Religious and Medical Pluralism Among Traditional Healers in Johannesburg, South Africa

Religion and spirituality are powerful social forces in contemporary South Africa. Traditional Health Practitioners (THPs) are commonly consulted for both spiritual and medical ailments as a first line of care. Many studies have assessed African traditional health seeking behaviors but few have examined beliefs, practices, and behaviors of THPs themselves. This study sought to explore spiritual worldviews among South African THPs. Semi-structured in-depth interviews were conducted with 18 THPs in Johannesburg, South Africa between January and May, 2022. Interviews were transcribed and translated into English. Data were managed using NVivo 12 software and thematically analyzed. The majority of THPs interviewed indicated that initiation as a THP was almost always preceded by a sickness accompanied by dreams/visions that represented an "ancestral calling" to become a healer. Most THPs also trained as both sangomas-who healed according to traditional beliefs-and prophets-who healed according to Christian beliefs. This reflects a syncretic relationship between traditional African beliefs and Christianity. However, not all churches are accepting of traditional beliefs and subsequently these THPs are members only at non-Pentecostal AIC churches who blend both African and Christian practices. Similar to these forms of religious pluralism melding Christianity and traditional beliefs, many THPs also often practice medical pluralism, mixing Western treatments with traditional practices/medicines. THPs are able to adapt elements of Western and African beliefs into healing practices that span multiple religious and medical fields. Thus, collaborative and decentralized healthcare services may be highly acceptable among such a pluralistic community.

Maladi Nanm, Maladi Zonbi, & Maladi Lalin: A qualitative study of cultural concepts of distress in northern Haiti

Cultural Concepts of Distress (CCDs) are culturally constructed diagnostic categories that exist within a specific society or culture. While several studies have assessed CCDs around the world, few studies have examined them in Haiti. This qualitative study examines manifestations of anxiety and depression via "sent spirits" in the form of maladi nanm ("Soul disorder") and maladi zonbi ("Zombie disorder"), and bipolar disorder in the form of maladi lalin ("Moon disorder"). Examples of CCDs were recorded as part of a study which interviewed 96 outpatients at the first mental health center in northern Haiti. Using qualitative methods, the authors identified three specific CCDs as reported by mental health patients. Maladi nanm and maladi zonbi represent alternative explanatory models of anxiety and depression in which the sufferer views mental illness as stemming from a sent spirit, or spirit which is intentionally sent supernaturally with the intent to cause harm. Maladi lalin is experienced by patients with bipolar disorder who associate cycles of mania and depression as in-sync with the phases of the moon. Understanding culture-bound forms of mental distress in settings such as Haiti is essential to developing accurate psychometrics for measuring mental health, as well as ensuring culturally appropriate and effective diagnosis and treatment.

Pathways to care among patients with mental illness at two psychiatric facilities in Johannesburg, South Africa

BACKGROUND

A patient's pathway to care is often characterized by a sequence of actions taken to remedy ill-health. Research exploring the help-seeking behavior of individuals with mental health problems in sub-Saharan Africa is relatively limited. This study assessed the perceptions and experiences of mental illness and treatment among patients with mental illness at two psychiatric facilities in Johannesburg, South Africa.

METHODS

309 interviewer administered surveys were conducted between January and July 2022. We used a logistic regression model to examine factors associated with receiving treatment for mental illnesses from traditional healers. Semi-structured interviews were conducted with 18 participants during the same period. Interviews were transcribed and translated into English. Data were managed using NVivo 11 software and thematically analyzed.

FINDINGS

Results showed that 144 (47%) patients sought mental health care from traditional healers. Higher anxiety symptoms, number of people in the household, believing that traditional medicine can cure mental illnesses, and township living were associated with seeking mental healthcare from traditional healers. Qualitative analysis indicated that participants often believed that mental illness was due to bewitchment and consulted with multiple traditional healers, thus spending large amounts of money for treatment and ultimately delaying access to biomedical care.

CONCLUSION

Collaborative approaches between traditional healers and biomedical professionals show promise in terms of allowing for improved identification and treatment of individuals with mental disorders.

Examining the Etiology and Treatment of Mental Illness Among Vodou Priests in Northern Haiti

This study assesses the perspectives and experiences of Vodou priests (ougan) in the treatment of mental illness in northern Haiti. Our goal is to explore the etiology and popular nosologies of mental illness in the context of Haitian Vodou, through understandings of illness and misfortune which are often viewed as a result of sent spirits-or spirits sent supernaturally by others with the intent to cause harm. Using a qualitative approach, this study conducted semi-structured in-depth interviews with 20 ougan living near the city of Cap-Haïtien. Interviews highlight a sample of healers with little formal training who maintain beliefs and practices that differ significantly from current biomedical models. Ougan treat mental illness through a variety of means including prayer and conjuring of spirits, leaves for teas and baths, as well as combinations of perfumes, rum, human remains, and other powdered concoctions that are either imbibed or rubbed on the skin. The primary purpose of these treatments is to expel the spirit causing harm, yet they can often result in additional harm to the patient. Findings suggest that while ougan are willing to collaborate with biomedical practitioners, significant barriers remain preventing cooperation between these two groups.

Perceptions of causes and treatment of mental illness among traditional health practitioners in Johannesburg, South Africa

Mental disorders are among the most poorly treated illnesses in sub-Saharan Africa. It is estimated that 70%-80% of South Africans consult traditional health practitioners for the treatment of psychological ailments. As traditional health practitioners maintain a strong role in assessing and treating patients with mental illness in this context, this study contributes to the burgeoning research literature on the topic. Semi-structured in-depth interviews were conducted with 18 traditional health practitioners in Johannesburg, South Africa, between January and May 2022. Interviews were transcribed and translated into English. The data were managed using NVivo 12 software and thematically analysed. Traditional health practitioners interviewed generally perceived mental illness to be of supernatural causation, either as a result of bewitchment, a calling for patients to become THPs themselves, due to displeased ancestors, or due to natural causes. Traditional health practitioners identified eight primary treatments that they use for treating mental illness. Among these were throwing of bones (tinhlolo) to start communicating with ancestors, steaming (ukufutha) to start a cleansing process, sneezing (umbhemiso) to forcefully dispel the spirit causing the illness, induced vomiting (phalaza), and the administration of laxatives (mahlabekufeni) to remove the spirits poisoning the body as well as animal sacrifice to purge spirits and communicate with ancestors. This is all followed by cutting (ukucaba), which is the final part of the treatment and ensures that the evil spirit cannot return. Due to the ubiquity of traditional health practitioner usage for mental illness in sub-Saharan Africa, it is essential to understand what conceptions traditional health practitioners have of the aetiology of these disorders as well as their modalities for administering treatment.

Adverse childhood experiences, traumatic events, and mental health among adults at two outpatient psychiatric facilities in Johannesburg, South Africa: a cross-sectional analysis

BACKGROUND

Adverse childhood experiences and adult trauma, including sexual abuse, physical abuse, neglect, and interpersonal violence, are highly prevalent in low-resource settings and associated with adverse psychological outcomes. However, there is limited focus on the impact of ACEs and trauma on mental health in sub-Saharan Africa. Therefore, this study examines the impact of traumatic events and ACEs on depression, anxiety, and stress scores among outpatients receiving psychiatric care at two public mental health treatment facilities in Johannesburg, South Africa.

METHODS

A sample of 309 participants were recruited between January and June 2022 at Helen Joseph Hospital and Alexandra 18th Avenue Clinic. Participants completed screening measures for mental health outcomes, including the 9-item Patient Health Questionnaire (PHQ-9), the 7-item General Anxiety Disorder scale (GAD-7) and the 10-item Perceived Stress Scale. We fitted modified Poisson and linear regression models to estimate the impact of ACEs and adult experiences of trauma on depression, anxiety, and stress scale scores.

RESULTS

47.57% (n = 147) of participants screened positive for anxiety, 44.66% (n = 138) for depression, and 17% (n = 54) for severe stress. More females screened positive for anxiety (65.31%), depression (65.94%), and stress (77.78%). Each ACE was associated with a 12% increased risk of depression, a 10% increased risk of anxiety, and a 17% increased risk of stress. In separately estimated models, each additional traumatic event during adulthood was associated with a 16% increased risk for depression, an 8% increased risk of anxiety, and a 26% increased risk of stress. Across all models, being male and self-reported physical health were consistently associated with a reduced risk for depression, anxiety, and stress.

CONCLUSIONS

ACEs and experiences of traumatic events as adults were associated with significantly increased risks of anxiety, depression, and severe stress. Given high exposure to ACEs and trauma and the associated impact on the mental health of individuals, families, and communities, there is a need to strengthen and scale innovative combination interventions that address multiple stressors impacting people in low-resource settings.

Determinants of mental illness and care seeking behaviours in Northern Haiti: an assessment of demographic, social, and religio-cultural factors among patients at the first mental health clinic in the region

Populations in countries such as Haiti demonstrate a high level of need for mental health care despite a lack of services and trained professionals. In addition to the dearth of biomedical services, local belief systems and explanatory models contribute to a majority of the population relying on traditional medicine as their first option for care. Using a mixed-methods approach, we aim to characterise mental illness at the first mental health clinic in the region - Sant Sante Mantal Mòn Pele (SSMMP) - by interviewing 96 patients with a demographic questionnaire as well as Anxiety, Depression, and Functionality Scales. Multivariate logistic and linear regression models were conducted examining the impact of demographic variables on whether patients believed their illness was caused by sent spirits or previously visited a Vodou priest for treatment, as well as Depression, Anxiety, and Functionality Scale scores. Factors associated with mental illness in this sample included sex, number of traumatic events, physical health status, and number of sessions attended at SSMMP. Factors which impacted traditional beliefs or practices related to mental illness included sex, age, and income.

Perceptions of HIV and Mental Illness as "Western" or "Traditional" Illnesses: A Cross-Sectional Study from Limpopo Province, South Africa

Although Western biomedical treatment has dramatically increased across sub-Saharan African health systems, traditional medicine as a form of healing and beliefs in supernatural powers as explanations for disease remain prevalent. Research in this region has identified HIV in particular as a disease located within both the traditional African and Western medical paradigms, whilst mental illness is ascribed to primarily supernatural causes. Within this context, this study sought to understand and explore the perceptions of HIV and mental illness among a population of rural women in Limpopo, South Africa. 82 in-depth interviews were conducted between January and December, 2022. Interviews were transcribed and translated into English. Data were managed using NVivo 11 software and thematically analyzed. The majority of participants identified HIV as a Western illness requiring biomedical treatment with causation largely attributed to biological mechanisms. A traditional form of HIV only cured using traditional treatments was also denoted. Unlike for HIV, the majority of respondents felt that there was no biological or behavioral cause for mental illness but rather the illness was conceptualized supernaturally thus likely impacting patient care pathways. Further research to study HIV and mental health perceptions among a larger sample in different regions of sub-Saharan Africa is warranted.

Ze Lekòl: Contextual Factors Affecting Use of Eggs in School Feeding in Cap-Haïtien, Haiti

Objectives

Eggs are a rich source of bioavailable nutrients for children, yet have been underutilized in school feeding programs in low- and middle-income countries. The purpose of the Ze Lekòl Project was to identify contextual facilitators, barriers, and resources needed at both the school and food system levels to link local egg value chains to school feeding programs in Cap-Haïtien, Haiti.

Methods

Key stakeholder interviews (n = 23) were conducted with school principals, representatives from the Ministry of Health and Ministry of Agriculture, domestic egg producers, and egg vendors. Focus groups (n = 4) were conducted with school staff and child caregivers. Interviews and focus groups were transcribed into Haitian Creole or French, and translated into English. Using inductive and deductive coding, interviews were analyzed for factors that facilitate

or hinder the potential for incorporating locally produced eggs in school feeding programs. The approach to data collection and analysis was informed by the EPIS Implementation Science framework.

Results

School administrators and staff described facilitators (i.e., desire for nutritious foods, acceptability of eggs), barriers (i.e., preparation methods, national school feeding program structure) and potential benefits (i.e., improved student focus, reduced caregiver burden) for including eggs in school feeding programs. Local egg producers and vendors expressed facilitators (bulk purchases, customer preference for domestic eggs) and barriers (local availability of supplies, veterinary care, political disruption) to producing and selling locally produced eggs in Cap-Haïtien.

Conclusions

Locally produced eggs are an acceptable food to include in school feeding programs in Cap-Haïtien, Haiti. However, lack of sufficient infrastructure for domestic egg production prevents the ability to consistently provide the quantity of eggs needed for such programs without additional investments in domestic agriculture and school feeding programs. Findings from this study will inform interventions aimed at linking local agriculture to school feeding programs in low and middle-income countries.

Funding Sources

The Washington University in St. Louis Institute for Public Health–Center for Dissemination and Implementation funded this study.

Seizure activity and anion gap metabolic acidosis secondary to adverse effect of nalidixic acid-a case report

Nalidixic acid is a commonly prescribed treatment for suspected dysentery in Middle Eastern populations. We describe a case of convulsions resulting from a single dose of nalidixic acid in a previously healthy two-month-old child in Northern Iraq who was being treated for a diarrhoeal illness. The child presented to us with new onset seizures, irritability, and acidaemia. Nalidixic acid was thought to be responsible after the exclusion of other potential causes of seizures. Symptoms resolved by treatment with intravenous (IV) diazepam, and cessation of nalidixic acid, and the child recovered fully and was discharged home neurologically intact after two days of observation. In regions where it is commonly prescribed, such as Northern Iraq, nalidixic acid should be considered as a cause of convulsions in any seizing child who has been exposed to the drug. Furthermore, quinolones such as nalidixic acid are contraindicated in children < 3 months of age.

High-contrast integral field spectrograph (HCIFS): multi-spectral wavefront control and reduced-dimensional system identification

Any high-contrast imaging instrument in a future large space-based telescope will include an integral field spectrograph (IFS) for measuring broadband starlight residuals and characterizing the exoplanet's atmospheric spectrum. In this paper, we report the development of a high-contrast integral field spectrograph (HCIFS) at Princeton University and demonstrate its application in multi-spectral wavefront control. Moreover, we propose and experimentally validate a new reduced-dimensional system identification algorithm for an IFS imaging system, which improves the system's wavefront control speed, contrast and computational and data storage efficiency.

Outcome after total ankle arthroplasty with a minimum of five years follow-up: A systematic review and meta-analysis

BACKGROUND

Total ankle arthroplasty (TAA) is increasingly gaining recognition as an alternative to ankle arthrodesis in the treatment of end-stage ankle arthritis. Despite high rates of adverse events during early inception, newer generations of uncemented prosthesis and design modifications have improved outcomes. Questions remain regarding the long-term outcomes and implant survivorship of TAA.

AIM

This analysis aims to establish an updated review of intermediate and long-term clinical outcome and complication profile of TAA.

PATIENTS AND METHODS

A multi database search was performed on 14th October 2018 according to PRISMA guidelines. All articles that involved patients undergoing uncemented TAA with 5 years minimum follow-up, reported clinical outcome or complication profile of TAA were included. Seventeen observational studies were included in the review, with 1127 and 262 ankles in the 5 and 10 years minimum follow-up groups respectively.

RESULTS

Mean difference between pre- and post-operative AOFAS score was 43.60 (95%CI: 37.51-49.69, p<0.001) at 5 years minimum follow-up. At 5 years minimum follow-up, pooled proportion (PP) of prostheses revision for any reason other than polyethylene exchange was 0.122 (95%CI: 0.084-0.173), all cause revision was 0.185 (95%CI: 0.131-0.256), unplanned reoperation was 0.288 (95%CI: 0.204-0.390) and all infection was 0.033 (95%CI: 0.021-0.051). At 10 years minimum follow-up, PP of prostheses revision for any reason other than polyethylene exchange was 0.202 (95%CI: 0.118-0.325), all cause revision was 0.305 (95%CI: 0.191-0.448), unplanned reoperation was 0.422 (95%CI: 0.260-0.603) and all infection was 0.029 (95%CI: 0.013-0.066).

CONCLUSION

Despite good intermediate and long-term functional outcome measures, TAA has relatively higher revision surgery prevalence with longer follow-up periods. Further research should be directed towards identifying patient populations that would best benefit from TAA and those at greatest risk of requiring revision surgery.

Using Integrated Environmental Modeling to Assess Sources of Microbial Contamination in Mixed-Use Watersheds

Microbial fate and transport in watersheds should include a microbial source apportionment analysis that estimates the importance of each source, relative to each other and in combination, by capturing their impacts spatially and temporally under various scenarios. A loosely configured software infrastructure was used in microbial source-to-receptor modeling by focusing on animal- and human-impacted mixed-use watersheds. Components include data collection software, a microbial source module that determines loading rates from different sources, a watershed model, an inverse model for calibrating flows and microbial densities, tabular and graphical viewers, software to convert output to different formats, and a model for calculating risk from pathogen exposure. The system automates, as much as possible, the manual process of accessing and retrieving data and completes input data files of the models. The workflow considers land-applied manure from domestic animals on undeveloped areas; direct shedding (excretion) on undeveloped lands by domestic animals and wildlife; pastureland, cropland, forest, and urban or engineered areas; sources that directly release to streams from leaking septic systems; and shedding by domestic animals directly to streams. The infrastructure also considers point sources from regulated discharges. An application is presented on a real-world watershed and helps answer questions such as: What are the major microbial sources? What practices contribute to contamination at the receptor location? What land-use types influence contamination at the receptor location? and Under what conditions do these sources manifest themselves? This research aims to improve our understanding of processes related to pathogen and indicator dynamics in mixed-use watershed systems.

Capturing Microbial Sources Distributed in a Mixed-use Watershed within an Integrated Environmental Modeling Workflow

Many watershed models simulate overland and instream microbial fate and transport, but few provide loading rates on land surfaces and point sources to the waterbody network. This paper describes the underlying equations for microbial loading rates associated with 1) land-applied manure on undeveloped areas from domestic animals; 2) direct shedding (excretion) on undeveloped lands by domestic animals and wildlife; 3) urban or engineered areas; and 4) point sources that directly discharge to streams from septic systems and shedding by domestic animals. A microbial source module, which houses these formulations, is part of a workflow containing multiple models and databases that form a loosely configured modeling infrastructure which supports watershed-scale microbial source-to-receptor modeling by focusing on animal- and human-impacted catchments. A hypothetical application - accessing, retrieving, and using real-world data - demonstrates how the infrastructure can automate many of the manual steps associated with a standard watershed assessment, culminating in calibrated flow and microbial densities at the watershed's pour point.

Mobile device application for monitoring cyanobacteria harmful algal blooms using Sentinel-3 satellite Ocean and Land Colour Instruments

Cyanobacterial harmful algal blooms (cyanoHAB) cause human and ecological health problems in lakes worldwide. The timely distribution of satellite-derived cyanoHAB data is necessary for adaptive water quality management and for targeted deployment of water quality monitoring resources. Software platforms that permit timely, useful, and cost-effective delivery of information from satellites are required to help managers respond to cyanoHABs. The Cyanobacteria Assessment Network (CyAN) mobile device application (app) uses data from the European Space Agency Copernicus Sentinel-3 satellite Ocean and Land Colour Instrument (OLCI) in near realtime to make initial water quality assessments and quickly alert managers to potential problems and emerging threats related to cyanobacteria. App functionality and satellite data were validated with 25 state health advisories issued in 2017. The CyAN app provides water quality managers with a user-friendly platform that reduces the complexities associated with accessing satellite data to allow fast, efficient, initial assessments across lakes.

Tumourigenic non-small-cell lung cancer mesenchymal circulating tumour cells: a clinical case study

BACKGROUND

Over the past decade, numerous reports describe the generation and increasing utility of non-small-cell lung cancer (NSCLC) patient-derived xenografts (PDX) from tissue biopsies. While PDX have proven useful for genetic profiling and preclinical drug testing, the requirement of a tissue biopsy limits the available patient population, particularly those with advanced oligometastatic disease. Conversely, 'liquid biopsies' such as circulating tumour cells (CTCs) are minimally invasive and easier to obtain. Here, we present a clinical case study of a NSCLC patient with advanced metastatic disease, a never smoker whose primary tumour was EGFR and ALK wild-type. We demonstrate for the first time, tumorigenicity of their CTCs to generate a patient CTC-derived eXplant (CDX).

PATIENTS AND METHODS

CTCs were enriched at diagnosis and again 2 months later during disease progression from 10 ml blood from a 48-year-old NSCLC patient and implanted into immunocompromised mice. Resultant tumours were morphologically, immunohistochemically, and genetically compared with the donor patient's diagnostic specimen. Mice were treated with cisplatin and pemetrexed to assess preclinical efficacy of the chemotherapy regimen given to the donor patient.

RESULTS

The NSCLC CDX expressed lung lineage markers TTF1 and CK7 and was unresponsive to cisplatin and pemetrexed. Examination of blood samples matched to that used for CDX generation revealed absence of CTCs using the CellSearch EpCAM-dependent platform, whereas size-based CTC enrichment revealed abundant heterogeneous CTCs of which ∼80% were mesenchymal marker vimentin positive. Molecular analysis of the CDX, mesenchymal and epithelial CTCs revealed a common somatic mutation confirming tumour origin and showed CDX RNA and protein profiles consistent with the predominantly mesenchymal phenotype.

CONCLUSIONS

This study shows that the absence of NSCLC CTCs detected by CellSearch (EpCAM(+)) does not preclude CDX generation, highlighting epithelial to mesenchymal transition and the functional importance of mesenchymal CTCs in dissemination of this disease.

Patient journey to a specialist amyotrophic lateral sclerosis multidisciplinary clinic: an exploratory study

Background

The multidisciplinary approach in the management of Amyotrophic Lateral Sclerosis (ALS) has been shown to provide superior care to devolved care, with better survival, improved quality of care, and quality of life. Access to expert multidisciplinary management should be a standard for patients with ALS. This analysis explores the patient journey from symptom onset and first engagement with health services, to the initial visit to a specialist ALS Multidisciplinary Clinic (MDC) in Dublin, Ireland.

Methods

A retrospective exploratory multi-method study details the patient journey to the MDC. Data from medical interviews and systematic chart review identifies interactions with the health services and key timelines for thirty five new patients presenting with a diagnosis of ALS during a 6 month period in 2013.

Results

The time from first symptom to diagnosis was a mean of 16 months (median 13 months), with a mean interval of 19 months (median 14.6) from first symptoms to arrival at the MDC. The majority of patients were seen by a general practitioner, and subsequently by neurology services. There was an average of four contacts with health services and 4.8 investigations/tests, prior to their first Clinic visit. On the first visit to the MDC patients are linked into an integrated ‘system’ that can provide specialist care and link with voluntary, palliative and community services as required.

Conclusions

Engagement with a multidisciplinary team has implications for service utilization and quality of life of patients and their families. We have demonstrated that barriers exist that delay referral to specialist services. Comprehensive data recording and collection, using multiple data sources can reconstruct the timelines of the patient journey, which can in turn be used to identify pathways that can expedite early referral to specialist services.

Opening-wedge high tibial osteotomy with a secure bone allograft (Osteopure™) and locked plate fixation: Retrospective clinical and radiological evaluation of 69 knees after 7.5years follow-up

BACKGROUND

Medial opening-wedge high tibial osteotomy (OWHTO) provides reliable and long-lasting benefits, despite the wide range of wedge-filling and internal-fixation techniques used. The purpose of this work was to assess the clinical and radiological outcomes in a case-series of OWHTO performed using a secure bone allograft and locked plate fixation.

HYPOTHESIS

The clinical and radiological outcomes of OWHTO with a high-safety bone allograft and locked plate fixation are similar to those reported in previous case-series studies.

MATERIALS AND METHODS

A single-centre retrospective design was used to study 69 knees in 64 patients with a mean age of 51.8years (31-53years) and a preoperative hip-knee-ankle (HKA) angle of 173° (165°-180°). The wedge was filled with secure Osteopure™ bone allograft and fixation was achieved using an Integra Surfix(®) locked plate. Mean follow-up was 7.5years (5-9.3years). Clinical and functional outcomes were assessed by determining the IKS and KOOS-PS scores and recording complications related or unrelated to the allograft. The main criterion for assessing OWHTO survival was the time to revision surgery for symptom recurrence. Radiological assessment criteria were the HKA angle, tibial slope, patellar height, and osteoarthritis grade. GESTO criteria were used to evaluate the behaviour of the allograft.

RESULTS

Of the 69 knees, 64 (92.8%) were re-evaluated. The survival rate after 9.3years was 95%±2.7% (3 failures managed with arthroplasty). The functional IKS score improved significantly, by 20 points (P<0.001). Mean increases of 7.8° for the HKA angle and 3.5° for tibial slope were recorded. Bone healing without radiological abnormalities was consistently achieved within 6months. There were no complications related to the allograft (infections, allergies; local or systemic toxicity).

DISCUSSION

The clinical, radiological, and safety outcomes documented in our study were similar to those reported in earlier work.

LEVEL OF EVIDENCE

IV, retrospective case-series study.

The importance of composite foods for estimates of vegetable and fruit intakes

Objective:

To evaluate the contribution of composite foods to vegetable and fruit intakes in Irish adults and to compliance with dietary guidelines for vegetable and fruit intake.

Design:

Data were analysed from the North/South Ireland Food Consumption Survey of 18–64-year-old adults (n= 1379; 662 men, 717 women), which used a 7-day food diary to estimate food intake.

Results:

The mean intake of vegetables (excluding potatoes) was 140g day−1(men 149g day−1; women 132g day−1), of fruit was 136 g day−1(men 133g day−1; women 140 g day−1) and of potatoes was 227 g day−1(men 296g day−1; women 163 g day−1). The mean daily intakes of vegetables, fruit and potatoes from composite foods were 37 g (26%), 6 g (5%) and 17 g (7%), respectively. The mean intake of vegetables from composite foods was unrelated to age or gender, but increased with increasing social class and level of education attained. The proportions of men and women meeting the recommendation for ≥400g day−1(5 servings of 80 g per day) of vegetables and fruit were 21% (15% excluding composite foods) and 19% (12% excluding composite foods), respectively. Compliance with the dietary recommendation decreased with decreasing levels of educational attainment and social class.

Conclusion:

Intakes of vegetables and fruit are low compared with current dietary recommendations, particularly in those of lower levels of educational attainment and social class. Composite foods are an important source of vegetables (less importantly of fruit) and should be included when estimating vegetable intakes. Failure to do so may result in bias in estimates of intake and of compliance with dietary guidelines for population groups, as well as misclassification of individuals by level of intake.

Evaluation of a spray-dried lacticin 3147 powder for the control of Listeria monocytogenes and Bacillus cereus in a range of food systems

AIMS

The potential of a powdered preparation of the bacteriocin, lacticin 3147, was investigated for the inhibition of Listeria monocytogenes and Bacillus cereus.

METHODS AND RESULTS

A 10% solution of reconstituted demineralized whey powder was fermented with Lactococcus lactis DPC3147 for the generation of a lacticin 3147 containing powdered product. A 99.9% reduction in L. monocytogenes numbers occurred in the presence of the lacticin 3147 powder within 2 h in natural yogurt, and an 85% reduction was observed in cottage cheese within the same time frame. Counts of B. cereus were reduced by 80% in soup, in the presence of 1% (w/w) lacticin 3147 powder, within 3 h.

CONCLUSIONS

A powdered preparation of lacticin 3147 was effective for the control of Listeria and Bacillus in natural yogurt, cottage cheese and soup.

SIGNIFICANCE AND IMPACT OF THE STUDY

The bioactive lacticin 3147 powder may find broad applications for control of Gram-positive pathogens/spoilage bacteria in a range of foods.

Physical activity patterns in a nationally representative sample of adults in Ireland

OBJECTIVE

To evaluate habitual levels of physical activity in a nationally representative sample of adults in Ireland.

DESIGN

Cross-sectional survey using a self-administered questionnaire. Usual levels of work, recreational and household activities were evaluated in relation to anthropometric, demographic and socio-economic characteristics. The amount and intensity of all activities were quantified by assigning metabolic equivalents (METS) to each activity.

SETTING

Republic of Ireland and Northern Ireland, 1997-1999.

SUBJECTS

Random sample of 1379 adults aged 18-64 years.

RESULTS

Men were approximately twice as active in work and recreational activity (139.7 +/- 83.9 METS) as women (68.5 +/- 49.8 METS; P<0.001) but women were three times more active in household tasks (65.9 +/- 58.7 METS vs. 22.6 +/- 24.6 METS; P<0.001). Overall levels of physical activity declined with increasing age, particularly leisure activity in men. In women the decline in work activity was offset by spending more time in household pursuits. Twenty-five per cent of the subjects were extremely overweight (body mass index (BMI>28 kg m(-2)) or obese (BMI >30 kg m (-2)). Fewer obese subjects reported higher levels of work and leisure activities. However, a higher percentage of obese women reported participation in the higher levels of household activities. Participation rates in recreational activities were low. Walking was the most important leisure activity of both men (41%) and women (60%). In terms of hours per week spent in vigorous physical activity, men were more active than women, professional and skilled non-manual women were more active than women in other social classes, and younger subjects (aged 18-35 years) were more active than older subjects.

CONCLUSIONS

The holistic approach used in the assessment of physical activity in this study has revealed important and subtle differences in the activity patterns of men and women. Failure to fully characterise the respective activity patterns of men and women could lead to ill-informed public health policy aimed at promoting and sustaining lifetime habits of physical activity. The results suggest that simple population-focused programmes to promote physical activity are unlikely to offer the same chance of long-term success as more sensitive and individualised strategies.

High prevalence of the very rare Wilson disease gene mutation Leu708Pro in the Island of Gran Canaria (Canary Islands, Spain): a genetic and clinical study

The molecular basis of Wilson disease (WD), an autosomal recessive disorder, is the presence of mutations in the ATP7B gene, a copper transporting ATPase. Hospital records indicated a higher prevalence of WD (1 in 2,600) in some counties in the northeastern region of the island of Gran Canaria (Canary Islands, Spain) that was around 10-fold higher than that described for European populations (1 in 30,000). The ATP7B gene was analyzed for mutations in 24 affected subjects, revealing a high prevalence of the rare Leu708Pro mutation present in 12 homozygous and 7 heterozygous individuals. In these patients, who constitute one of the largest described cohorts of WD homozygotes, we found a variable clinical presentation of the disease, although the biochemical picture was homogenous and characteristic, thereby confirming that the Leu708Pro change is indeed a mutation associated with WD. Haplotype analysis of subjects homozygous for the Leu708Pro mutation showed a conserved shared region smaller than 1 centimorgan (cM), and the region of linkage disequilibrium between the Leu708Pro mutation and neighboring microsatellite markers extended approximately 4.6 cM. When comparing the amount of linkage disequilibrium versus genetic distance from the disease mutation, it was estimated that a common ancestral Leu708Pro chromosome may have been introduced in Gran Canaria over 56 generations ago, dating it back to pre-Hispanic times. The prevalence, and the tight geographical distribution of the Leu708Pro chromosome suggests that the Canary Islands can be considered a genetic isolate for linkage disequilibrium studies.

Physical mapping of the CXC chemokine locus on human chromosome 4

A physical map of the CXC chemokine locus on chromosome 4 has been constructed by PCR analysis and PFGE mapping of YAC clones. The genes for IL8, GRO1, PPBP, PF4, SCYB5 (ENA-78) and SCYB6 (GCP-2) have been co-localized on a 335-kb genomic fragment. The GRO2 and GRO3 genes did not map within this region and based on analysis of a YAC contig overlapping IL8 we speculate that GRO2 and GRO3 map downstream of this region. We have also assigned the novel CXC chemokine gene, SCYB9B (alias H174/betaR1) to chromosome 4q21, upstream and within 12 kb of INP10. Like INP10 and MIG, INP10 and SCYB9B are arranged in a head to tail manner. The chromosomal arrangement of these genes appears to reflect the evolution of this multigene family and supports the theory that it arose by gene duplication.

Melanocortin 3 receptor (MC3R) gene variants in extremely obese women

OBJECTIVE

Following several reports of linkage of obesity related phenotypes to human chromosome 20q we sought to determine whether variations of the melanocortin 3 receptor (MC3R) gene are associated with obesity.

DESIGN

We screened the MC3R gene coding region and approximately 2 kb of 5' and 3' flanking sequences for DNA variants in unrelated extremely obese women and average weight controls using polymerase chain reaction (PCR) single strand conformation polymorphism (SSCP) analysis and DNA sequencing.

SUBJECTS

124 unrelated extremely obese women (body mass index, (BMI)>/=40 kg/m2) and 85 average weight controls (BMI<27 kg/m2).

MEASUREMENTS

Radiation hybrid (RH) mapping was performed to localize the MC3R gene. 5' and 3' flanking sequences of MC3R gene were cloned. PCR-SSCP and DNA sequencing were used to detect mutations in the MC3R gene coding region and flanking sequences.

RESULTS

RH mapping localized the MC3R gene to 20q13, between markers D20S100 and D20S149. 1083 bp 5' and 653 bp 3' flanking region of the MC3R gene were cloned. A missense mutation (+241, codon 81 ATT/GTT, Ile-->Val) was found in the MC3R coding region. Four more variants were detected in the 5' flanking sequence: -201(C-->G), -239 (A-->G), -762(A-->T) and -769(T-->C). Compared with controls, no significant allele frequency differences were found. Racial differences were found for the +241, -201, -239 and -762 polymorphisms.

CONCLUSIONS

Several sequence variants were found in the MC3R gene coding region and in 5' flanking sequences. However, none of the variants were associated with obesity phenotypes. The linkage of extreme human obesity on 20q13 is likely caused by genes other than MC3R. International Journal of Obesity (2000) 24, 206-210

Development of a lacticin 3147-enriched whey powder with inhibitory activity against foodborne pathogens

The broad-spectrum bacteriocin lacticin 3147, produced by Lactococcus lactis DPC3147, is inhibitory to a wide range of gram-positive food spoilage and pathogenic organisms. A 10% solution of demineralized whey powder was fermented with DPC3147 at a constant pH of 6.5. The fermentate was spray dried, and the resulting powder exhibited inhibitory activity. The ability of the lacticin 3147-enriched powder to inhibit Listeria monocytogenes Scott A and Staphylococcus aureus 10 was assessed in buffer at both acidic (pH 5) and neutral (pH 7) pH. In addition, the ability of the powder to inhibit L. monocytogenes Scott A in an infant milk formulation was assessed. Resuspension of approximately 10(8) midexponential phase L. monocytogenes Scott A cells in a 10% solution of the lacticin 3147-enriched powder resulted in a 1,000-fold reduction in viable cells at pH 5 and pH 7 after 3 h at 30 degrees C. In the case of S. aureus 10, resuspension of 2.5 x 10(7) midexponential phase cells in a 15% solution of the lacticin 3147-enriched powder at pH 5 resulted in only a 10-fold reduction in viable cell counts, compared with a 1,000-fold reduction at pH 7, following incubation for 3 h at 30 degrees C. The use of the lacticin 3147 powder in an infant milk formulation resulted in greater than a 99% kill of L. monocytogenes within 3 h at 30 degrees C. These results suggest that this bioactive lacticin 3147 food ingredient may find applications in many different foods, including those with pH close to neutrality.

Developing applications for lactococcal bacteriocins

While much of the applied research carried out to date with bacteriocins has concerned nisin, lactococci produce other bacteriocins with economic potential. An example is the two component bacteriocin lacticin 3147, which is active over a wide pH range and has a broad spectrum of activity against gram-positive bacteria. Since the genetic determinants for lacticin 3147 are encoded on a large self-transmissible plasmid, the bacteriocin genes may be conveniently transferred to different lactococcal starters. The resulting food-grade strains can then be used to make a significant impact on the safety and quality of a variety of fermented foods, through the inhibition of undesirable microflora. The bacteriocin is heat stable so it can also be used as an ingredient in a powdered form such as a spray-dried fermentate. Given the observation that lacticin 3147 is effective at physiological pH, there is also considerable potential for biomedical applications. Field trials have demonstrated its efficacy in the prevention of mastitis infections in dairy cows. In contrast to lacticin 3147, the lactococcin bacteriocins A, B and M have a narrow spectrum of activity limited to lactococci. Strains which produce these inhibitors can be exploited in the acceleration of cheese ripening by assisting the premature lysis of starter cultures.

Fast and reliable screening of mutations in human tumors: use of multiple fluorescence-based long linker arm nucleotides assay (mf-LLA)

Human tumor samples were screened for point mutations by adapting a mobility-shift assay to automated DNA sizing. This screen identifies the type of point mutation and relative amount of mutated DNA sequences present in a sample. Test samples having known hypoxanthine-guanine phosphoribosyl transferase (hprt)/exon-3 sequence mutations were characterized by: (i) PCR amplification, (ii) fluorescent dye-primer extension with 36-atom linker derived deoxycytosine or deoxyuridine triphosphate and the remaining three natural nucleotides and (iii) sizing of the resulting fluorescently labeled modified strands, using an automated DNA sequencer. Routinely, a range of sizes is observed among the sequence variants of a single DNA target sequence. This is because nucleotide analogs are incorporated into DNA strands in a sequence-dependent manner, resulting in composition-dependent electrophoretic mobility. Thus, point mutations are identified as shifts in mobility between the fluorescently labeled modified strands of the control and test samples. The twenty different hprt/exon-3 single-base substitution mutations tested were easily identified, even at fourfold dilution with control DNA.

Lacticin 3147 displays activity in buffer against gram-positive bacterial pathogens which appear insensitive in standard plate assays

Lacticin 3147 is a broad-spectrum bacteriocin produced by Lactococcus lactis subsp. lactis DPC3147, which has been shown to be active against a range of food-borne bacteria. The reported inhibitory range for lacticin is extended to include methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus faecalis, penicillin-resistant Pneumococcus, Propionibacterium acne and Streptococcus mutans. This extended host range is not obvious from traditional agar plate-based methods, but reductions in bacterial cell numbers by up to 6 log10 cfu ml-1 was observed after 2 h in time-kill curve studies conducted in broth, suggesting that the bacteriocin may have potential as a therapeutic agent in the treatment of human infections.

"A satellite primer on tuberculosis:" a collaboration in distance education

"A Satellite Primer on Tuberculosis" was offered as a distance-based certificate course on tuberculosis (TB) fundamentals to a national audience of over 5,000 individuals. The course was a collaborative effort of a school of public health, a state health department, and the Centers for Disease Control and Prevention. Instruction was provided through print-based self-study modules that were complemented by live, interactive satellite conferences. Course completers, over 70 percent of whom were nurses and employees of public health departments, scored significantly higher on a course posttest than on a pretest, and the vast majority felt the course provided valuable training.

Moralization of attachment: a fourth domain of conscience functioning

OBJECTIVES

To define discrete developmental levels of understanding regarding the ways in which normal children and adolescents link remembered and current attachment experiences to their moral belief system and to study the correlation between this progression and previously identified stages of conscience conceptualization.

METHOD

Using the moralization of attachment section from the semistructured Stilwell Conscience Interview, 132 normal volunteers between the ages of 5 and 17 years were individually interviewed. Analysis of the interviews resulted in five levels of understanding.

RESULTS

By analyses of variance and covariance, the five attachment levels showed significant correlation with the five conceptualization stages. Conceptualization stage showed a stronger correlation than age.

CONCLUSIONS

In normal development, moralization of attachment is a domain of conscience functioning which follows a five-level hierarchical developmental progression; first, the child's sense of security and empathic responsiveness become paired with a sense of moral obligation; caretaker rules are then incorporated; an understanding of how empathy modifies strict rule-following develops; idols and ideals are chosen that reflect earlier learning in attachment relationships; finally, a visualization of the self as moral standard-bearer or teacher unfolds.

Peripheral blood stem cell transplantation in myeloma using CD34 selected cells

We have performed nine CD34 selection procedures on peripheral blood stem cells harvested from eight patients with myeloma using the Cellpro avidin-biotin immunoaffinity column (Ceprate). They all received CVAMP chemotherapy to maximum response prior to mobilisation. Six of the patients have been transplanted using these cells, one receiving successive autografts. Median absolute cell numbers processed and retrieved were: 31.1 x 10(9) pre-column, 2.07 x 10(8) in the final product and 30.4 x 10(9) in the column waste. Mean CD34 positivity in the product was 49% (range 18.4-98) with a median CD34+ yield of 31.4% (range 21-37.8). IgH PCR was performed and seven of the eight patients were amplifiable. Of these, two were positive in the pre-column product and both of these were successfully purged with a negative result in the final, post-column product. Patients were transplanted with a median of 2.0 x 10(6) CD34+ cells/kg (range 1.5-9.4) following conditioning with melphalan 200 mg/m2. The mean time to recovery of neutrophils to > 0.5 x 10(9)/l and platelets to > 20 x 10(9)/l was 16 and 17 days, respectively. At a mean follow-up of 9 months, four of the six patients transplanted are alive, three of them in complete remission and one in a clinically stable relapse. One has died of disease relapse and one of progressive neurological problems the aetiology of which was uncertain but there was no sign of progression of their myeloma. We conclude that PBSCT using CD34 selected cells is safe and practical in myeloma following remission induction with CVAMP chemotherapy.

Moral valuation: a third domain of conscience functioning

OBJECTIVE

To assess development of moral valuation in normal children and adolescents, that is, how moral rules for living are derived and justified, and to examine the relationship of this progression with previously identified stages of conceptualization of conscience.

METHOD

Using three semistructured questions from the Stilwell Conscience Interview, 132 normal volunteers between the ages of 5 and 17 years were assessed. All moral valuation responses were examined within three aspects of social reference: authority-derived, self-derived, and peer-derived. Each aspect was scaled for complexity into six anchored levels.

RESULTS

The levels of all three aspects correlated positively with conceptualization stages as well as with each other. When the covariate, age, was taken into consideration, peer-derived valuation was significantly correlated with both age and stage.

CONCLUSIONS

Moral valuation is a domain of conscience functioning in which moral rules and their justifications are socially referenced in relationship to authority, self, and peers. Anchored levels of these three aspects of moral valuation provide developmental guidelines for mental status examinations in patients between 5 and 17 years of age as well as providing criteria for future comparative studies in various diagnostic categories of psychopathology.

Practicing population-based care in an HMO: evaluation after 18 months

OBJECTIVE

To determine whether population-based care in a primary care practice results in improvement in compliance with patient care guidelines.

DESIGN

Time series analysis.

SETTING

One primary care practice in Group Health Cooperative of Puget Sound (GHC).

PARTICIPANTS

Approximately 1500 enrollees cared for by the practice.

INTERVENTIONS

An ongoing approach to aid clinical planning at the level of the primary care team--population-based care--that depends on clinical guidelines, a computing system to provide epidemiologic data on guideline performance in the practice and reminders, and a process whereby the practice team analyzed and designs interventions for specific clinical problems.

MAIN OUTCOME MEASURES

We compared compliance with practice guidelines for preventive care and chronic illness management at baseline and after 18 months in the intervention population with other patients in the same clinic and with patients in GHC as a whole.

RESULTS

Compliance with breast cancer screening and colorectal cancer screening guidelines in the intervention population increased from baseline 32% and 18% respectively. These increases were significantly greater than in the remainder of the clinic or in GHC as a whole.

CONCLUSIONS

The availability of practice-based data, clinical guidelines and a local intervention design process resulted in significant improvements in compliance with patient care guidelines.

Serum dopamine beta hydroxylase and maltreatment in psychiatrically hospitalized boys

Fifty boys, hospitalized on a school-age and an adolescent unit in an intermediate length psychiatric hospital, were studied while off psychoactive medication to determine how serum dopamine beta hydroxylase (DBH) activity varies with different childhood maltreatment experiences. Childhood maltreatment was categorized according to onset (before 36 months old, between 36-72 months old and over 72 months old). Childhood maltreatment groups were compared with a group of psychiatrically hospitalized boys who had neither been abused nor neglected. Boys who were younger than 72 months at age of onset of maltreatment had significantly lower DBH activity than those who had experienced maltreatment later in childhood and those who had not been subjected to abuse or neglect. This difference appeared attributable to the DBH activity of school age (but not adolescent) boys who had been abused/neglected before 72 months. Boys with a principal diagnosis of conduct disorder solitary aggressive type had lower DBH activity than boys without this diagnosis regardless of whether or not they had been maltreated. Low serum DBH may be a biological sequela of maltreatment early in life that correlates with the development of conduct disorder solitary aggressive type in boys.

Moral-emotional responsiveness: a two-factor domain of conscience functioning

OBJECTIVE

The purpose of this study was to assess the progression in development of moral-emotional responsiveness in children and adolescents and to examine the relationship of this progression with previously identified stages of conceptualization of conscience.

METHOD

Using three semistructured questions from the Stilwell Conscience Interview, 132 normal volunteers between the ages of 5 and 17 years were assessed regarding comprehension of their emotional responses to moral stimuli.

RESULTS

Rational analysis of the responses identified six items; each item was scaled for complexity into five stages. Factor analysis of the six items revealed two factors: moral-emotional responsiveness 1 contained items relating to external anxiety, internal anxiety, and mood; more-emotional responsiveness 2 contained items relating to the restoration of psychophysiological equilibrium through the processes of reparation and healing. Differences between conceptualization stages, with the moral-emotional responsiveness factors serving as dependent variables, were accounted for by stage differences in age and the positive correlations between the moral-emotional responsiveness factors and age.

CONCLUSIONS

Moral-emotional responsiveness is a two-factor domain of the conscience. The findings provide additional developmental guidelines for assessing conscience development and functioning both in clinical practice and in research.

Acute nutrition management in insulin-dependent diabetes: presentation of an index case

Diabetic patients unable to ingest nutrients orally but who have functioning gastrointestinal tracts should be nutritionally supported via enteral feeding. Provision of enteral nutrition can be problematic in terms of glycemic control. Diabetes compounded with kidney failure further complicates calorie delivery and distribution. Enteral-nutrition formulas should be carefully selected with attention to macronutrient profile, specific carbohydrate constituents, and presence or absence of dietary fiber. Modular components can be added to standard enteral feedings to alter calorie distribution while enhancing calorie provision. Selecting the method of insulin infusion (i.e., intermittent subcutaneous insulin therapy versus continuous intravenous or continuous subcutaneous infusion) for maximizing glucose control is an important step in the acute nutrition management of insulin-dependent diabetic patients. Attention to nutrition indices, fingersticks, and parameters of enteral-feeding intolerance is of utmost importance. The transition from enteral to oral nutrition will depend on adequacy of oral intake as determined by calorie counts.

Nutrition management in acute renal failure

A case report is presented in which a man developed acute renal failure after a surgical misadventure. The initial management, postoperative course with the manifestation of acute tubular necrosis with oliguria and its physiological sequelae, nutrition management in the context of the overall treatment, hospital course, and patient's disease are discussed in detail. The rationale for giving nutrition support, the general considerations for providing nutrients, and the specific nutrition considerations as they pertain to the patient under discussion are outlined to provide a comprehensive guide and overview of the nutrition management of a patient with acute renal failure.