Abstract A02: MEK-CDK4/6 inhibition induces plasma cell tumor infiltration and sensitizes de novo MPNSTs to immune checkpoint blockade

Malignant peripheral nerve sheath tumors (MPNSTs) are deadly, Ras-driven sarcomas that lack effective therapies. Many tumors are unresectable and toxic chemotherapies are ineffectual. The sensitivity of MPNSTs to immune checkpoint blockade (ICB) therapies is not known, although sarcomas are generally unresponsive. Patient tumor analyses comparing MPNSTs to benign precursors identified Ras effectors, MEK and CDK4/6 kinases, as rational targets for therapy. We tested the efficacy of dual MEK-CDK4/6 inhibition versus single drug therapy using preclinical MPNST models. In MPNST cells, low-dose drug combinations synergistically reactivated the retinoblastoma (RB1) tumor suppressor, induced cell death and decreased clonogenic survival. In de novo MPNSTs in immune competent mice, combination therapy caused tumors to shrink, substantially delayed resistant tumor outgrowth and improved survival relative to monotherapies. Tumor regression was associated with an immune activation gene expression profile featuring plasma cell infiltration, an event not previously observed with MEK-CDK4/6 inhibitor therapy. In other human tumor types, intratumoral plasma cells prognose better overall survival and improved response to ICB therapies. Excitingly, MEK-CDK4/6 therapy sensitized de novo MPNSTs to anti-programmed death ligand 1 (PD-L1) therapy with the combination achieving complete tumor ablation and apparent cure in 10% of mice. These findings implicate a critical role for plasma cells in mediating MPNST regression in response to kinase inhibitor therapy and sensitizing tumors to PD-L1 targeting. This novel therapeutic combination is a promising option for MPNST therapy that could improve ICB efficacy in other solid tumors.

Citation Format: Joshua Lingo, Jordan Kohlmeyer, Courtney Kaemmer, Amanda Scherer, Ellen Voigt, Michael Chimenti, Munir Tanas, Varun Monga, Ben Darbro, David Meyerholz, Rebecca Dodd, Dawn Quelle. MEK-CDK4/6 inhibition induces plasma cell tumor infiltration and sensitizes de novo MPNSTs to immune checkpoint blockade [abstract]. In: Proceedings of the AACR Special Conference: Tumor Immunology and Immunotherapy; 2022 Oct 21-24; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2022;10(12 Suppl):Abstract nr A02.

Scaling-up food policies in the Pacific Islands: protocol for policy engagement and mixed methods evaluation of intervention implementation

BACKGROUND

There is a crisis of non-communicable diseases (NCDs) in the Pacific Islands, and poor diets are a major contributor. The COVID-19 pandemic and resulting economic crisis will likely further exacerbate the burden on food systems. Pacific Island leaders have adopted a range of food policies and regulations to improve diets. This includes taxes and regulations on compositional standards for salt and sugar in foods or school food policies. Despite increasing evidence for the effectiveness of such policies globally, there is a lack of local context-specific evidence about how to implement them effectively in the Pacific.

METHODS

Our 5-year collaborative project will test the feasibility and effectiveness of policy interventions to reduce salt and sugar consumption in Fiji and Samoa, and examine factors that support sustained implementation. We will engage government agencies and civil society in Fiji and Samoa, to support the design, implementation and monitoring of evidence-informed interventions. Specific objectives are to: (1) conduct policy landscape analysis to understand potential opportunities and challenges to strengthen policies for prevention of diet-related NCDs in Fiji and Samoa; (2) conduct repeat cross sectional surveys to measure dietary intake, food sources and diet-related biomarkers; (3) use Systems Thinking in Community Knowledge Exchange (STICKE) to strengthen implementation of policies to reduce salt and sugar consumption; (4) evaluate the impact, process and cost effectiveness of implementing these policies. Quantitative and qualitative data on outcomes and process will be analysed to assess impact and support scale-up of future interventions.

DISCUSSION

The project will provide new evidence to support policy making, as well as developing a low-cost, high-tech, sustainable, scalable system for monitoring food consumption, the food supply and health-related outcomes.

Strengthening Knowledge to Practice on Effective Salt Reduction Interventions in Low- and Middle-Income Countries

PURPOSE OF REVIEW

The objective of this review was to consolidate available published information on the implementation and evaluation of salt reduction interventions in low- and middle-income countries (LMICs).

RECENT FINDINGS

The Science of Salt database (made up of studies identified in a weekly Medline search) was used to retrieve articles related to the implementation of salt reduction interventions from June 2013 to February 2020. Studies that measured the effects of the interventions in LMICs, based on four outcome measures-salt intake; sodium levels in foods; knowledge, attitudes, and behaviours (KABs) towards salt; and blood pressure-were included. Results were summarised overall and according to subgroups of intervention type, duration, sample size, country's income class, and regional classification. The review identified 32 studies, representing 13 upper middle-income and four lower middle-income countries. The main salt reduction interventions were education, food reformulation, and salt substitution; and many interventions were multi-faceted. More studies reported a positive effect of the interventions (decreased salt intake (12/17); lower sodium levels in foods or compliance with agreed targets (6/6); improved KAB (17/19); and decreased blood pressure (10/14)) than a null effect, and no study reported a negative effect of the intervention. However, many studies were of small scale and targeted specific groups, and none was from low-income countries. Consumer education, food reformulation, and salt substitution, either alone or in combination, were effective in their target populations. Supporting scale-up of salt reduction interventions in LMICs is essential to cover broader populations and to increase their public health impact.

Economic Contraction from COVID-19 in the Pacific: Implications for Health Financing

Pacific Island countries (PIC) have emerged as among the most at-risk globally from the collateral economic damage resulting from the COVID-19 pandemic, despite being largely spared its direct health effects so far. Current projections indicate that all PIC will experience an economic contraction in 2020, ranging from -1.0% in Tuvalu to -21.7% in Fiji, worse than most countries globally on average. Given that more than 80% of financing for health in the Pacific comes from domestic and external public sources, the net impact of the economic contraction on resources for health will depend on whether overall public spending can offset the decline in economic activity and how health will be prioritized in government budgets relative to other sectors. Without active reprioritization, most countries could see a slowdown or even decline in per capita levels of public spending for health in the region, risking gains made in advancing universal health coverage in recent years. If health ministries do not act quickly and in consort with other ministries (particularly ministries of finance), including by taking active steps to improve the efficient use of existing resources and other measures to mitigate the economic effects of the crisis on resources for health, it is likely that current economic circumstances will result in unplanned changes. These changes may not deliver the health outcomes that the health ministries would select themselves and may result in a reversal of hard-fought health gains.

Effectiveness and Feasibility of Taxing Salt and Foods High in Sodium: A Systematic Review of the Evidence

Diets high in salt are a leading risk for death and disability globally. Taxing unhealthy food is an effective means of influencing what people eat and improving population health. Although there is a growing body of evidence on taxing products high in sugar, and unhealthy foods more broadly, there is limited knowledge or experience of using fiscal measures to reduce salt consumption. We searched peer-reviewed databases [MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and the Cochrane Database of Systematic Reviews] and gray literature for studies published between January 2000 and October 2019. Studies were included if they provided information on the impact on salt consumption of: taxes on salt; taxes on foods high in salt, and taxes on unhealthy foods defined to include foods high in salt. Studies were excluded if their definition of unhealthy foods did not specify high salt or sodium. We found 18 relevant studies, including 15 studies reporting the effects of salt taxes through modeling (8), real-world evaluation (4), experimental design (2), or review of cost-effectiveness (1); 6 studies providing information relevant to country implementation of salt taxes; and 2 studies reporting stakeholder perceptions toward salt taxation. Although there is some evidence on the potential effectiveness and cost-effectiveness of salt taxation, especially from modeling studies, uptake of salt taxation is limited in practice. Some modeling studies suggested that food taxes can have unintended outcomes such as reduced consumption of healthy foods, or increased consumption of unhealthy, untaxed substitutes. In contrast, modeling studies that combined taxes for unhealthy foods with subsidies found that the benefits were increased. Modeling suggests that taxing all foods based on their salt content is likely to have more impact than taxing specific products high in salt given that salt is pervasive in the food chain. However, the limited experience we found suggests that policy-makers favor taxing specific products.

Phase Ib study of decitabine in combination with gemcitabine in treatment of advanced soft tissue and bone sarcomas

11550

Background: Sarcomas are a heterogeneous group of tumors and are associated with high rates of metastases leading to poor prognosis. Numerous epigenetic changes including hypermethylation have been identified in several sarcoma subtypes. Restoration of normal methylation patterns using DNA hypomethylating agent when combined with chemotherapy has shown to slow tumor growth in preclinical studies. Low continuous dosing of hypomethylating agent has epigenetic modulating effect with less toxicity. We conducted a Phase 1b study evaluating safety & tolerability and identifying the recommended phase 2 dose (RP2D) of subcutaneous (SQ) decitabine (DEC) given with fixed dose infusion gemcitabine (GEM) in patients with advanced soft tissue sarcomas (STS) and bone sarcomas. Methods: Eligible patients at least age 18 yrs with metastatic histologically confirmed STS or bone sarcoma after progression on one line or if refused adriamycin for STS were included. Prior GEM use was permitted. A modified 3+3 dose escalation design was used exploring two dose cohorts of DEC, 0.1 and 0.2 mg/kg SQ administered on a twice weekly schedule for three weeks and GEM given as 900 mg/m2, IV over 90 min on days 1, 8 & 15 of a 28-day cycle. Treatment was continued until disease progression or unacceptable toxicity. Dose limiting toxicity (DLT) was defined as any drug related non-hematological grade 3 or 4 toxicity per CTCAE v4.0. Disease assessment was performed every 8 weeks using RECIST v1.1. Results: 31 patients (25 STS & 6 bone sarcomas) were enrolled of which 7 were non-evaluable. There were 12 evaluable patients in each dosing cohort. Of the total 744 adverse events (AE) 17.2% were grade 3/4 and most were neutropenia without neutropenic fever. 45.7% AEs were possibly (44.6%) or probably (1.1%) attributed to DEC use. The toxicities were not significantly different between DEC doses. No DLTs were observed. One patient died due to progressive disease. Conclusions: Combination of fixed dose infusion GEM with low dose subcutaneous DEC is moderately toxic. Most toxicities were hematological. While there were few responses, the RP2D of DEC selected was 0.1 mg/kg as it showed prolonged disease stabilization. Clinical trial information: NCT02959164 . [Table: see text]

Primary health care financing interventions: a systematic review and stakeholder-driven research agenda for the Asia-Pacific region

INTRODUCTION

Interventions targeting the financing of primary health care (PHC) systems could accelerate progress towards universal health coverage; however, there is limited evidence to guide best-practice implementation of these interventions. This study aimed to generate a stakeholder-led research agenda in the area of PHC financing interventions in the Asia-Pacific region.

METHODS

We adopted a two-stage process: (1) a systematic review of financing interventions targeting PHC service delivery in the Asia-Pacific region was conducted to develop an evidence gap map and (2) an electronic-Delphi (e-Delphi) exercise with key national PHC stakeholders was undertaken to prioritise these evidence needs.

RESULTS

Thirty-one peer-reviewed articles (including 10 systematic reviews) and 10 grey literature reports were included in the review. There was limited consistency in results across studies but there was evidence that some interventions (removal of user fees, ownership models of providers and contracting arrangements) could impact PHC service access, efficiency and out-of-pocket cost outcomes. The e-Delphi exercise highlighted the importance of contextual factors and prioritised research in the areas of: (1) interventions to limit out-of-pocket costs; (2) financing models to enhance health system performance and maintain PHC budgets; (3) the design of incentives to promote optimal care without unintended consequences and (4) the comparative effectiveness of different PHC service delivery strategies using local data.

CONCLUSION

The research questions which were deemed most important by stakeholders are not addressed in the literature. There is a need for more research on how financing interventions can be implemented at scale across health systems. Such research needs to be pragmatic and balance academic rigour with practical considerations.

Organisation of primary health care systems in low- and middle-income countries: review of evidence on what works and why in the Asia-Pacific region

INTRODUCTION

This paper synthesises evidence on the organisation of primary health care (PHC) service delivery in low-income and middle-income countries (LMICs) in the Asia Pacific and identifies evidence of effective approaches and pathways of impact in this region.

METHODS

We developed a conceptual framework describing key inputs and outcomes of PHC as the basis of a systematic review. We searched exclusively for intervention studies from LMICs of the Asia-Pacific region in an effort to identify 'what works' to improve the coverage, quality, efficiency, equity and responsiveness of PHC. We conducted a narrative synthesis to identify key characteristics of successful interventions.

RESULTS

From an initial list of 3001 articles, we selected 153 for full-text review and included 111. We found evidence on the impact of non-physician health workers (NPHWs) on coverage and quality of care, though better integration with other PHC services is needed. Community-based services are most effective when well integrated through functional referral systems and supportive supervision arrangements, and have a reliable supply of medicines. Many studies point to the importance of community engagement in improving service demand. Few studies adopted a 'systems' lens or adequately considered long-term costs or implementation challenges.

CONCLUSION

Based on our findings, we suggest five areas where more practical knowledge and guidance is needed to support PHC systems strengthening: (1) NPHW workforce development; (2) integrating non-communicable disease prevention and control into the basic package of care; (3) building managerial capacity; (4) institutionalising community engagement; (5) modernising PHC information systems.

Organisation of primary health care in the Asia-Pacific region: developing a prioritised research agenda

Health system planners in low- and middle-income countries (LMIC) of the Asia-Pacific region seeking to reorient primary health care (PHC) systems to achieve universal health coverage may be hindered by lack of knowledge of what works in their setting. With limited resources for research available, it is important to identify evidence-based strategies for reorganising PHC delivery, determine where relevant evidence gaps exist and prioritise these for future study. This paper describes an approach for doing this using the best available evidence combined with consultation to establish evidence priorities. We first reviewed PHC organisational interventions in Asia-Pacific LMICs and ascertained evidence gaps. The largest gaps related to interventions to promote access to essential medicines, patient management tools, effective health promotion strategies and service planning and accountability. Evidence from Pacific Island countries was particularly scant. We then engaged an expert panel of 22 PHC stakeholders from seven Asia-Pacific LMICs in a Delphi exercise to identify priority questions for future research. Research priorities were: (1) identifying effective PHC service delivery models for chronic diseases; (2) devising sustainable models of disease integration; (3) optimising task shifting; (4) understanding barriers to care continuity; (5) projecting future PHC needs; and (6) designing appropriate PHC service packages. Notably, stakeholder-determined priorities reflected large, context-dependent system issues, while evidence gaps centred on discrete interventions. Future research on the organisation of PHC services in Asia-Pacific LMICs should incorporate codesign principles to engage researchers and national PHC system stakeholders, and innovative methods that build on existing evidence and account for system complexity.

Strengthening and measuring research impact in global health: lessons from applying the FAIT framework

Background

To date, efforts to measure impact have largely focused on health research in high-income countries, reflecting where the majority of health research funding is spent. Nevertheless, there is a growing body of health and medical research being undertaken in low- and middle-income countries (LMICs), supported by both development aid and established research funders. The Framework to Assess the Impact of Translational health research (FAIT) combines three approaches to measuring research impact (Payback, economic assessment and case study narrative). Its aim is to strengthen the focus on translation and impact measurement in health research. FAIT has been used by several Australian research initiatives; however, it has not been used in LMICs. Our aim was to apply FAIT in an LMIC context and evaluate its utility.

Methods

We retrospectively applied all three FAIT methods to two LMIC studies using available data, supplemented with group discussion and further economic analyses. Results were presented in a scorecard format.

Results

FAIT helped clarify pathways of impact for the projects and provided new knowledge on areas of impact in several domains, including capacity-building for research, policy development and economic impact. However, there were constraints, particularly associated with calculating the return on investment in the LMIC context. The case study narrative provided a layperson’s summary of the research that helped to explain outcomes and succinctly communicate lessons learnt.

Conclusion

Use of FAIT to assess the impact of LMIC research was both feasible and useful. We make recommendations related to prospective use, identification of metrics to support use of the Payback framework, and simplification of the economic assessment, which may facilitate further application in LMIC environments.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0451-0) contains supplementary material, which is available to authorized users.

The impact of out-of-pocket costs on treatment commencement and adherence in chronic kidney disease: a systematic review

Chronic kidney disease (CKD) is a significant and growing driver of the global non-communicable diseases (NCD) burden, responsible for 1.2 million deaths in 2016. While previous research has estimated the out-of-pocket costs of CKD treatment and resulting levels of catastrophic health expenditures, less is known about the impact of such costs on access to, and maintenance of, care. Our study seeks to fill this gap by synthesizing available evidence on cost as a determinant of CKD treatment discontinuation. We searched for studies which considered the financial burden of treatment and medication for CKD patients and the extent to which this burden was associated with patients forgoing or discontinuing treatment. We identified 14 relevant studies, 5 from high-income countries and 9 from low-middle income countries. All suggest that cost adversely influences adherence to CKD medication and dialysis treatment. In poorer countries, those entering treatment programs were typically diagnosed late, under-dialysed and suffered very high levels of mortality. Identified studies present consistent findings regardless of study context: cost is barrier to treatment and a driver of non-adherence and discontinuation, with poorer households worst affected. This is in line with previous research. Major gaps in the literature remain, however, in relation to differential impact of the cost burden on men and women, the coping strategies of poor households and the effect of insurance coverage.

Abstract PR09: Modeling the tumor microenvironment in sarcoma: The impact on MPNST biology and chemotherapeutic response

NF1 haploinsufficiency is a hallmark of neurofibromatosis Type 1 and is critical for neurofibroma development. The role of the supporting stroma (endothelial cells, immune cells, fibroblasts, etc.) in the development of patient neurofibromas is well established. However, the impact of NF1 haploinsufficiency on MPNST biology is less clear. Sporadic MPNSTs arise in patients with NF1 wild-type stroma (NF1 +/+), while NF1-associated MPNSTs arise in neurofibromatosis patients with NF1 haploinsufficient stroma (NF1 -/+). Patients with NF1-associated MPNSTs have worse outcome than patients with sporadic MPNSTs, but the cause of this difference is under debate. To define the impact of stromal genetics on tumor biology, we have developed unique mouse models that reflect the genetics of patient-associated MPNSTs.

Using paired littermate mice, we model the genetic status of NF1 in the tumor microenvironment of different MPNST patient populations. We use Adenovirus-Cre injections to generate MPNSTs in NF1 Flox/Flox; CDKN2A Flox/Flox and NF1 Null/Flox; CDKN2A Flox/Flox paired littermate mice to model tumors from NF1 wild-type and NF1-assoicated patients, respectively. We find that NF1 haploinsufficiency (NF1 +/- stroma) accelerates tumor onset, which is accompanied by an increase in immune cells comprising CD11B+ cells, monocytes, and mast cells. Furthermore, mast cells are also enriched in human NF1-associated MPNSTs. We used these mouse models in a preclinical trial to examine how the tumor microenvironment influences response to multiagent chemotherapy and found that the stromal NF1 status does not impact the response of MPNSTs to chemotherapy. Taken together, these studies help clarify the role of the NF1 haploinsufficient tumor microenvironment in MPNSTs.

This abstract is also being presented as Poster B15.

Citation Format: Rebecca Dodd, Chang-Lung Lee, Mary Overton, Wesley Huang, William Eward, Davis Ingram, Diana Cordona, Alexander Lazar, David Kirsch. Modeling the tumor microenvironment in sarcoma: The impact on MPNST biology and chemotherapeutic response [abstract]. In: Proceedings of the AACR Conference on Advances in Sarcomas: From Basic Science to Clinical Translation; May 16-19, 2017; Philadelphia, PA. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(2_Suppl):Abstract nr PR09.

Current and future implications of basic and translational research on amyloid-β peptide production and removal pathways

Inherited variants in multiple different genes are associated with increased risk for Alzheimer's disease (AD). In many of these genes, the inherited variants alter some aspect of the production or clearance of the neurotoxic amyloid β-peptide (Aβ). Thus missense, splice site or duplication mutants in the presenilin 1 (PS1), presenilin 2 (PS2) or the amyloid precursor protein (APP) genes, which alter the levels or shift the balance of Aβ produced, are associated with rare, highly penetrant autosomal dominant forms of Familial Alzheimer's Disease (FAD). Similarly, the more prevalent late-onset forms of AD are associated with both coding and non-coding variants in genes such as SORL1, PICALM and ABCA7 that affect the production and clearance of Aβ. This review summarises some of the recent molecular and structural work on the role of these genes and the proteins coded by them in the biology of Aβ. We also briefly outline how the emerging knowledge about the pathways involved in Aβ generation and clearance can be potentially targeted therapeutically. This article is part of Special Issue entitled "Neuronal Protein".

Health systems and noncommunicable diseases in the Asia-Pacific region: a review of the published literature

Addressing the growing burden of noncommunicable diseases (NCDs) in countries of the Asia-Pacific region requires well-functioning health systems. In low- and middle-income countries (LMICs), however, health systems are generally characterized by inadequate financial and human resources, unsuitable service delivery models, and weak information systems. The aims of this review were to identify (a) health systems interventions being implemented to deliver NCD programs and services and their outcomes and (b) the health systems bottlenecks impeding access to or delivery of these programs and services in LMICs of the Asia-Pacific region. A search of 4 databases for literature published between 1990 and 2010 retrieved 36 relevant studies. For each study, information on basic characteristics, type of health systems bottleneck/intervention, and outcome was extracted, and methodological quality appraised. Health systems interventions and bottlenecks were classified as per the World Health Organization health systems building blocks framework. The review identified interventions and bottlenecks in the building blocks of service delivery, health workforce, financing, health information systems, and medical products, vaccines, and technologies. Studies, however, were heterogeneous in methodologies used, and the overall quality was generally low. There are several gaps in the evidence base around NCDs in the Asia-Pacific region that require further investigation.

Development cooperation for health: reviewing a dynamic concept in a complex global aid environment

The 4^th High Level Forum on Aid Effectiveness, held in Busan, South Korea in November 2011 again promised an opportunity for a "new consensus on development cooperation" to emerge. This paper reviews the recent evolution of the concept of coordination for development assistance in health as the basis from which to understand current discourses. The paper reviews peer-reviewed scientific literature and relevant 'grey' literature, revisiting landmark publications and influential authors, examining the transitions in the conceptualisation of coordination, and the related changes in development assistance. Four distinct transitions in the understanding, orientation and application of coordination have been identified: coordination within the sector, involving geographical zoning, sub-sector specialisation, donor consortia, project co-financing, sector aid, harmonisation of procedures, ear-marked budgetary support, donor agency reform and inter-agency intelligence gathering; sector-wide coordination, expressed particularly through the Sector-Wide Approach; coordination across sectors at national level, expressed in the evolution of Poverty Strategy Reduction Papers and the national monitoring of the Millennium Development Goals; and, most recently, global-level coordination, embodied in the Paris Principles, and the emergence of agencies such as the International Health Partnerships Plus. The transitions are largely but not strictly chronological, and each draws on earlier elements, in ways that are redefined in the new context. With the increasing complexity of both the territory of global health and its governance, and increasing stakeholders and networks, current imaginings of coordination are again being challenged. The High Level Forum in Busan may have been successful in recognising a much more complex landscape for development than previously conceived, but the challenges to coordination remain.

Intraoperative angiography for cranial dural arteriovenous fistula

BACKGROUND AND PURPOSE

IA is a valuable adjunct during surgery for a variety of neurovascular diseases; however, there are no reported series describing IA for DAVFs. This study was undertaken to evaluate the safety and efficacy of IA for DAVFs.

MATERIALS AND METHODS

A retrospective review of DAVF surgical cases during a 20-year period was conducted, and cases with IA were evaluated. Clinical details, surgical and angiographic findings, and postoperative outcomes were reviewed. The incidence of residual fistula on IAs, the utility of the surgical procedure, and the incidence of false-negative findings on IA were also determined.

RESULTS

IA was performed in 29 patients (31 DAVFs) for DAVFs. The distribution of the fistulas was the following: transverse-sigmoid (n = 9), tentorial (n = 6), torcular (n = 3), cavernous sinus (n = 4), SSS (n = 4), foramen magnum (n = 3), and temporal-middle fossa (n = 2). Twelve patients had undergone prior embolization, while 6 patients had unsuccessful embolization procedures. Thirty-eight surgeries were performed for DAVF in 29 patients, and IA was performed in 34 surgeries. Forty-four angiographic procedures were performed in the 34 surgeries. Nine patients underwent multiple angiographies. In 11 patients (37.9%), IA revealed residual fistula after the surgeon determined that no lesion remained. This led to further exploration at the same sitting in 10 patients, while in 1 patient, further surgery was performed at a later date. False-negative findings on IA occurred in 3 patients (10.7%).

CONCLUSIONS

IA is an important adjunct in surgery for DAVF. In this series, it resulted in further surgical treatment in 37.9% of patients. However, there was a 10% false-negative rate, which justified subsequent postoperative angiography.

Where did all the aid go? An in-depth analysis of increased health aid flows over the past 10 years

OBJECTIVE

To examine how health aid is spent and channelled, including the distribution of resources across countries and between subsectors. Our aim was to complement the many qualitative critiques of health aid with a quantitative review and to provide insights on the level of development assistance available to recipient countries to address their health and health development needs.

METHODS

We carried out a quantitative analysis of data from the Aggregate Aid Statistics and Creditor Reporting System databases of the Organisation for Economic Co-operation and Development, which are the most reliable sources of data on official development assistance (ODA) for health from all traditional bilateral and multilateral sources and from partnerships such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.

FINDINGS

The analysis shows that while health ODA is rising and capturing a larger share of total ODA, there are significant imbalances in the allocation of health aid which run counter to internationally recognized principles of "effective aid". Countries with comparable levels of poverty and health need receive remarkably different levels of aid. Funding for Millennium Development Goal 6 (combat HIV/AIDS, malaria and other diseases) accounts for much of the recent increase in health ODA, while many other health priorities remain insufficiently funded. Aid is highly fragmented at country level, which entails high transaction costs, divergence from national policies and lack of coherence between development partners.

CONCLUSION

Although political momentum towards aid effectiveness is increasing at global level, some very real aid management challenges remain at country level. Continued monitoring is therefore necessary, and we recommend that a review of the type presented here be repeated every 3 years.

Programme alignment in higher-level planning processes: a four-country case-study for Sexual and Reproductive Health

With international development assistance focussed on poverty reduction, national and sector-wide planning processes have become increasingly important in setting agendas. Sector-Wide Approaches (SWAps), Poverty Reduction Strategy Papers (PRSPs), and other higher level planning processes, including Millennium Development Goals (MDGs) reporting, have required new levels of engagement in national and sectoral planning processes. For Sexual and Reproductive Health (SRH), this has had mixed consequences, despite raising the profile of SRH in national planning agendas, and emphasizing the potential of SRH to contribute to the reduction of poverty.Drawing on case-study research from four countries, this paper analyzes alignment of SRH policy with higher-level planning processes. It found that SRH managers are rarely engaged in higher-level planning processes, and while SRH features prominently in the [health] sections of PRSPs, it is not reflected in other sections, and does not necessarily correspond to more resources. Despite these limitations, these planning processes offer synergies that could improve the contribution of SRH to health sector development and poverty reduction. The paper recommends that local donor organizations, including key UN agencies, offer greater support for SRH programme managers in promoting the pro-poor and systems-wide strengths of SRH programmes to planners and policy makers.

Paris on the Mekong: using the aid effectiveness agenda to support human resources for health in the Lao People's Democratic Republic

BACKGROUND

This study examines the potential of aid effectiveness to positively influence human resources for health in developing countries, based on research carried out in the Lao People's Democratic Republic (Lao PDR). Efforts to make aid more effective--as articulated in the 2005 Paris Declaration and recently reiterated in the 2008 Accra Agenda for Action--are becoming an increasingly prominent part of the development agenda. A common criticism, though, is that these discussions have limited impact at sector level. Human resources for health are characterized by a rich and complex network of interactions and influences--both across government and the donor community. This complexity provides a good prism through which to assess the potential of the aid effectiveness agenda to support health development and, conversely, possibilities to extend the impact of aid-effectiveness approaches to sector level.

METHODS

The research adopted a case study approach using mixed research methods. It draws on a quantitative analysis of human resources for health in the Lao People's Democratic Republic, supplementing this with a documentary and policy analysis. Qualitative methods, including key informant interviews and observation, were also used.

RESULTS

The research revealed a number pathways through which aid effectiveness is promoting an integrated, holistic response to a range of human resources for health challenges, and has identified further opportunities for stronger linkages. The pathways include: (1) efforts to improve governance and accountability, which are often central to the aid effectiveness agenda, and can be used as an entry point for reforming workforce planning and regulation; (2) financial management reforms, typically linked to provision of budget support, that open the way for greater transparency and better management of health monies and, ultimately, higher salaries and revenues for health facilities; (3) commitments to harmonization that can be used to improve coherence of donor support in areas such as salary supplementation, training and health information management.

CONCLUSION

If these opportunities are to be fully exploited, a number of constraints will need to be overcome: limited awareness of the aid effectiveness agenda beyond a core group in government; a perception that this is a donor-led agenda; and different views among partners as to the optimal pace of aid management reforms. In conclusion, we recommend strategic engagement of health stakeholders in the aid effectiveness agenda as one means of strengthening the health workforce.

Health, development and the Millennium Development Goals

The Millennium Development Goals (MDG), which emerged from the United Nations Millennium Summit in 2000, are increasingly recognized as the over-arching development framework. As such, the MDG are increasingly guiding the policies of poor countries and aid agencies alike. This article reviews the challenges and opportunities for health presented by the MDG. The opportunities include that three of the eight MDG relate to health--a recognition that health is central to global agenda of reducing poverty, as well as an important measure of human well-being in its own right. A related point is that the MDG help to focus attention on those health conditions that disproportionally affect the poor (communicable disease, child health and maternal health), which should, in turn, help to strengthen the equity focus of health policies in low-income countries. Further, because the MDG are concrete, it is possible to calculate the cost of achieving them, which in turn strengthens the long-standing calls for higher levels of aid for health. The challenges include that, while the MDG focus on specific diseases and conditions, they cannot be achieved without strengthening health systems. Similarly, progress towards the MDG will require health to be prioritized within overall development and economic policies. In practice, this means applying a health 'lens' to processes such as civil-service reform, decentralization and the drawing-up of frameworks of national expenditure. Finally, the MDG cannot be met with the resources available in low-income countries. While the MDG framework has created pressure for donors to commit to higher levels of aid, the challenge remains to turn these commitments into action. Data are presented to show that, at current rates of progress, the health-related MDG will not be achieved. This disappointing trend could be reversed, however, if the various challenges outlined are met.

Health sector reform and sexual and reproductive health services in Mongolia

Since its transition to democracy, Mongolia has undergone a series of reforms, both at national level and in the health sector. This paper examines the pace and scope of these reforms, the ways in which they have impacted on sexual and reproductive health services and their implications for the health workforce. Formerly pro-natalist, Mongolia has made significant advances in contraceptive use, women's education and reductions in maternal mortality. However, rising adolescent pregnancy and sexually transmitted infections, and persisting high levels of abortion, remain challenges. The implementation of the National Reproductive Health Programme has targeted skills development, outreach and the provision of resources. Innovative adolescent-friendly health services have engaged urban youth, and the development of family group practices has created incentives to provide primary medical care for marginalised communities, including sexual and reproductive health services. The Health Sector Strategic Masterplan offers a platform for coordinated development in health, but is threatened by a lack of consensus in both government and donor communities, competing health priorities and the politicisation of emerging debates on fertility and abortion. With previous gains in sexual and reproductive health vulnerable to political change, these tensions risk the exacerbation of existing disparities and the development by default of a two-tiered health care system.

Identification of three novel HLA class I alleles: HLA-B*3928, HLA-B*400104 and HLA-B*4437

Three new human leukocyte antigen (HLA) class I alleles have been identified in the Tissue Typing Laboratory in Sydney, Australia. Sequence analysis of exon 2 and exon 3 of the HLA-B gene revealed the novel polymorphism. A silent substitution of C to T at nucleotide position 369 has been identified for the HLA-B*400104 allele when compared to the closest matched allele, HLA-B*400101. The HLA-B*3928 allele was identified with a nucleotide substitution of G to C at position 362 when compared to the closest matched allele, HLA-B*390101, resulting in an amino acid substitution of Arginine to Threonine. A nucleotide substitution of C to G at position 572 resulting in the amino acid change Serine to Tryptophan was identified in the new allele HLA-B*4437, when compared to the closest matched allele HLA-B*440301. Both amino acid substitutions implicate a different specificity and affinity of antigen binding for the alleles HLA-B*3928 and HLA-B*4437.

Identification of new HLA-C alleles by polymerase chain reaction-sequence specific oligonucleotide typing: Cw*0314 and Cw*1511*

In this article, we report two new human leukocyte antigen-C (HLA-C) alleles, HLA-Cw*0314 and Cw*1511, which were identified during routine tissue typing of donors for the Australian Bone Marrow Donor Registry and Australian Cord Blood Bank. HLA-Cw*0314 shows six codon changes in exon 3 compared to Cw*030401 and shares some sequence homology with Cw*07 alleles. Cw*1511 has two nucleotide changes compared with Cw*150201 in exon 2, both resulting in amino acid changes in the protein sequence.

New HLA-B alleles detected by polymerase chain reaction-sequence-specific oligonucleotide typing: HLA-B*0725, B*0728, and B*3808

Three novel alleles, human leukocyte antigen (HLA)-B*0725, B*0728, and B*3808, were discovered during routine genotyping of samples for the Australian Bone Marrow Donor Registry and Australian Cord Blood Bank. The new alleles contain amino acid changes in the antigen-binding site of the expressed HLA protein, which may alter the antigen-binding properties of the functional protein.

Detection of a novel HLA-A allele by polymerase chain reaction-sequence-specific oligonucleotide typing: HLA-A*0252

Anew human leukocyte antigen (HLA) class I allele, HLA-A*0252, has been found during routine typing of samples for the Australian Bone Marrow Donor Registry. A*0252 differs from A*020101 at four codon positions, with all the new polymorphisms resulting in an amino acid change. The amino acids involved are located in the antigen-binding region of the HLA protein.

A new HLA-B allele, B*1565, identified in three unrelated samples

Anew human leukocyte antigen-B allele, B*1565, has been identified during routine typing of cord blood samples. Subsequently, two individuals from the same family as the first cord blood sample plus two unrelated Australian Bone Marrow Donor Registry samples have been found to carry this novel allele.

Six new HLA class I alleles detected by PCR-SSO genotyping

This paper describes six new alleles; A*0240, A*2614, B*3924, B*4425, Cw*0807 and Cw*12023, which were discovered during routine genotyping with sequence specific oligonucleotides (SSO's). Five of the new alleles have changes in residues which belong to the antigen binding site of the HLA protein. These new variants may have altered antigen binding properties and may cause differential immunological responses that could affect transplantation outcome1.

Description of a novel HLA-DRB1 allele, DRB1*1207

A new DRB1 allele has been identified during routine HLA-DRB1 generic typing with sequence specific oligonucleotides. The new allele was confirmed by PCR-restriction fragment length polymorphism analysis and subsequently sequenced. This showed the novel allele, named HLA-DRB1*1207, was similar in sequence to DRB1*12011, except for codon 69 of exon 2.