Developing a spinal cord injury rehabilitation service in Madagascar

Rehabilitation for people with spinal cord injury in many low- and middle-income countries is not avail-able or is in the early stages of development. However, rehabilitation is recognized as crucial in order to optimize functional recovery and outcomes for patients with spinal cord injury. With an increasing incidence of spinal cord injury, the unmet need for rehabilitation is huge. This report describes the early development of a specialist rehabilitation service for spinal cord injury in Madagascar, one of the poorest countries in the world. The sustained input to an expanding rehabilitation team has led to reductions in avoidable complications. The input of the rehabilitation team has been welcomed by the neurosurgery department, which has recognized fewer delays in patients undergoing surgical treatments. Cost, lack of resources and trained staff, and poor understanding of disability continue to provide challenges. However, the development of the rehabilitation service using low technology, but with a high level of knowledge and systematic management, is a source of considerable pride. This development in Madagascar can be regarded as a model for spinal cord injury rehabilitation in other low-resource settings

Evaluating a global health partnership rehabilitation training programme in Madagascar.

Objective: Rehabilitation services play an important role in optimizing functional ability and societal integration for people with disabilities. The Madagascar Rehabilitation Programme (2011–2013) resulted from a global training partnership and led to 8 doctors achieving a university diploma in rehabilitation medicine. This paper describes a 2014 evaluation of the programme methods, results and learning points. Methods: A combination of qualitative methods was used for the evaluation, based on a Theory of Change model, with informants from Madagascar and the UK. Results: Malagasy trainees and UK volunteers gained new theoretical knowledge and practical skills. For Madagascar, it led to changes in working practice and the formation of a national rehabilitation association. Key to its success was the strong collaboration between Malagasy and UK professionals, with support from the University and Ministry of Health in Madagascar, and the UK partners. Having a clear common vision ensured the programme met the needs of the Malagasy clinicians. Conclusion: Rehabilitation is increasingly recognized as an important focus for international development. Successful rehabilitation training programmes can be achieved at modest costs with global health partnerships. The combination of factors that enabled this programme to be a success is reproducible in other contexts

Acceptability and usability of smartphone-based brainwave entrainment technology used by individuals with chronic pain in a home setting

Background: Brainwave entrainment (BWE) using rhythmic visual or auditory stimulation has many potential clinical applications, including the management of chronic pain, where there is a pressing need for novel, safe and effective treatments. The aim of this study was to gain qualitative feedback on the acceptability and usability of a novel BWE smartphone application, to ensure it meets the needs and wishes of end users. Methods: Fifteen participants with chronic pain used the application at home for 4 weeks. Semi-structured telephone interviews were then carried out. A template analysis approach was used to interpret the findings, with an initial coding template structured around the constructs of a theoretical framework for assessing acceptability of healthcare interventions. Structured data analysis generated a final modified coding structure, capturing themes generated across participants’ accounts. Results: The four main themes were ‘approach to trying out the app: affective attitude and ethicality’, ‘perceived effectiveness’, ‘opportunity costs and burden’ and ‘intervention coherence and self-efficacy’. All participants were willing to engage with the technology and welcomed it as an alternative approach to medications. Participants appreciated the simplicity of design and the ability to choose between visual or auditory stimulation. All the participants felt confident in using the application. Conclusion: The findings demonstrate preliminary support for the acceptability and usability of the BWE application. This is the first qualitative study of BWE to systematically assess these issues

Energy compensation following consumption of sugar-reduced products: a randomized controlled trial

PURPOSE: Consumption of sugar-reformulated products (commercially available foods and beverages that have been reduced in sugar content through reformulation) is a potential strategy for lowering sugar intake at a population level. The impact of sugar-reformulated products on body weight, energy balance (EB) dynamics and cardiovascular disease risk indicators has yet to be established. The REFORMulated foods (REFORM) study examined the impact of an 8-week sugar-reformulated product exchange on body weight, EB dynamics, blood pressure, arterial stiffness, glycemia and lipemia. METHODS: A randomized, controlled, double-blind, crossover dietary intervention study was performed with fifty healthy normal to overweight men and women (age 32.0 ± 9.8 year, BMI 23.5 ± 3.0 kg/m2) who were randomly assigned to consume either regular sugar or sugar-reduced foods and beverages for 8 weeks, separated by 4-week washout period. Body weight, energy intake (EI), energy expenditure and vascular markers were assessed at baseline and after both interventions. RESULTS: We found that carbohydrate (P < 0.001), total sugars (P < 0.001) and non-milk extrinsic sugars (P < 0.001) (% EI) were lower, whereas fat (P = 0.001) and protein (P = 0.038) intakes (% EI) were higher on the sugar-reduced than the regular diet. No effects on body weight, blood pressure, arterial stiffness, fasting glycemia or lipemia were observed. CONCLUSIONS: Consumption of sugar-reduced products, as part of a blinded dietary exchange for an 8-week period, resulted in a significant reduction in sugar intake. Body weight did not change significantly, which we propose was due to energy compensation

Systematic development of a self-regulation weight-management intervention for overweight adults

Background. This paper describes the systematic development of an intervention for the prevention of obesity among overweight adults. Its development was guided by the six steps of Intervention Mapping (IM), in which the establishment of program needs, objectives and methods is followed by development of the intervention and an implementation and evaluation plan. Methods. Weight gain prevention can be achieved by making small changes in dietary intake (DI) or physical activity (PA). The intervention objectives, derived from self-regulation theory, were to establish goal-oriented behaviour. They were translated into a computer-tailored Internet-delivered intervention consisting of four modules. The intervention includes strategies to target the main determinants of self-regulation, such as feedback and action planning. The first module is intended to ensure adults' commitment to preventing weight gain, choosing behaviour change and action initiation. The second and third modules are intended to evaluate behaviour change, and to adapt action and coping plans. The fourth module is intended to maintain self-regulation of body weight without use of the program. The intervention is being evaluated for its efficacy in an RCT, whose protocol is described in this paper. Primary outcomes are weight, waist circumference and skin-fold thickness. Other outcomes are DI, PA, cognitive mediators and self-regulation skills. Discussion. The IM protocol helped us integrating insights from various theories. The performance objectives and methods were guided by self-regulation theory but empirical evidence with regard to the effectiveness of theoretical methods was limited. Sometimes, feasibility issues made it necessary to deviate from the original, theory-based plans. With this paper, we provide transparency with regard to intervention development and evaluation. Trial registration. NTR1862

Uptake of the Necrotic Serpin in Drosophila melanogaster via the Lipophorin Receptor-1

The humoral response to fungal and Gram-positive infections is regulated by the serpin-family inhibitor, Necrotic. Following immune-challenge, a proteolytic cascade is activated which signals through the Toll receptor. Toll activation results in a range of antibiotic peptides being synthesised in the fat-body and exported to the haemolymph. As with mammalian serpins, Necrotic turnover in Drosophila is rapid. This serpin is synthesised in the fat-body, but its site of degradation has been unclear. By “freezing” endocytosis with a temperature sensitive Dynamin mutation, we demonstrate that Necrotic is removed from the haemolymph in two groups of giant cells: the garland and pericardial athrocytes. Necrotic uptake responds rapidly to infection, being visibly increased after 30 mins and peaking at 6–8 hours. Co-localisation of anti-Nec with anti-AP50, Rab5, and Rab7 antibodies establishes that the serpin is processed through multi-vesicular bodies and delivered to the lysosome, where it co-localises with the ubiquitin-binding protein, HRS. Nec does not co-localise with Rab11, indicating that the serpin is not re-exported from athrocytes. Instead, mutations which block late endosome/lysosome fusion (dor, hk, and car) cause accumulation of Necrotic-positive endosomes, even in the absence of infection. Knockdown of the 6 Drosophila orthologues of the mammalian LDL receptor family with dsRNA identifies LpR1 as an enhancer of the immune response. Uptake of Necrotic from the haemolymph is blocked by a chromosomal deletion of LpR1. In conclusion, we identify the cells and the receptor molecule responsible for the uptake and degradation of the Necrotic serpin in Drosophila melanogaster. The scavenging of serpin/proteinase complexes may be a critical step in the regulation of proteolytic cascades

Earliest evidence for the ivory trade in southern Africa : isotopic and ZooMS analysis of seventh-tenth century AD ivory from KwaZulu-Natal

KwaGandaganda, Ndondondwane and Wosi were major Early Farming Community settlements in what is today the KwaZulu-Natal province of South Africa. These sites have yielded, among other remains, abundant evidence of ivory and ivory working dating to the seventh–tenth centuries ad, pre-dating by approximately 200 years the better-known ivory artefacts from sites in the Limpopo River Valley and surrounding regions. We report the results of carbon, nitrogen and strontium isotope analysis to explore the origins and procurement of this ivory, in combination with Zooarchaeology by Mass Spectrometry (ZooMS) to identify the species of animals from which it was derived. All of the ivory studied using ZooMS was elephant, despite the presence of hippopotamus remains on all three sites. Some ivory was probably obtained from elephant herds that lived close to the sites, in the densely wooded river valleys favoured by both elephants and early farmers. Other material came from savannah environments further afield. Ivory found at these three sites was drawn from different catchments, implying a degree of landscape/resource partitioning even at this early stage. These communities clearly invested substantial effort in obtaining ivory from across the region, which speaks to the importance of this commodity in the economy of the time. We suggest that some ivory items were for local use, but that some may have been intended for more distant markets via Indian Ocean trade

The Ionizing Radiation-Induced Bystander Effect: Evidence, Mechanism, and Significance

It has long been considered that the important biological effects of ionizing radiation are a direct consequence of unrepaired or misrepaired DNA damage occurring in the irradiated cells. It was presumed that no effect would occur in cells in the population that receive no direct radiation exposure. However, in vitro evidence generated over the past two decades has indicated that non-targeted cells in irradiated cell cultures also experience significant biochemical and phenotypic changes that are often similar to those observed in the targeted cells. Further, nontargeted tissues in partial body-irradiated rodents also experienced stressful effects, including oxidative and oncogenic effects. This phenomenon, termed the “bystander response,” has been postulated to impact both the estimation of health risks of exposure to low doses/low fluences of ionizing radiation and the induction of second primary cancers following radiotherapy. Several mechanisms involving secreted soluble factors, oxidative metabolism, gap-junction intercellular communication, and DNA repair, have been proposed to regulate radiation-induced bystander effects. The latter mechanisms are major mediators of the system responses to ionizing radiation exposure, and our knowledge of the biochemical and molecular events involved in these processes is reviewed in this chapter

A saturated map of common genetic variants associated with human height

Common single-nucleotide polymorphisms (SNPs) are predicted to collectively explain 40-50% of phenotypic variation in human height, but identifying the specific variants and associated regions requires huge sample sizes(1). Here, using data from a genome-wide association study of 5.4 million individuals of diverse ancestries, we show that 12,111 independent SNPs that are significantly associated with height account for nearly all of the common SNP-based heritability. These SNPs are clustered within 7,209 non-overlapping genomic segments with a mean size of around 90 kb, covering about 21% of the genome. The density of independent associations varies across the genome and the regions of increased density are enriched for biologically relevant genes. In out-of-sample estimation and prediction, the 12,111 SNPs (or all SNPs in the HapMap 3 panel(2)) account for 40% (45%) of phenotypic variance in populations of European ancestry but only around 10-20% (14-24%) in populations of other ancestries. Effect sizes, associated regions and gene prioritization are similar across ancestries, indicating that reduced prediction accuracy is likely to be explained by linkage disequilibrium and differences in allele frequency within associated regions. Finally, we show that the relevant biological pathways are detectable with smaller sample sizes than are needed to implicate causal genes and variants. Overall, this study provides a comprehensive map of specific genomic regions that contain the vast majority of common height-associated variants. Although this map is saturated for populations of European ancestry, further research is needed to achieve equivalent saturation in other ancestries.A large genome-wide association study of more than 5 million individuals reveals that 12,111 single-nucleotide polymorphisms account for nearly all the heritability of height attributable to common genetic variants

Delays to accessing healthcare and rehabilitation following trauma in Madagascar – a qualitative study

Purpose: To explore the factors affecting access to timely trauma care and rehabilitation in Madagascar. Materials and methods: A qualitative study based in the outpatient departments of two large rehabilitation centres. Semi-structured interviews and focus groups were conducted with 12 patients or family members and 11 healthcare professionals. Interviews and focus groups were conducted with a local interpreter and were audio-recorded and transcribed. The data were analysed deductively with thematic content analysis, utilising the Health Care Access Barriers model. Results: Participants experienced delays in deciding to seek treatment, accessing healthcare facilities and in receiving appropriate treatment. Cognitive barriers included understanding and awareness of healthcare, structural barriers included distance and transportation to health facilities, financial barriers included affordability of healthcare and difficulty accessing funds. Conclusions: Delays to accessing healthcare may result in increased mortality and disability following trauma, as well as increased financial burden. Addressing the acceptability of services should be a focus for future service development, through training and education schemes. More importantly, improving both physical and financial accessibility of services must be a long-term priority. These findings may help to guide the ongoing development of trauma and rehabilitation pathways in Madagascar. IMPLICATIONS FOR REHABILITATION: Delays in accessing timely trauma care and rehabilitation can lead to complications such as pain, infection, malunion of fractures and loss of function, with devastating financial and social consequences for patients and their families. The acceptability of services is a key barrier to accessing hospital care and may be targeted through training schemes for healthcare professionals and education for the public. Improving the physical and financial accessibility of services in the long-term is paramount. Consideration should be given to these issues in the future development of co-ordinated trauma care and rehabilitation pathways in Madagascar