Do tuition-free lower secondary education policies matter for antenatal care among women in sub-saharan African countries?

BACKGROUND

Antenatal care (ANC) is critical to reducing maternal and infant mortality. However, sub-Saharan Africa (SSA) continues to have among the lowest levels of ANC receipt globally, with half of mothers not meeting the WHO minimum recommendation of at least four visits. Increasing ANC coverage will require not only directly reducing geographic and financial barriers to care but also addressing the social determinants of health that shape access. Among those with the greatest potential for impact is maternal education: past research has documented a relationship between higher educational attainment and antenatal healthcare access, as well as related outcomes like health literacy and autonomy in health decision-making. Yet little causal evidence exists about whether changing educational policies can improve ANC coverage. This study fills this research gap by investigating the impact of national-level policies that eliminate tuition fees for lower secondary education in SSA on the number of ANC visits.

METHODS

To estimate the effect of women's exposure to tuition-free education policies at the primary and lower secondary levels on their ANC visits, a difference-in-difference methodology was employed. This analysis leverages the variation in the timing of education policies across nine SSA countries.

RESULTS

Exposure to tuition-free primary and lower secondary education is associated with improvements in the number of ANC visits, increasing the share of women meeting the WHO recommendation of at least four ANC visits by 6-14%. Moreover, the impact of both education policies combined is greater than that of tuition-free primary education alone. However, the effects vary across individual treatment countries, suggesting the need for further investigation into country-specific dynamics.

CONCLUSIONS

The findings of this study have significant implications for policymakers and stakeholders seeking to improve ANC coverage. Removing the tuition barrier at the secondary level has shown to be a powerful strategy for advancing health outcomes and educational attainment. As governments across Africa consider eliminating tuition fees at the secondary level, this study provides valuable evidence about the impacts on reproductive health outcomes. While investing in free education requires initial investment, the long-term benefits for both human development and economic growth far outweigh the costs.

Impact of laws prohibiting domestic violence on wasting in early childhood

Intimate partner violence (IPV) affects an estimated 641 million women and girls globally with far-reaching consequences for the health of women and children. Yet, laws that prohibit domestic violence (DV) are not universal. Countries actively debate the effectiveness of DV laws in improving conditions given the inconclusive evidence on deterrent effects within households particularly in low- and middle-income countries that have limited infrastructure, and fewer resources to implement and enforce policy changes. This is the first study to rigorously examine the impact of DV laws on women's health decision-making and the intergenerational impact on children's wasting, a key predictor of mortality. We used the Demographic and Health Surveys (DHS) data collected between 2000-2020 across 23 African countries. Exploiting the staggered adoption of laws, we used a difference-in-differences study design to estimate the impact of DV laws in the treated countries compared to countries without such laws. We find that DV laws increased women's decision-making autonomy in healthcare by 16.7% as well as other measures of women's autonomy that matter for health such as financial autonomy by 6.3% and social mobility by 11.0%. The improvements in women's autonomy translated into reductions in the probability of wasting among children aged 0-23 months by 5.4% points, a 30.9% reduction from the mean. DV laws also reduced wasting among older children aged 24-59 months by 3.6% points, a 38.7% reduction from the mean. The laws were effective in all 6 countries analyzed individually that criminalized DV. A civil prohibition in the seventh country was not found to be effective. The effect was positive and significant for all wealth and geographical categories. Our findings demonstrate the value of enacting criminal laws that prohibit domestic violence as one important tool to reducing the profound health impacts of IPV, a critical health and human rights issue.

The intergenerational effect of tuition-free lower-secondary education on children's nutritional outcomes in Africa

One in five child deaths under age 5 are a result of severe wasting. Malnutrition at early ages is linked to lifelong consequences, such as reduced cognitive skills, reduced earnings in adulthood and chronic health conditions. Countries worldwide have committed to addressing child undernutrition, and ending hunger is foundational to the Millennium Development Goals. In this paper, we study the intergenerational effect of providing free tuition in secondary school on future children's nutrition. We combined a novel longitudinal dataset that captures educational policies for 40 African countries from 1990 to 2019 with the Demographic and Health Survey (DHS). We identified three countries that introduced free secondary education several years after implementing free primary education. Exploiting this variation in timing we estimate the additional impact of providing free secondary education over free primary education. Using a difference-in-difference approach, we find that introducing free secondary education significantly reduced wasting. Cohorts exposed to free secondary had an 18% relative decrease in wasting. The impact on cohorts exposed only to free primary was smaller and not statistically significant. Expanding free secondary education has long-term, intergenerational benefits and is an effective path to reducing malnutrition. Results are robust to different specifications.

Impacts of the COVID-19 Lockdown on Healthcare Inaccessibility and Unaffordability in Uganda

Several studies have reported adverse consequences of the COVID-19 lockdowns on the utilization of healthcare services across Africa. However, little is known about the channels through which lockdowns impacted healthcare utilization. This study focuses on unaffordability as a reason for not utilizing healthcare services. We estimate the causal impacts of the COVID-19 lockdown on healthcare inaccessibility and affordability in Uganda relative to the nonlockdown periods of the pandemic. We use nationally representative longitudinal household data and a household fixed-effects model to identify the impact of the lockdown on whether households could not access medical treatment and whether the reason for not getting care was the lack of money. We find that the lockdown in Uganda was associated with an 8.4% higher likelihood of respondents being unable to access healthcare when treatment was needed relative to the nonlockdown periods. This implies a 122% increase in the share of respondents unable to access healthcare. As lockdown restrictions eased, the likelihood of being unable to access medical treatment decreased. The main reason for the increase in inaccessibility was the lack of money, with a 71% increase in the likelihood of respondents being unable to afford treatment. We find little evidence that the effects of the lockdown differed by wealth status or area of residence. Our results indicate the need for policymakers to consider immediate social support for households as a strategy for balancing the disruptions caused by lockdowns.

Private pharmacies as healthcare providers in Odisha, India: analysis and implications for universal health coverage

INTRODUCTION

In India, as in many low-income and middle-income countries, the private sector provides a large share of health care. Pharmacies represent a major share of private care, yet there are few studies on their role as healthcare providers. Our study examines: (1) What are the characteristics of and services provided by private pharmacies and how do these compare with other outpatient care providers? (2) What are the characteristics of patients who opted to use private pharmacies? (3) What are the reasons why people seek healthcare from private pharmacies? (4) What are the quality of services and cost of care for these patients? Based on our findings, we discuss some policy implications for universal health coverage in the Indian context.

METHODS

We analyse data from four surveys in Odisha, one of India's poorest states: a household survey on health-seeking behaviours and reasons for healthcare choices (N=7567), a survey of private pharmacies (N=1021), a survey of public sector primary care facilities (N=358), and a survey of private-sector solo-providers (N=684).

RESULTS

17% of the households seek outpatient care from private pharmacies (similar to rates for public primary-care facilities). 25% of the pharmacies were not registered appropriately under Indian regulations, 90% reported providing medical advice, and 26% reported substituting prescribed drugs. Private pharmacies had longer staffed hours and better stocks of essential drugs than public primary-care facilities. Patients reported choosing private pharmacies because of convenience and better drug stocks; reported higher satisfaction and lower out-of-pocket expenditure with private pharmacies than with other providers.

CONCLUSION

This is the first large-scale study of private pharmacies in India, with a comparison to other healthcare providers and users' perceptions and experiences of their services. To move towards universal health coverage, India, a country with a pluralistic health system, needs a comprehensive health systems approach that incorporates both the public and private sectors, including private pharmacies.

The Great Recession and Physical Activity of Young Adults

Objective. Since physical inactivity has been identified as a pandemic and a public health priority, it is crucial to understand the role of adverse economic shocks on physical activity. In this study, we examine the impact of job losses during the U.S. Great Recession from January 2008 to June 2009 on the likelihood of physical activities of young adults. Methods. We use individual fixed effects estimation on a nationally representative longitudinal data from 2005 to 2015, the Panel Study of Income Dynamics (PSID), to examine the impact of job losses of young adults, their spouses, and their parents on physical exercise of young adults aged 18 to 27 years. Results. Own job losses during the Great Recession led to a decrease in the likelihood of physical exercise among young adults. However, job losses of parents and partners had no effect on the likelihood of young adults' physical exercise. Conclusion. Our findings indicate a negative impact of the recession on physical activity of young adults and highlights the need for policymakers to consider the impact of major economic downturns on the physical activity of young adults.

Stepping into adulthood during a recession: Did job losses during the Great Recession impact health of young adults?

This is the first study to comprehensively examine the impact of job losses during the Great Recession on mental health, physical health, health behavior, and risky health behavior of young adults (ages 18-27). We employ U.S. longitudinal data with individual fixed effects to control for time-invariant factors that may bias the results. We find that job losses during the recession of young adults living by themselves led to increased onset of doctor-diagnosed mental health problems and worries related to jobs. Poorer individuals suffered more from increased worries, obesity, and binge drinking. In contrast, for those living with their parents, job loss of young adults did not negatively affect their own health. Instead, fathers' job losses led to worse mental health, physical health, and health behavior for young adults. Overall, the results suggest that when living on their own, young adults were responsible for their households' livelihood, and consequently, own job losses led to stress and negative health outcomes. However, when living with parents, they were financially reliant on their parents. Therefore, own job losses did not affect health, but job losses of fathers, the primary income earners for most households, worsened the health of young adults.

Catastrophic Health Expenditure on Private Sector Pharmaceuticals: A Cross-Sectional Analysis from the State of Odisha, India

India has high rates of catastrophic health expenditure (CHE): 16% of Indian households incur CHE. To understand why CHE is so high, we conducted an in-depth analysis in the state of Odisha—a state with high rates of public sector facility use, reported eligibility for public insurance of 80%, and the provision of drugs for free in government-run facilities—yet with the second-highest rates of CHE across India (24%). We collected household data in 2019 representative of the state of Odisha and captured extensive information about healthcare seeking, including the facility type, its sector (private or public), how much was spent out-of-pocket, and where drugs were obtained. We employ Shapley decomposition to attribute variation in CHE and other financial hardship metrics to characteristics of healthcare, controlling for health and social determinants. We find that 36.3% (95% uncertainty interval: 32.7–40.1) of explained variation in CHE is attributed to whether a private sector pharmacy was used and the number of drugs obtained. Of all outpatient visits, 13% are with a private sector chemist, a similar rate as public primary providers (15%). Insurance was used in just 6% of hospitalizations and its use explained just 0.2% (0.1–0.4) of CHE overall. Eighty-six percent of users of outpatient care obtained drugs from the private sector. We estimate that eliminating spending on private drugs would reduce CHE by 56% in Odisha. The private sector for pharmaceuticals fulfills an essential health system function in Odisha—supplying drugs to the vast majority of patients. To improve financial risk protection in Odisha, the role currently fulfilled by private sector pharmacies must be considered alongside existing shortcomings in the public sector provision of drugs and the lack of outpatient care and drug coverage in public insurance programs.

Clinical phenotypes of cardiac sarcoidosis by latent class analysis

Background

Sarcoidosis is a systemic granulomatous disease with cardiac involvement reported in 20–27% of patients [1]. Cardiac sarcoidosis (CS) can lead to atrial or ventricular arrhythmias, various conduction system disorders, heart failure or sudden cardiac death, depending on the location of myocardial involvement [2]. Previous studies have investigated the possible types of CS based on the distribution of myocardial involvement on imaging as well as the role of genetic factors [3,4]. However, there are no studies describing the clinical heterogeneity of CS patients.

Purpose

In order to determine if clinical clusters exist in CS, we carried out a latent class analysis (LCA) to explore potential phenotypes in a large sample of CS patients from the National Inpatient Sample (NIS).

Methods

We identified 848 patients with a diagnosis of CS from the NIS in 2016–2018. A LCA was performed based on comorbidities. Utilizing the Bayesian information criterion and Akaike's information criterion we divided our study population into 3 cohorts. We subsequently applied the LCA model for our study population to fit each patient into one of the 3 cohorts. Finally, we compared the clinical outcomes among the 3 groups.

Results

Following LCA, patients in cohort 3 were strongly associated with a cardiometabolic syndrome profile with the highest prevalence of congestive heart failure (CHF, 95.1%), chronic kidney disease (CKD, 69.7%), diabetes mellitus (68.9%), hyperlipidemia (52.5%) and obesity (45.1%). Patients in cohort 2 had an intermediate prevalence of cardiometabolic syndrome with a universal diagnosis of hypertension (100%) but with the lowest number of CHF (32.5%) patients and none with CKD. Finally, patients in cohort 1 had the least comorbidities in comparison to the other groups but there was a higher prevalence of CHF (71.7%). There was no significant difference in mortality among the 3 groups, but acute respiratory failure was the highest in cohort 3. However, ventricular arrhythmias were more prevalent in cohort 1 patients (Table).

Conclusion

We identified 3 different types of CS based on their clinical phenotype. The clinical outcomes varied among the cohorts with ventricular arrhythmias being the most prevalent in patients with the least cardiometabolic comorbidities.

Funding Acknowledgement

Type of funding sources: None.

Legislative approaches to nondiscrimination at work: a comparative analysis across 13 groups in 193 countries

Purpose

There is substantial evidence of discrimination at work across countries and powerful evidence that antidiscrimination laws can make a difference. This study examines the extent of protections from discrimination at work in countries around the world and which groups were best covered.

Design/methodology/approach

This study assesses legal protections in hiring, pay, promotions/demotions, terminations and harassment for 13 different groups across 193 countries using a database the authors created based on analysis of labor codes, antidiscrimination legislation, equal opportunity legislation and penal codes. Differences in levels of protection were examined across social groups and areas of work, as well as by country income level using Chi-square tests.

Findings

Protection from gender and racial/ethnic discrimination at work was the most common, and protection across migrant status, foreign national origin, sexual orientation and gender identity was among the least. For all groups, discrimination was more often prohibited in hiring than in promotion/demotion. There was inconsistent protection from harassment and retaliation.

Research limitations/implications

Addressing discrimination at work will require a broad range of synergistic approaches including guaranteeing equal legal rights, implementation and enforcement of laws and norm change. This study highlights where legislative progress has been made and where major gaps remain.

Originality/value

This article presents findings from an original database containing the first data on laws to prevent discrimination in the workplace in all 193 countries around the world. The study analyzes legal protections for a wide range of groups and considers a full range of workplace protections.

Postpartum atypical hemolytic uremic syndrome: Evaluating thrombotic microangiopathy in the pregnant woman

Acute kidney injury in women during pregnancy and the puerperium is often ascribed to hypertensive complications of pregnancy, especially pre-eclampsia. However, rarer causes, including atypical hemolytic uremic syndrome (aHUS) can be triggered by pregnancy. We present a case of a woman with post-partum acute kidney injury due to aHUS, which was successfully treated with the C5a inhibitor eculizumab. We also present a summary of the evaluation and management of thrombotic microangiopathy in pregnancy.

Improving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms

Evidence that gender inequalities and restrictive norms adversely affect health is extensive; however, far less research has focused on testing solutions. We first comprehensively reviewed the peer-reviewed and grey literature for rigorously evaluated programmes that aimed to reduce gender inequality and restrictive gender norms and improve health. We identified four mutually reinforcing factors underpinning change: (1) multisectoral action, (2) multilevel, multistakeholder involvement, (3) diversified programming, and (4) social participation and empowerment. Following this review, because little research has investigated the effects of national-level law and policy reforms, we conducted original quasi-experimental studies on laws and policies related to education, work, and income, all social determinants of health in which deep gender inequalities exist. We examined whether the laws and policies significantly affected health outcomes and gender norms, and whether law-induced and policy-induced changes in gender norms mediated the health effects, in areas for which longitudinal data existed. Laws and policies that made primary education tuition-free (13 intervention countries with the law and/or policy and ten control countries without) and that provided paid maternity and parental leave (seven intervention and 15 control countries) significantly improved women's and their children's health (odds ratios [OR] of 1·16-2·10, depending on health outcome) and gender equality in household decision making (OR 1·46 for tuition-free and 1·45 for paid maternity and parental leave) as a proxy indicator of gender norms. Increased equality partially mediated the positive effects on health outcomes. We conclude by discussing examples of how improved governance can support gender-equitable laws, policies, and programmes, immediate next steps, and future research needs.

Solid pseudopapillary tumour of pancreas

Solid pseudopapillary tumour of pancreas (SPT) is an extremely rare pancreatic tumour, which has a low malignant potential and occurs mainly in young women. Pathologic and imaging findings include a well defined encapsulated pancreatic mass with cystic and solid components with evidence of haemorrhage. This is a case of a 16 years old girl who presented with upper abdominal pain of long duration and epigastric mass on palpation. Computed Tomography (CT) scan demonstrated a large well defined heterogenous attenuation mass of solid enhancing and cystic non enhancing areas, arising from the head of the pancreas. Radiologically it was diagnosed as a case of pancreatic neoplasm. Fine needle aspiration cytology (FNAC) and histopathology of the biopsy material diagnosed as solid pseudopapillary tumour of pancreas.

Light induced toxicity of merocyanine 540-silica nanoparticle complex

The electrostatic binding between the negatively charged lipophilic dye Merocyanine 540 and silica nanoparticles having 3-amino propyl groups at the surface has been characterized using absorption and fluorescence spectroscopy. The binding of the dye with the nanoparticle resulted in significant changes in its absorption spectra. Further the fluorescence intensity and lifetime gets enhanced by more than an order of magnitude. The results obtained suggest that this is due to the reduced photoisomerization rate of the dye bound to the nanoparticle. Consistent with the expectation that a reduction in the photoisomerization rate should enhance the singlet oxygen yield of the dye via intersystem crossing, the light induced toxicity of the dye-nanoparticle complex (tested with MCF cells) was observed to be higher compared to the free dye.

SilkSatDb: a microsatellite database of the silkworm, Bombyx mori

The SilkSatDb (silkmoth microsatellite database) (http://www.cdfd.org.in/silksatdb) is a relational database of microsatellites extracted from the available expressed sequence tags and whole genome shotgun sequences of the silkmoth, Bombyx mori. The database has been rendered with a simple and robust web-based search facility, developed using PHP. The SilkSatDb also stores information on primers developed and validated in the laboratory. Users can retrieve information on the microsatellite and the protocols used, along with informative figures and polymorphism status of those microsatellites. In addition, the interface is coupled with Autoprimer, a primer-designing program, using which users can design primers for the loci of interest.

Clipping of cerebral aneurysm under hypothermic cardiac arrest and simultaneous coronary artery bypass grafting: case report

This report describes a case where joint neurological and cardiac surgery teams cooperated to perform simultaneous procedures of clipping a complex internal carotid artery under hypothermic cardiac arrest and coronary artery bypass grafting. A 69 year old man was evaluated for complaints of double vision, pain behind his right eye, and progressively worsening headaches. Examination showed bilateral upgoing toes and difficulty performing a tandem gait. The patient had a history of myocardial infarction. Brain MRI showed a 1.6 cm diameter, partially thrombosed aneurysm of the right internal carotid artery and posterior communicating artery. Cardiac catheterisation showed critical coronary artery disease of the distal segment of the right coronary artery with 90% stenosis of the midcircumflex artery and an ejection fraction of 40%. After initial exposure of the aneurysm, the cardiac team instituted hypothermic cardiac arrest (21 degree C). The aneurysmal sac was collapsed and dissected from the surrounding perforators. An encircling fenestrated clip was applied and a small part of the neck of the aneurysm was further clipped with straight clips. The cardiac surgery team performed the coronary artery bypass grafting procedure. The patient recovered fully, returned to his normal activities, and is functioning independently.

Induction of phr gene expression in E. coli strain KY706/pPL-1 by He-Ne laser (632.8 nm) irradiation

We have observed that He-Ne laser irradiation of E. coli strain KY706/pPL-1 leads to induction of photolyase gene, phr. The magnitude of induction was found to depend on the He-Ne laser fluence, fluence rate and post-irradiation incubation period in the nutrient medium. The optimum values for fluence and fluence rate were 7x10(3) J/m(2) and 100 W/m(2), respectively, and the induction of phr gene was observed to saturate beyond an incubation period of approximately 2 h. Experiments carried out with singlet oxygen quenchers and with D(2)O suggest that the effect is mediated via singlet oxygen. Photoreactivation studies carried out after UVC exposure of both the He-Ne laser-exposed as well as unexposed cells showed a larger surviving fraction in the He-Ne laser pre-irradiated cells. This can be attributed to He-Ne laser irradiation-induced induction of phr expression. However, since even without photoreactivating light He-Ne laser pre-irradiated cells show higher survival against UVC radiation it appears that He-Ne laser irradiation induces both light-dependent as well as dark DNA repair processes.

Absorption and accumulation of nitrate in plants: influence of environmental factors

Plants adopt various strategies to fulfill their nitrogen nutrition requirement, the most important being the uptake of nitrate from the soil and its subsequent assimilation in to amino acids. The uptake of nitrate is energy dependent and is an active process involving high affinity and low affinity transport systems. The net uptake of the anion depends upon both influx as well as on its passive efflux. When the uptake far exceeds over its assimilation in the plant, there is considerable accumulation of nitrate in the plant parts making them unfit for human and cattle consumption. Various environmental factors affect the uptake and accumulation of nitrate, which along with the genetic component of the plant affecting the net uptake and accumulation of the nitrate, need to be considered and carefully manipulated for effective nitrogen management in the plant, soil and aquatic environment.

Anterior cervical instrumentation enhances fusion rates in multilevel reconstruction in smokers

This retrospective consecutive case study evaluated the effect of anterior plating on multilevel anterior cervical decompressions and fusions in smokers and non-smokers. Multilevel anterior cervical decompression and fusion surgery in smokers provides an important challenge. Higher nonfusion rates in smokers have been reported. Cigarette smoking has been shown to interfere with bone metabolism and revascularization and to suppress bone formation. One hundred six patients underwent anterior cervical decompression and fusion using autografts or allografts and anterior plating. The minimum follow-up was 12 months. The mean age was 50.12 years (+/- 11.72; range, 27 to 80 years). Autografts were used in 90 patients and allograft in 16. The mean level fused was 2.74 (+/- 0.61). Forty-six (45.5%) patients were smokers. Successful fusion was achieved in all but three patients (97.17%). C5 root weakness was seen in four patients (3.8%); two patients experienced acute airway obstruction, of which one required tracheotomy. Temporary recurrent laryngeal nerve palsy developed in three (2.8%) patients. A fusion rate of 97% was achieved in multilevel anterior cervical decompression and fusions using anterior plating. No difference in fusion rates between smokers and nonsmokers was seen. Anterior cervical plating markedly improved the fusion rate in smokers.

Outcomes after posterolateral lumbar fusion with instrumentation in patients treated with adjunctive pulsed electromagnetic field stimulation

Fusion success and clinical outcome were determined in 48 high-risk patients who underwent posterolateral lumbar fusions with internal fixation and were treated with adjunctive pulsed electromagnetic field (PEMF) stimulation postoperatively. An independent radiographic assessment demonstrated a success rate of 97.9%. Following treatment, 59% of the working patients returned to their employment. Overall clinical assessment was excellent in 4.2% of patients, good in 79.2%, and fair in 16.7%; no patient had a poor clinical assessment.

N2 laser-induced oxidation of hemoproteins in red blood cell lysate

Irradiation of red blood cell lysate with a N(2) laser (337 nm) was observed to induce oxidation of hemoproteins. This process showed a strong dependence on the concentration of red blood cell lysate and the dose of radiation. Studies of mechanisms and experiments with deoxygenated red blood cell lysate rule out involvement of any reactive oxygen species and suggest that the process is not a photodynamic reaction.

Activation of expression of the c-fos oncogene by UVA irradiation in cultured human skin fibroblasts

Both broad-spectrum and near-monochromatic (334 nm, 365 nm and 405 nm) UVA (320-380 nm) and near-visible radiations strongly activate accumulation of mRNA corresponding to the nuclear oncogene and transcription factor, c-fos, in cultured human skin fibroblasts within a dose-range encountered in the environment. The oxidizing component of UVA is clearly of central importance to the activation observed because the absence of reduced glutathione strongly enhances the response. In contrast to observations in rodent cells, we observe negligible activation of the gene in human cells after UVB (290-320 nm) radiation. The results of this study provide evidence that UVA radiation strongly activates c-fos gene expression in human dermal fibroblasts, a phenomena that is likely to be reflected in UVA-mediated modulation of genes containing active AP-1-based enhancer elements in the promoter region.

An overview of cerebral aneurysms. Which factors affect the outcome of microsurgical treatment

There is a higher incidence of subarachnoid hemorrhage (SAH) with advancing age. Considerable controversy exists as to whether aggressive therapy is indicated in the elderly. With increased life expectancy, a greater number of elderly patients with SAH will require treatment in the future. This study was undertaken to evaluate the effect of age, aneurysm characteristics, Hunt-Hess grade on admission, race, and smoking status to the eventual outcome. The results of 76 consecutive aneurysms clipped in 67 patients by a single surgeon (B.B.) were analyzed. Among the variables, Hunt-Hess grade at admission seemed to be the only significant factor influencing the outcome in this series (X2MH = 17.136, p < 0.001). Advancing age did not worsen the prognosis after SAH and therefore age should not be a contraindication for aggressive management.

Catalytic mechanism and specificity for hydrolysis and transglycosylation reactions of cytosolic beta-glucosidase from guinea pig liver

Cytosolic beta-glucosidase (CBG) from mammalian liver is known for its broad substrate specificity and has been implicated in the transformation of xenobiotic glycosides. CBG also catalyzes a variety of transglycosylation reactions, which have been been shown with other glycosylhydrolases to function in synthetic and genetic regulatory pathways. We investigated the catalytic mechanism, substrate specificity, and transglycosylation acceptor specificity of guinea pig liver CBG by several methods. These studies indicate that CBG employs a two-step catalytic mechanism with the formation of a covalent enzyme-sugar intermediate and that CBG will transfer sugar residues to primary hydroxyls and equatorial but not axial C-4 hydroxyls of aldopyranosyl sugars. Kinetic studies revealed that correction for transglycosylation reactions is necessary to derive correct kinetic parameters for CBG. Further analyses revealed that for aldopyranosyl substrates, the activation energy barrier is affected most by the presence of a C-6 carbon and by the configuration of the C-2 hydroxyl, whereas the binding energy is affected modestly by the configuration and substituents at C-2, C-4, and C-5. These data indicate that the transglycosylation activity of CBG derives from the formation of a covalently linked enzyme-sugar intermediate and that the specificity of CBG for transglycosylation reactions is different from its specificity for hydrolysis reactions.

Anterior cervical fusion using Caspar plating: analysis of results and review of the literature

BACKGROUND

Ninety-seven patients underwent anterior cervical fusions after discectomy and/or corpectomy. Fibular allograft was used in 13 cases and iliac crest was used in the remaining 84 patients.

METHODS

Lateral cervical spine X-rays were reviewed for evaluation of fusion and instrumentation failures.

RESULTS

Solid fusion was achieved in all but two patients (97.91%). Nineteen patients developed instrumentation related failures. Seven patients developed fracture of one screw each (one superior and six inferior). Ten patients developed screw back out (inferior screw) and in one patient the superior screws were found to be 2 mm posterior to the posterior cortex but did not cause any neurological deficits. Seven of these patients underwent revision surgery. No complications related to the instrumentation were encountered in the last 34 cases. There were no infections in this series. Five patients developed temporary dysphagia. Two developed temporary deltoid weakness and three patients developed transient recurrent laryngeal nerve palsy. One developed acute airway obstruction but the patient had a pre-existing epiglottic anomaly and sleep apnea disorder.

CONCLUSIONS

In selected cases, the Caspar plating system affords an effective means of improving the fusion rate (97.91%) with acceptable instrumentation-related morbidity that improves with experience, (10.7% in the first 38 cases and 1.69% in the last 59 with an overall rate of 7.2%). Temporary neurological deficits seen in this series were probably not related to the Caspar plating procedure itself. Intraoperative fluoroscopic films can be misleading. Therefore regular lateral cervical spine X-rays postplating in the operating room prior to closure are recommended. Lower screws backed out in all failures and this was circumvented by using the bigger (rescue) screws at the inferior end of long constructs.

Correlation between UVA-induced changes in microviscosity, permeability and malondialdehyde formation in liposomal membrane

The lipid peroxidation, 14C-glucose leakage and microviscosity of liposomal membrane increased linearly with increasing UVA fluence. A positive and highly significant correlation was found between these properties of the UVA-exposed liposomal membrane. The possible involvement of singlet oxygen in the UVA-induced damage of liposomal membrane is discussed.

On the induction of protective responses in Salmonella typhimurium strain TA1535/pSK1002 by UVA (365 nm)

Exposure to UVA (365 nm) led to growth delay, loss of viability and inhibition of 3H-thymidine incorporation into the cells of Salmonella typhimurium strain TA1535 containing multiple copies of a plasmid pSK1002 carrying a umuC'-'lacZ fusion gene. Ultraviolet-A induced umu gene expression, as monitored by the estimation of beta-galactosidase, in a linear fluence-dependent manner. The induction of umu gene expression increased with the increase of postirradiation incubation period of the cells in the LB-ampicillin (LBA) medium at 37 degrees C and leveled off from 2 h onward. The induction of gene expression depended on concomitant protein synthesis and represented the induction of the SOS response in the particular S. typhimurium cells used. The exposure to low fluences (sublethal) of UVA also led to the induction of an adaptive response in the same bacterial cells, which made them resistant to subsequent challenge by a much higher fluence of the same radiation. The adaptive response, as monitored by the assays of viability and beta-galactosidase units, increased with the period of exposure to sublethal fluences of UVA, attained a maximum at the UVA exposure of 4.5 kJ/m2 (15 min) and thereafter gradually decreased with further increase of UVA exposure period. Modulation studies involving D2O, LBA growth medium, different scavengers of free radicals and quenchers of activated oxygen species indicated the involvement of both hydroxyl free radicals and singlet oxygen in the UVA-induced umu gene expression.

UVA-induced peroxidation of lipid in the dried film state

Exposure of a dried lipid thin film to UVA produced a dose-dependent linear increase in the three peroxidation products, conjugated diene, lipid hydroperoxide and malondialdehyde (MDA). All three lipid peroxidation products exhibited an inverse dose rate effect. Identical amounts of malondialdehyde were produced when the lipid film was exposed to UVA either directly or through the thickness of the Corning glass on which the film was cast. Antioxidants, alpha-tocopherol, butylated hydroxytoluene (BHT) and the singlet oxygen quencher beta-carotene significantly inhibited the UVA-induced peroxidation of the lipid film. The biological implications of the UVA-induced peroxidation of the dried lipid film are discussed.

Effect of UV-A on the linolenic acid micelles

UV-A produced a dose-dependent linear increase of peroxidation in linolenic acid micelles as detected by the assay of (i) conjugated dienes, (ii) hydroperoxides, (iii) malondialdehyde (MDA), and (iv) the fluorescent adduct formed by the reaction of MDA with the amino acid, glycine. While sodium formate, dimethyl sulfoxide, superoxide dismutase, and ethylenediamine-tetraacetic acid produced no significant inhibition, some generally used singlet oxygen quenchers, beta-carotene, dimethylfuran, L-histidine, and sodium azide, caused significant inhibition of the UV-A-induced peroxidation of the linolenic acid micelles. alpha-Tocopherol and butylated hydroxytoluene produced more than 90% inhibition of the UV-A-induced peroxidation. ESR spectrometry revealed the formation of 2,2,6,6-tetramethylpiperidine oxide in the UV-A-irradiated aqueous solution of 2,2,6,6-tetramethylpiperidine. The involvement of singlet oxygen (1O2) in the UV-A-induced peroxidation of linolenic acid micelles is discussed.

An audit of preschool vision screening

An audit was carried out to clarify the dispute surrounding the vision screening test at 3.5 years. The uptake was 53.5%, sensitivity 77%, specificity 96%, and positive predictive value 50%. In particular the uptake was poor and the test needed a clear policy for the future.

Membrane lipid peroxidation by UV-A: mechanism and implications

UV-A produced a dose-dependent linear increase of lipid peroxidation in liposomal membrane, as detected by the assay of (i) conjugated dienes, (ii) lipid hydroperoxides, (iii) malondialdehydes (MDA), and (iv) the fluorescent adducts formed by the reaction of MDA with glycine and also a linear dose-dependent increase of [14C]glucose efflux from the liposomes. UV-A-induced MDA production could not be inhibited by any significant degree by sodium formate, dimethyl sulfoxide, EDTA, or superoxide dismutase but was very significantly inhibited by butylated hydroxytoluene, alpha-tocopherol, sodium azide, L-histidine, dimethylfuran, and beta-carotene. MDA formation increased with an increase in the D2O content in water, leading to a maximal amount of nearly 50% enhancement of lipid peroxidation in 100% D2O vis-à-vis water used as dispersion medium. The experimental findings indicate the involvement of singlet oxygen as the initiator of the UV-A-induced lipid peroxidation.

An approach towards understanding the genesis of sunlight-induced skin cancer

The molecular basis of the sunlight-induced skin carcinogenesis has been elucidated. Of the two ultraviolet components of sunlight that reach the earth's surface the UV-B is known to be carcinogenic but the mode of action of UV-A, the predominant component of sunlight, is ill understood. Using the liposomes as a model system, it has been shown here that UV-A causes dose-dependent lipid peroxidation as estimated by measurements of conjugated dienes, lipid hydroperoxides, malondialdehydes and the fluorescent adducts (Schiff bases) produced by the reaction of MDA with glycine. Direct exposure to sunlight has also been shown to cause dose-dependent lipid peroxidation. The UV-A induced lipid peroxidation has also been shown to be dependent on dose rate. While the sodium formate, dimethyl sulphoxide, superoxide dismutase and EDTA do not have any significant effect, sodium azide, histidine, beta-carotene and dimethylfuran were shown to inhibit significantly the UV-A induced lipid peroxidation, thereby providing significant evidence of the involvement of singlet oxygen (1O2) as the initiating agent. The use of D2O in place of H2O as the liposome dispersing medium enhanced to great extent the UV-A induced lipid peroxidation, thereby lending additional support to the finding that singlet oxygen was the initiating agent. The possible mode of formation of 1O2 on exposure to UV-A was discussed. This study also highlighted the role of environmental factors on the sunlight-induced cutaneous damage. Finally, the relation between lipid peroxidation, DNA damage and carcinogenesis has been discussed in a way to suggest the possible link between sunlight exposure and causation of skin cancer.

CO2 reactivity and heterogeneity of cerebral blood flow in ischemic, border zone, and normal cortex

Regional arterial CO2 tension (PaCO2) reactivity of cerebral blood flow (CBF) and the effect of PaCO2 on the spatial and temporal heterogeneity of CBF were investigated by using autoradiographically determined CBF in the rat middle cerebral artery occlusion model after a 2-h period under pentobarbital anesthesia to clarify the relation between PaCO2 reactivity, CBF heterogeneity, and the temporal cycling of CBF. PaCO2 was adjusted to one of four levels. CBF was determined in four cortical areas and white matter using the tissue fractionation of [14C]iodoantipyrine [( 14C]IAP) in combination with vessel mapping using in vivo 4% thioflavine S. Specific PaCO2 reactivity and CBF were normal in the nonischemic cortex, normal, although slightly depressed, in the border zone far from the ischemic core area, and depressed in the border zone adjacent to the ischemic core area (P less than 0.001) and the ischemic core (P less than 0.001). In normocapnic and hypocapnic animals, CBF heterogeneity in the form of regularly spaced CBF columns perpendicular to the cortical surface was observed in the nonischemic hemisphere but was absent in the ischemic core area. In hypercapnic rats, flow columns were present in the ischemic core areas and border zones but were absent on the nonischemic side. There was a highly significant interaction (P less than 0.0001) in observer-determined heterogeneity grades between PaCO2 level and each of three areas, normal, border zone, and ischemic core. In normal cortex, comparison of the thioflavine S-stained vessels with the flow columns provided evidence supporting the concept of capillary recruitment and cycling as a mode of normal cerebral blood flow control. The presence of flow columns in severely ischemic areas in hypercapnic animals indicates that a short period of high PaCO2 transiently augments microregional flow and could enhance the delivery of a therapeutic agent to these microregions of the ischemic core. The regional analysis of PaCO2 reactivity suggests an index of future tissue viability.

Evolving focal cerebral ischemia in cats: spatial correlation of nuclear magnetic resonance imaging, cerebral blood flow, tetrazolium staining, and histopathology

The spatial correlation of nuclear magnetic resonance imaging (NMRI) and cerebral blood flow (CBF) may improve our ability to identify ischemic brain lesions and may provide further insight into the pathophysiology of early cerebral ischemia. Eleven pentobarbital-anesthetized adult cats underwent exposure of the common carotid arteries bilaterally and the right middle cerebral artery through a transorbital approach. Baseline NMRI images were obtained with a single spin-echo, multislice technique using a 0.6-T field, 0.4-cm slice thickness, and a surface coil. Focal ischemia was produced with right middle cerebral artery occlusion and potentiated with bilateral common carotid artery ligation. Sequential NMRI studies were then performed at 1, 2, 4, 6, and 12 hours or until CBF was determined in the same cats using [14C]iodoantipyrine at either 2 (n = 2), 4 (n = 2), 6 (n = 2), or 12 (n = 1) hours after the time of occlusion. This protocol allowed temporal and spatial correlation of NMRI and CBF. Alternate 5-mm brain slices were incubated with 1% 2,3,5-triphenyltetrazolium chloride (TTC) for 45 minutes at 37-41 degrees C and frozen in liquid Freon for later autoradiographic CBF determination. Four cats were studied only with NMRI and TTC (not CBF). The correlation between areas of increased NMRI signal intensity observed in T2-weighted images (repetition time 2,000 msec, echo time 120 msec), vital staining with TTC, low CBF, and routine histology was evaluated. During the early phase (less than 6 hours), T2-weighted NMRI changes were localized to the central ischemic gray matter areas, as defined in the later CBF images, with no involvement of the white matter. By the twelfth hour the NMRI changes involved the entire ischemic area including gray and white matter. The initial visible changes seen on T2-weighted NMRI are suggestive of cellular edema, and the later changes are characteristic of vasogenic edema. The spread of NMRI changes compared with the ischemic area determined from autoradiographic CBF is consistent with the previously described biphasic evolution of ischemic injury. These data suggest that T2-weighted NMRI could be used clinically to delineate areas of acute ischemic stroke.

A once daily theophylline preparation in prevention of nocturnal symptoms in childhood asthma

Twenty school children with chronic asthma who despite regular prophylactic therapy continued to have troublesome nocturnal wheeze or cough entered a double-blind cross-over study in which a once daily theophylline preparation was compared with placebo to assess control of these symptoms. Seventeen children completed both phases of the study. Significant improvement was noted in the day and night symptom scores, the morning dip index and daily peak flow readings with a significant reduction in rescue bronchodilator inhaler usage during the active treatment period. Satisfactory serum theophylline concentrations were obtained 11-12 h post dose in all children using a standard dose of 18 mg/kg per day at 2000 hours. Three children were withdrawn because of minor side-effects. The theophylline preparation studied in conjunction with other conventional anti-asthma therapy was thus effective in controlling nocturnal symptoms.

Small intestinal permeability in pediatric clinical practice

Passive permeability of small intestine to lactulose and mannitol was studied in children suspected of having intestinal disease, using a hypertonic differential sugar absorption test. Children with coeliac disease and cows' milk intolerance were shown to have an elevated urinary lactulose/mannitol recovery ratio when compared with controls, children with normal jejunal biopsy, or children in whom alternative explanations for failure to thrive had been demonstrated. The abnormality in permeability ratio principally reflects a reduced urinary recovery of mannitol following oral administration. This study demonstrates that a hypertonic sugar absorption test is well tolerated even by young children, is practicable in routine clinical pediatric practice, and is capable of demonstrating abnormal intestinal function in children with small intestinal disease.

Features of di George syndrome in a child with 45,XX,-3,-22,+der(3),t(3;22)(p25;q11)

A child with an unbalanced translocation resulting in monosomy for chromosomes 22 (q11----pter) and 3(p25----pter) is described. Although no immunological dysfunction could be demonstrated, the abnormalities found are similar to those seen in the di George syndrome which has been associated with monosomy for the same region of chromosome 22.

Effects of nimodipine on acute focal cerebral ischemia

Nimodipine is a calcium slow channel blocker with several pharmacologic properties suggesting the potential to favorably modify outcome in focal cerebral ischemia. Thirty adult cats underwent unilateral middle cerebral artery (MCA) occlusion for 4 hours. Seventeen cats were treated with an ipsilateral intracarotid infusion of nimodipine (1 microgram kg-1 min -1) beginning 15 minutes before MCA occlusion and continuing throughout the occlusion period. Eight nimodipine treated cats maintaining MAP greater than 90 mmHg were assigned to a Higher Pressure Nimodipine (HPN) group. The remaining nine treated cats with MAP less than 90 mmHg were assigned to the Lower Pressure Nimodipine (LPN) group. Thirteen cats were untreated, receiving an isovolumetric amount of vehicle through the ipsilateral carotid artery. Local cerebral blood flow (ICBF) was continuously monitored using thermal diffusion probes. The brains, assessed for colloidal carbon perfusion, fluorescein and Evans blue staining, electroencephalographic activity (EEG), and histological changes, revealed no significant differences by any of these methods between the HPN and control animals with the exceptions of: HPN treated cats exhibited a preservation of EEG activity at 15 minutes post-occlusion compared to the untreated cats, and Post-ischemic surface colloidal carbon perfusion was better preserved in the treated cats than in the untreated cats. Mild hypotension, as demonstrated by the LPN group, negated these two positive effects. Prior to MCA occlusion, ICBF was bilaterally significantly increased after nimodipine infusion in the HPN group as compared to vehicle infusion. Intra-arterially infused nimodipine did not reduce infarct size.