleural effusion and their microbiological, cytological, and histopathological diagnoses.

RESULTS

A specific diagnosis was made in all cases. Diagnoses were Kaposi's sarcoma, 19 patients; para-pneumonic effusion, 16 patients; tuberculosis, eight patients; Pneumocystis carinii pneumonia, six patients; lymphoma, four patients; pulmonary embolus, two patients; and heart failure, aspergillus/leishmaniasis, and Cryptococcus neoformans, one case each. Most effusions (50/58) were small. Bilateral effusions were commoner in Kaposi's sarcoma (12/19) and lymphoma (3/4) than in para-pneumonic effusion (3/16). Concomitant interstitial parenchymal shadowing did not aid discrimination. A combination of bilateral effusions, focal air space consolidation, intrapulmonary nodules, and/or hilar lymphadenopathy suggests Kaposi's sarcoma. Unilateral effusion with focal air space consolidation suggests para-pneumonic effusion if intrapulmonary nodules are absent: if miliary nodules and/or mediastinal lymphadenopathy are detected, this suggests tuberculosis.

CONCLUSIONS

A wide variety of infectious and malignant conditions cause pleural effusions in HIV infected patients, the most common cause in this group was Kaposi's sarcoma. The presence of additional radiological abnormalities such as focal air space consolidation, intrapulmonary nodules, and mediastinal lymphadenopathy aids aetiological discrimination.

Design and validation of a machine for reproducible precision insertion of femoral hip prostheses for preclinical testing

Preclinical testing of orthopaedic implants is becoming increasingly important to eliminate inferior designs before animal experiments or clinical trials are begun. Preclinical tests can include both laboratory bench tests and computational modeling. One problem with bench tests is that variability in prosthesis insertion can significantly influence the failure rate; this makes comparison of prostheses more difficult. To solve this problem an insertion method is required that is both accurate and reproducible. In this work, a general approach to the insertion of hip prostheses into femoral bones is proposed based on physically replicating an insertion path determined using computer animation. As a first step, the seated prosthesis position is determined from templates and femur radiographs. Three-dimensional images of the prosthesis and bone are then imported into computer animation software and an insertion path in the coronal plane is determined. The insertion path is used to determine the profile of a cam. By attaching the prosthesis to a carriage, which is pneumatically moved along this cam, the required insertion motion of the prosthesis in the coronal plane can be achieved. This paper describes the design and validation of the insertion machine. For the validation study, a nonsymmetric hip prosthesis design (Lubinus SPII, Waldemar Link, Germany) is used. It is shown that the insertion machine has sufficient accuracy and reproducibility for preclinical mechanical testing.

Women's experience of maternal serum screening

OBJECTIVE

To explore the ideas, opinions, feelings, and experiences of women regarding prenatal genetic screening, specifically maternal serum screening (MSS).

DESIGN

Qualitative technique of focus groups.

SETTING

Northern, rural, inner-city, urban, and suburban communities in Ontario.

PARTICIPANTS

Women who had given birth to babies from January 1994 to May 1996, but who were not currently pregnant (n = 60).

METHOD

Six focus groups composed of women living in various communities who had recently given birth to babies explored the experience of MSS.

MAIN FINDINGS

Women want informed choice about prenatal genetic screening. Three factors influenced women's decisions to undergo or decline prenatal genetic screening: their personal values, including their philosophy of life, moral, and religious values, and attitudes regarding Down syndrome and disability; social support including their partners, families, and friends; and quality of information from health care providers. Women want their providers to give them information personally; they want to receive the information as early as possible in prenatal care to allow time for reflection; and they want unbiased, accurate information in order to make a decision that is in keeping with their personal values and beliefs.

CONCLUSIONS

Knowledge of women's ideas, opinions, feelings, and experiences regarding MSS suggests specific ways health care providers can facilitate informed decision making in prenatal screening. Providing information about genetic testing needs to be individualized, with women actively participating in the decision-making process. Information needs described by these women could apply to other prenatal genetic tests that might be available in the future.

Family physicians in maternity care. Still in the game? Report from the CFPC's Janus Project

OBJECTIVE

To describe family doctors' contribution to maternity care in Canada and to observe the influence of age, sex, region of the country, and practice population on provision of maternity care.

DESIGN

SURVEY

College of Family Physicians of Canada's Janus Project national family physician survey.

SETTING

All 10 provinces and two territories.

PARTICIPANTS

Random sample of family physicians and general practitioners, both members and non-members of the College.

MAIN OUTCOME MEASURES

Proportion of family doctors participating in prenatal, intrapartum, postpartum, and newborn care, and proportion of doctors involved in intrapartum care by age, sex, location in Canada, and practice population.

RESULTS

Overall response rate was 58%. Just over 50% of all family doctors in Canada are involved in some aspect of maternity care; 19% do intrapartum care; and 33% are involved in prenatal (shared) care. Similar proportions of men and women still do intrapartum care, but women care for more pregnancies than men. More family doctors serving rural areas are doing intrapartum care compared with doctors in urban areas, although those in urban areas tend to do more deliveries. The western provinces have the highest percentages of intrapartum caregivers. A gradual decline in percentage of intrapartum caregivers by age group increases among the 55- to 64-year-old cohort. Almost a quarter of women doctors younger than 35 years are doing intrapartum care. Most physicians doing prenatal (shared) care look after women until the third trimester.

CONCLUSIONS

Family doctors are still providing a large proportion of maternity care in Canada. This contribution must be nurtured by the College through its Maternity and Newborn Care Committee and other contacts to encourage family doctors to continue offering this essential service to childbearing women in Canada.

Parenteral ivermectin in Strongyloides hyperinfection

Strongyloides hyperinfection, unresponsive to oral ivermectin and oral albendazole, was controlled by subcutaneous administration of a veterinary preparation of ivermectin.