Barriers and facilitators to integrating depression care in tuberculosis services in South Asia: a multi-country qualitative study

BACKGROUND

Depression is common among people with tuberculosis (TB). The condition is typically unrecognised or untreated despite available and effective treatments in most low- and middle-income countries. TB services in these countries are relatively well established, offering a potential opportunity to deliver integrated depression screening and care. However, there is limited evidence on how such integration could be achieved. This study aimed to understand the barriers and facilitators to integrate depression care in TB services.

METHODS

We conducted nine workshops with 76 study participants, including people with TB, their carers, and health service providers in Bangladesh, India, and Pakistan, seeking views on integrating depression care into TB clinics. We used a deductive thematic approach to analyse the translated transcripts of audio recordings, contemporaneous notes made during workshops for Bangladesh and India and workshop reports for Pakistan. Using the SURE (Supporting the Use of Research Evidence) thematic framework, we extracted and categorised barriers and facilitators into various domains.

RESULTS

Reported barriers to integrating depression care in TB services included lack of knowledge about depression amongst patients and the staff, financial burden, and associated stigma for people with TB and their carers. Government buy-in and understanding of how to identify and screen for depression screening were potential facilitators reported. Additionally, breaking through mental health stigma and providing the additional resources required to deliver this service (human resources and consultation time) were essential for integrating depression and TB care.

CONCLUSIONS

Depression is a common condition found among people with TB, requiring early identification among people with TB. Integrating depression care into Tb services by health workers requires the availability of political support and the provision of resources.

Relationship between Amniotic Fluid Index and Perinatal Outcome

Aims:  This study was done to evaluate the predictive value of low amniotic fluid index (AFI) of < 5 cm for adverse perinatal outcome in term of caesarean section for fetal distress, birth weight, meconium stained liquor and APGAR scores. Methods: This was a prospective study of 200 antenatal women booked at Nepal Medical College Teaching Hospital during the year 2013-2014 with gestational age between 34 and 41 weeks. Patients history and clinical examination were recorded and AFI was measured and the perinatal outcome was compared between two groups i.e AFI <5 cm and >5 cm. Results: The caesarean section (C/S) rate for fetal distress and low birth weight babies (<2.5 kg) was higher in patients with low AFI (p=0.048, 0.001 respectively). There was no significant difference in meconium staining, APGAR score at 5 minutes between the two groups (p=0.881, 0.884 respectively). Conclusions: Caesarean section for fetal distress and low birth weight babies was significantly associated with low amniotic fluid index. There was no significant difference in meconium staining liquor, APGAR score at 5 minutes between the two groups.  

ROS-PIASγ cross talk channelizes ATM signaling from resistance to apoptosis during chemosensitization of resistant tumors

With the existing knowledge of ATM's role in therapeutic resistance, the present study aimed at identifying the molecular mechanisms that influence ATM to oscillate between chemoresistance and chemosensitivity. We observed that the redox status of tumors functions as a major determinant of ATM-dependent ‘resistance-to-apoptosis' molecular switch. At a low reactive oxygen species (ROS) condition during genotoxic insult, the ATM/sumoylated-IKKγ interaction induced NFκB activation that resisted JNK-mediated apoptosis, whereas increasing cellular ROS restored ATM/JNK apoptotic signaling. A search for the upstream missing link revealed that high ROS induces oxidation and ubiquitin-mediated degradation of PIASγ, thereby disrupting PIASγ-IKKγ cross talk, a pre-requisite for IKKγ sumoylation and subsequent NFκB activation. Interruption in the PIASγ-mediated resistance pathway channels ATM signaling toward ATM/JNK pro-death circuitry. These in vitro results also translated to sensitive and resistant tumor allograft mouse models in which low ROS-induced resistance was over-ruled in PIASγ knockout tumors, while its overexpression inhibited high ROS-dependent apoptotic cues. Cumulatively, our findings identified an unappreciated yet critical combinatorial function of cellular ROS and PIASγ in regulating ATM-mediated chemosensitization of resistant tumors. Thus, therapeutic strategies employing ROS upregulation to inhibit PIASγ during genotoxic therapy may, in future, help to eliminate the problems of NFκB-mediated tumor drug resistance.

Carotid intima media thickness: an independent marker for assessment of macrovascular risk in diabetic patients

In view of the global epidemic of diabetes with India being the hottest reservoir of the disease, it was tried to identify carotid intima media thickness as a surrogate marker for atherosclerosis in diabetic subjects. The study becomes more relevant because diabetes is now considered a disease of the endothelium and a risk equivalent of coronary atherosclerosis (paradigm shift). The study incorporated 41 normotensive patients of diabetes and 31 age and sex matched controls. Plasma glucose and lipid profiles were assessed in all and the carotid intima media thickness was measured. Results were statistically analysed for significance and correlation coefficient between values of plasma glucose and carotid intima media thickness. Results clearly showed that carotid intima media thickness abnormality can pick up atherosclerosis even if the lipid parameters are nearly normal. So it crystallises from this small study that, as a non-invasive test carotid intima media thickness is a better and early predictor of atherosclerosis in diabetic subjects. It also revealed the linear relationship between both fasting and postprandial blood sugar with carotid intima media thickness.

Pulse radiolysis of the DNA-binding bisbenzimidazole derivatives Hoechst 33258 and 33342 in aqueous solutions

PURPOSE

The DNA-minor-groove-ligands bisbenzimidazoles Hoechst 33258 and 33342 have been reported to protect against radiation-induced DNA-strand breakage. In order to elucidate the mechanisms of protection by these DNA-binding compounds, pulse radiolysis studies on the reactions of the OH radical, the solvated electron and the H atom with Hoechst as well as OH-radical-induced nucleotide radical quenching by free Hoechst (model level) was investigated.

MATERIALS AND METHODS

The pulse radiolysis of Hoechst 33258 and 33342 was studied in N2O and N2O/O2-(4:1)-saturated aqueous solutions in the absence and presence of azide and bromide ions and nucleotides.

RESULTS

In a fully scavenged system (3 x 10(-2) mol x dm(-3) t-butanol, N2O/O2-saturated), a transient is formed which in the presence of phosphate buffer is no longer observed. This is assigned metastable quinonoid forms of Hoechst (lambdamax(Hoechst) = 340; lambdamax(transient) = 370 nm) which is generated in protonation/ deprotonation reactions by H+/OH- formed during the pulse. To prevent their formation 10(-3) mol x dm(-3) phosphate buffer was added in all other experiments. The transient spectra formed upon OH-radical attack (k=9 x 10(9) dm3 x mol(-1) x s(-1)) indicate that a major part of the primary OH-adduct radicals undergo rapid transformation (k approximately 5 x 10(5) x s(-1)), attributed to water elimination yielding an N-centered radical. This intermediate, also generated by N3. (k = 4 x 10(9) dm3 mol(-1) x s(-1)), subsequently complexes with a Hoechst molecule [k = 8 x 10(8) dm3 x mol(-1) x s(-1) epsilon(440 nm) = 1.4 x 10(4) dm3 mol(-1) x cm(-1)]. The N-centered radical does not react with O2 (k < 5 x 10(5) dm3 mol(-1) x s(-1)), but reacts readily with the superoxide radical (k= 1.0 x 10(9) dm3 x mol(-1) x s(-1)). Hoechst reacts with the peroxyl radicals derived from uridine (k approximately 5 x 10(6) dm3 x mol(-1) x s(-1)) or 5'-UMP (k approximately 1 x 10(7) dm3 mol(-1) x (s-1)), but not with the less oxidizing (e.g. methylperoxyl radical) yielding intermediates whose spectral properties are similar to those of the N-centered radical. However, they decay at a much lower rate (2k approximately 1 x 10(8) dm3 mol(-1) x s(-1)) than the N-centered radicals generated by N3. (2k= 1.1 x 10(9) dm3 x mol(-1) s(-1)), and it has been suggested that these peroxyl radicals form adducts rather than undergoing electron transfer. The H atom (k= 7 x 10(9) dm3 x mol(-1) x s(-1)) and the solvated electron (k= 2.3 x 10(10) dm3 x mol(-1) x s(-1)) yield, albeit noticeably different, H-adduct radicals which also strongly absorb in the 440 nm region. The reduction potential of Hoechst 33258 has been determined electrochemically at 0.84-0.90 V vs. NHE at pH 6.8.

CONCLUSION

Hoechst reacts fast only with strongly oxidizing radicals by electron transfer (e.g. with the adenine-and guanine-derived heteroatom-centered radicals), but also more slowly with nucleo-base-derived peroxyl radicals, here albeit via addition. This may have important implications with regard to its protection owing to DNA-radical quenching under oxic vs. anoxic conditions.

Studies on the modulation of DNA damage. 1: A simple kinetic model for radioprotection of DNA in aqueous solution

A simple kinetic model, based on the assumption that direct and indirect interactions of ionising radiations with DNA lead to formation of DNA-radicals which are precursors of single strand break (ssb) and double strand break (dsb) is presented. Considering accessibility of OH attack on DNA and assuming homogenous kinetics, the model has been validated by using experimental data on radiation-induced strand break formation in presence of methanol (MeOH) and glutathione (GSH). Fitting the D37 values for ssb in aqueous solution of pBR322 DNA in the presence of the predominantly A-T minor groove-ligand Hoechst 33258, the value of the rate constant of OH scavenging by DNA-bound Hoechst was estimated by Martin and his group as 2.7 x 10(11) dm3 mol-1 s-1 (Martin, R.F. and Denison, L. (1992), Int. J. Radiat. Oncol. Biol. Phys., 23, 578-584). Using aqueous solution of calf thymus DNA in the presence of Hoechst this rate constant has been determined by pulse radiolysis as 1.1 x 10(9) dm3 mol-1 s-1. The yield of strand breaks has also been measured by low angle laser light scattering. Using the experimentally measured value of the rate constant of OH scavenging by DNA-bound Hoechst in the model, calculations show that OH scavenging alone could not explain the overall protection provided by Hoechst; there should be quenching of DNA-radicals by Hoechst. Fitting the yield of radiation-induced ssb (G(ssb)) obtained for CT DNA and pBR322 DNA, the rate constant of this DNA-radical quenching has been calculated as 10(6) dm3 mol-1 s-1, which agrees with pulse radiolytic data. Using these rate constant values, calculations show that the protection against radiation-induced dsb formation provided by the combination of Hoechst with GSH is more than that by the combination of MeOH with GSH.