A micro-costing analysis of nutritional support for persons with TB and their families in India.

Undernutrition is the leading risk factor for TB infection and death in India. We undertook a micro-costing analysis of a nutritional intervention for household contacts of people living with TB in Puducherry, India. We found that the total 6-month food cost for a family of four was USD4/day. We also identified several alternative regimens and cost-lowering strategies to encourage wider adoption of nutritional supplementation as a public health tool.

La sous-nutrition est le principal facteur de risque d'infection et de décès dus à la TB en Inde. Nous avons entrepris une analyse de micro-coût d'une intervention nutritionnelle destinée aux contacts familiaux des personnes atteintes de la TB à Puducherry, en Inde. Nous avons constaté que le coût total de la nourriture pendant 6 mois pour une famille de quatre personnes était de 4 USD par jour. Nous avons également identifié plusieurs régimes alternatifs et stratégies de réduction des coûts pour encourager une adoption plus large de la supplémentation nutritionnelle en tant qu'outil de santé publique.

How much do Indians pay for tuberculosis treatment? A cost analysis.

SETTING: India's National Tuberculosis Elimination Programme (NTEP) covers diagnostic and therapeutic costs of TB treatment. However, persons living with TB (PLWTB) continue to experience financial distress due to direct costs (payment for testing, treatment, travel, hospitalization, and nutritional supplements) and indirect costs (lost wages, loan interest, and cost of domestic helpers). OBJECTIVE: To analyze the magnitude and pattern of TB-related costs from the perspective of Indian PLWTB. DESIGN: We identified relevant articles using key search terms ('tuberculosis,' 'India,' 'cost,' 'expenditures,' 'financing,' 'catastrophic' and 'out of pocket') and calculated variance-weighted mean costs. RESULTS: Indian patients incur substantial direct costs (mean: US$46.8). Mean indirect costs (US$666.6) constitute 93.4% of the net costs. Mean direct costs before diagnosis can be up to four-fold that of costs during treatment. Treatment in the private sector can result in costs up to six-fold higher than in government facilities. As many as one in three PLWTB in India experience catastrophic costs. CONCLUSION: PLWTB in India face high direct and indirect costs. Priority interventions to realize India's goal of eliminating catastrophic costs from TB include decreasing diagnostic delays through active case finding, reducing the need for travel, improving awareness and perception of NTEP services, and ensuring sufficient reimbursement for inpatient TB care.

Pancreatic Cancer Incidence, Mortality, and Survival in Puerto Rico, 2001-2015.

OBJECTIVE: To perform an epidemiologic profile of pancreatic cancer (PC) in Puerto Rico (PR) with data gathered from 2001 to 2015. METHODS: Using data from the PR Central Cancer Registry we estimated incidence and mortality rates and trends of PC in PR, and performed survival analyses. We also compared the age-standardized incidence and mortality rates of PC in people in PR with those of Hispanics, non-Hispanic whites, and non Hispanic blacks in the United States (US). RESULTS: From 2011 to 2015, 7.8 per 100,000 persons were diagnosed with PC in PR; higher rates were observed in men than in women (9.2 vs. 6.7 per 100,000, respectively) and in persons 65 years old and older (42.7 per 100,000 persons). For the same period, 6.7 per 100,000 persons died from PC; men and persons 65 years and older had higher mortality rates. Incidence and mortality trends of PC in PR increased from 2001-2015 (annual percent change [APC] = 3.8% and 1.9%, respectively (p<0.05). Lower risk of being diagnosed with and dying from PC was seen in PR than in members of several racial/ethnic groups in the US. The median survival time for PC cases diagnosed in PR during the period of 2008 to 2012 was 5.3 months. CONCLUSION: We observed increasing mortality rates and low survival in PC patients in PR. Research on access and response to treatment is needed to elucidate the reasons for the observed results and have a positive impact on PC burden and survival.

Epidemiology of Pancreatic Cancer in Puerto Rico (1987-2010): Incidence, Mortality and Survival.

BACKGROUND & OBJECTIVE: Pancreatic cancer is an uncommon type of cancer worldwide. Nonetheless, even with early diagnosis, mortality rates are high. This study aims to perform an epidemiologic profile of pancreatic cancer in Puerto Rico (PR) from 1987-2010. METHODS: Using data from the Puerto Rico Central Cancer Registry, age-standardized incidence and mortality rates of pancreatic cancer in PR were compared with Hispanics, non-Hispanic Whites, and non-Hispanic Blacks in the United States of America (USA). Incidence and mortality trends of pancreatic cancer were estimated, and survival analyses were also performed. RESULTS: In 2005-2010, 5.8 per 100,000 persons were diagnosed with pancreatic cancer in PR and mortality rates were similar. Pancreatic cancer was more frequent in men (6.5 per 100,000 men) than women (5.2 per 100,000 women), and in persons older than 65 years (32.0 per 100,000 persons). Moreover, the median survival for the people diagnosed with pancreatic cancer in PR during 2006-2007 was 4 months and at the end of the third year after diagnosis, only 13% of the patients survived. Incidence trends of pancreatic cancer showed an increase for men (APC=13.0%, p<0.05) from 2006 to 2010, but not for women (APC=-0.4, p>0.05). However, mortality trends showed a slight decrease for men (APC=-1.0%, p<0.05), but not for women (APC=1.4, p>0.05) in the period of 1987 to 2010. Meanwhile, Puerto Ricans in comparison to other racial/ethnic groups living in the USA showed a lower risk for being diagnosed and of dying from pancreatic cancer. CONCLUSION: Our results highlight the need for additional research in pancreatic cancer, in order to have an impact in disease survival in PR.

Morphometry of individual cerebellar lobules in schizophrenia.

OBJECTIVE: Previous imaging studies have described focal cortical changes in schizophrenia, with predominant findings of abnormalities in the temporal and frontal regions. The current study hypothesized that cerebellar regions involved in feedback and feed-forward loops with cortical regions affected in schizophrenia would also demonstrate structural changes. METHOD: Using magnetic resonance imaging, the authors measured the volume of individual cerebellar lobules in 19 patients with schizophrenia and 19 healthy comparison subjects. RESULTS: The inferior vermis was significantly smaller in the schizophrenic group than in the comparison group. Patients with schizophrenia also demonstrated a significantly smaller cerebellar asymmetry than the comparison subjects. CONCLUSIONS: The authors hypothesize that these morphometric changes may be developmental in origin and possibly related to cortical abnormalities.

Hippocampal volume in primary unipolar major depression: a magnetic resonance imaging study.

BACKGROUND: Previous studies have shown that major depression is frequently accompanied by hypercortisolemia. There is some evidence suggesting that an increase in the glucocorticoid levels may make hippocampal cells more vulnerable to insults caused by hypoxia, hypoglycemia, or excitatory neurotransmitters. Using magnetic resonance imaging (MRI), the hippocampi of patients with major depression were measured and compared with values observed in control subjects. METHODS: Thirty-eight patients with primary unipolar major depression were recruited. Twenty control subjects were matched for age, gender, and years of education. The hippocampal volume was measured from coronal MRI scans in all of the subjects. Patients were also grouped and compared as responders and nonresponders to treatment with fluoxetine of 20 mg/day, for 8 weeks. Hamilton Depression Rating Scale (HDRS) was used to determine the severity of depression. RESULTS: No significant differences were observed between the hippocampal volumes of patients with major depression and control subjects; however, a significant correlation was observed between the left hippocampal volume of men and their HDRS baseline values. In addition, female responders had a statistically significant higher mean right hippocampal volume than nonresponders. CONCLUSIONS: The results of our study indicate no reduction in the volume of the hippocampus in patients with major depression. Nonetheless, the results do suggest that the effects of disease severity, gender, and treatment response may influence hippocampal volume.

CxGELSIX: a novel preparation of type VI collagen with possible use as a biomaterial.

PURPOSE: This study was initiated to evaluate tissue acceptance and stability of a novel type VI collagen preparation (CxGelsix) as a biomaterial in the rabbit corneal stroma. We hypothesized that CxGelsix, embedded intrastromally, does not have any adverse affect on surrounding corneal tissues, and remains intact in the presence of an acute inflammatory reaction during corneal wound healing. METHODS: Type VI collagen was extracted and purified from rabbit corneal stroma under nondenaturing conditions. This preparation, Gelsix, was concentrated and cross-linked with polyethylene glycol to produce a transparent film (CxGelsix). Discs of CxGelsix, 4.0-mm diameter, 9- to 35-microm thick were implanted intrastromally and clinically examined periodically for 4 months. In another experiment, implantation of CxGelsix, 2.0-mm-diameter, was followed by corneal wounding adjacent to the implant and examined clinically for 30 weeks. At the end of these periods, the tissues from these experiments were processed for light and transmission electron microscopy. RESULTS: An intralamellar 4.0-mm-diameter disc of CxGelsix does not alter the structure of corneal epithelium above the implant, suggesting normal transport of nutrients through CxGelsix. Moreover, no structural abnormalities were seen in the rest of the cornea, and the cornea remains transparent. Although the cornea accepts the presence of CxGelsix disc as judged by clinical criteria, gradual degradation of the implant is seen ultrastructurally. CxGelsix is remarkably stable despite its exposure to endogenous enzymes during inflammation and wound healing. Partial degradation of the implant occurs only after many months, and it is gradually replaced with bundles of fine collagen fibrils reminiscent of normal cornea. CONCLUSION: The results of this study suggest that CxGelsix is potentially useful as a biomaterial.

mRNA levels of alpha1(VI) collagen, alpha1(XII) collagen, and beta ig in rabbit cornea during normal development and healing.

PURPOSE: Type VI and XII collagens and beta ig, major components of the interfibrillar matrix, may maintain proper spacing among collagen fibrils, necessary for corneal transparency. During normal corneal stroma development and healing, changes in mRNA levels of these proteins were measured to determine whether differences in steady state levels are indicative of the unique structure produced by each corneal tissue. METHODS: A full-thickness excision wound was made in each cornea of six adult rabbits and allowed to heal for 1, 2, or 4 weeks. Scar tissue from two rabbits (four scars) were used from each time period and processed for RNA extraction. Total RNA from 23-day-old fetal rabbit corneas (equivalent to approximately 1 week of stromal development) and 8-day-old neonate corneas (equivalent to approximately 3.5 weeks of stromal development) was also extracted. Relative quantities of alpha1(VI) collagen, alpha1(XII) collagen, beta ig, and beta-actin mRNAs were determined by competitive reverse transcriptase-polymerase chain reaction. Glyceraldehyde-3-phosphate dehydrogenase was used as a housekeeping gene. RESULTS: Increased mRNA levels for alpha1(VI) and alpha1(XII) collagens, beta ig, and beta-actin were seen during the first 2 weeks of healing and were followed by a decrease in 4-week-old scars. Similar increases were seen in fetal corneas with a further increase in the neonate. Differences in the beta ig mRNA levels relative to that of alpha1(XII) collagen in fetal stroma and in comparison with 1-week-old wounds suggest a higher production of beta ig in early healing tissue. CONCLUSIONS: Alterations of mRNA levels during healing and development are consistent with the cellular events and deposition of extracellular matrices in these corneal tissues. Assuming that extracellular matrix protein production is regulated at the transcriptional level, relative changes in beta ig and collagen mRNA levels reflect differences in protein deposition in early fetal and healing tissues. This is consistent with differences in the organization of the interfibrillar matrices of these tissues and their transparency.

Repair phenotype in corneal fibroblasts is controlled by an interleukin-1 alpha autocrine feedback loop.

PURPOSE: To explore the role of autocrine interleukin-1 alpha (IL-1 alpha) as a central regulator of the repair phenotype in corneal fibroblasts. METHODS: Disruption of the actin cytoskeleton with cytochalasin B (CB), which mimics changes in shape that occur in repair tissues, was used to stimulate repair gene expression in early-passage fibroblasts. Changes in expression of IL-1 alpha, IL-8, collagenase, and ENA-78 were determined by Northern blot analysis, radioimmunoassay, and an enzyme-amplified sensitivity immunoassay (EASIA). Expression of repair genes was also examined in repair fibroblasts, isolated from healing, penetrating keratectomy wounds in rabbits. RESULTS: Blocking IL-1 alpha activity prevented both constitutive and stimulated increases in synthesis of IL-8 and collagenase in early-passage cultures of corneal fibroblasts, demonstrating the role of IL-1 alpha as a necessary intermediate for expression of these genes. Evidence is also presented that the IL-1 alpha autocrine controls expression of an IL-8 related factor, ENA-78. Unlike early-passage fibroblasts, fibroblasts freshly isolated from the uninjured cornea did not express IL-1 alpha. However, fibroblasts freshly isolated from remodeling corneal repair tissue 3 weeks after injury were found to express substantial levels of IL-1 alpha, regulated through an autocrine feedback loop. Neutralization experiments demonstrated that the IL-1 alpha autocrine is largely responsible for controlling both collagenase and IL-8 synthesis in repair fibroblasts, as it is in early-passage fibroblasts. CONCLUSIONS: These findings provide evidence that activation of an autocrine IL-1 alpha feedback loop is an important mechanism by which fibroblasts adopt a repair phenotype during remodeling of the cornea.

Beta-ig. Molecular cloning and in situ hybridization in corneal tissues.

PURPOSE: To identify a protein that copurifies with type VI collagen from rabbit cornea and to determine its cell source in rabbit corneal tissues by in situ hybridization. METHODS: Type VI collagen was extracted from cornea with urea and purified by ammonium sulfate precipitation and gel chromatography. The purity of the collagen was assessed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). On reduction with mercaptoethanol or dithiothreitol, the alpha chains of type VI collagen ran into the gel. In addition to the type VI collagen polypeptides, an extra 68-kDa protein band appeared, suggesting that this protein is present as a large molecular weight component before reduction. Amino acid sequencing indicated that protein was related to beta ig-h3 from humans. Western blot analysis was used to determine immunologic similarity to this human protein. A rabbit stromal cell cDNA library was screened with human beta ig-h3 cDNA probe. Positive clones were sequenced and analyzed for sequence homology. Oligonucleotide probes prepared from rabbit cDNA sequences were used for Northern blot analysis and in situ hybridization of corneal tissues. RESULTS: Electroblotting of the SDS-PAGE and amino acid sequence analysis of the first 10 N-terminal amino acids of the 68-kDa band gave 100% homology with a known protein produced by human adenocarcinoma cells, beta ig-h3. This 68-kDa protein was identical immunologically to beta ig-h3 by Western blot analysis. Sequence analysis of a rabbit cDNA clone contained the whole coding region and had high identity with both human beta ig-h3 and mouse beta ig-m3. The deduced amino acid sequence had 92% identity with these species. An oligonucleotide probe from the rabbit cDNA sequence detected a single band of mRNA from cultures of stromal cells consistent in size with human beta ig-h3 mRNA. The authors refer to the rabbit form of beta ig-h3 as beta ig because the protein was obtained from normal rabbit cornea and the mRNA comes from primary cultures of rabbit stromal cells and not from a cloned cell line. In situ hybridization of rabbit corneal tissue indicated that the beta ig mRNA is located primarily in the epithelium of normal adult cornea, in fetal stromal cells, and both endothelium- and stroma-derived cells in healing corneal wounds. Normal adult endothelium and stroma did not show beta ig mRNA label. CONCLUSIONS: The highly conserved amino acid sequence homology between the human, mouse, and rabbit proteins and the temporal expression of beta ig message during corneal healing and development suggest this protein plays an important role in the morphogenesis of corneal tissues.

Beta ig-h3 is synthesized by corneal epithelium and perhaps endotheliumin Fuchs' dystrophic corneas.

PURPOSE: Deposition of abnormal sub-epithelial matrix and posterior collagenous layer by epithelium and endothelium, respectively, in Fuchs' dystrophy gives us the opportunity to determine if these tissues synthesize beta ig-h3. METHODS: Immunohisto-/immunocytochemistry of corneas were conducted with rabbit anti-human beta ig-h3 and monoclonal anti-human type VI collagen. Labeled sense and anti-sense beta ig-h3 oligonucleotide probes were used for in situ hybridization. RESULTS: beta ig-h3-specific fluorescence was found just beneath detached epithelium in the sub-epithelial matrix, abnormal Descemet's membrane and posterior collagenous layer. Type VI collagen co-localized with beta ig-h3 within abnormal sub-epithelial matrix and corneal stroma adjacent to Descemet's membrane. beta ig-h3 mRNA was detected in corneal epithelium of dystrophic corneas. CONCLUSIONS: Expression of beta ig-h3 in sub-epithelial matrix and posterior collagenous layer of Fuchs' dystrophy is consistent with the synthesis of new extracellular matrices by epithelial and endothelial tissues. beta ig-h3 mRNA in corneal epithelium further supports an epithelial source of this protein. Endothelial synthesis of beta ig-h3 is based on circumstantial evidence due to cell loss during surgical and histological procedures. Co-localization of beta ig-h3 with type VI collagen in abnormal sub-epithelial matrix and at the stromal/Descemet's membrane interface suggest this collagen in association with beta ig-h3 interacts with these tissues and anchors them to the adjacent stroma.

Transplanted corneal stromal cells in vitreous reproduce extracellular matrix of healing corneal stroma.

PURPOSE: To characterize the extracellular matrix (ECM) formed by corneal stromal cells after injection into the vitreous. This will provide a basis for future studies on the function of corneal ECM macromolecules. METHODS: Cell line from rabbit dermal fibroblasts (RAB9) and primary cultures of rabbit corneal stroma fibroblasts (NRCF) were grown to confluence. For each cell type, approximately 1 x 10(6) cells suspended in basal medium were injected into the vitreous of normal rabbits and observed periodically with a slit lamp. After 1,2, and 4 weeks, eyes were processed for transmission electron microscopy (TEM), immunohistochemistry, immunocytochemistry, and in situ hybridization. RESULTS: All cells showed gradual growth within the vitreous along the needle track. Occurrence of retinal detachment and inflammation was variable. Transmission electron microscopy of NRCF confirmed the deposition of ECM reminiscent of the organization of normal fetal corneal stroma. Similar matrices were produced by RAB9. NRCF deposited collagen fibrils similar in diameter to those seen in normal developing and healing corneal stroma. RAB9 produced collagen fibrils with larger diameters. NRCF-transplanted cells synthesized proteoglycans and collagen immunologically identical to decorin proteins and type VI collagen, indicating that the expression of specific ECM is maintained after transplantation. In addition, in situ hybridization showed that type XII collagen mRNA is synthesized by transplanted NRCF similar to healing corneas. CONCLUSIONS: Corneal stromal cells transplanted into vitreous produce a matrix morphologically and biochemically similar to that in healing corneal stroma.

Stratified squamous epithelia produce mucin-like glycoproteins.

The stratified squamous epithelia of the ocular surface, larynx, and vagina are mucus-coated epithelia, apices of which are subject to abrasive pressure from epithelia-epithelia interactions from eyelid, vocal cords, or vaginal folds, respectively. Mucus coats on these epithelia have generally been considered to be derived from the specialized mucin-producing cells embedded either in the epithelia or in adjacent tissues. Here we report the isolation, partial characterization, and cellular localization of a mucin-like glycoprotein produced by these stratified epithelia. In all three epithelia, the mucin-like molecule is present on cytoplasmic vesicles in subapical cells. As cells differentiate to their apical-most position adjacent to their mucus coat, the mucin-like molecule moves to the cell membrane where it is particularly prominent on microplicae folds. Lectin affinity chromatography was used to isolate the molecule from rat vaginal and corneal epithelium. Isolated material was approximately 60% carbohydrate and 40% protein. The major monosaccharide was N-acetylgalactosamine with lesser amounts of N-acetylglucosamine, galactose, mannose, xylose and fucose. Amino acid analysis demonstrated the predominant amino acids to be glycine, serine, threonine and proline. These data plus PAS and Alcian blue binding to the isolate indicate a mucin-like glycoprotein.

Localization of type XII collagen in normal and healing rabbit cornea by in situ hybridization.

To identify the cell types responsible for type XII collagen synthesis in normal and healing rabbit cornea, a partial cDNA sequence of rabbit type XII collagen, obtained from an adult rabbit cornea cDNA library, was used to develop highly specific oligonucleotide probes for Northern blot analysis and in situ hybridization. Approximately 2000 bases of a type XII collagen 2.2 kb cDNA clone were sequenced. Comparative sequence analysis of the bases showed a 74% identity with chick alpha 1 (XII) chain of type XII collagen. The deduced amino acid sequence indicated a 72% identity with chick type XII collagen. Northern blot analysis showed that cultures of cornea stromal and endothelial cells each contain two RNA species, greater than 10 kb, that hybridize to rabbit type XII collagen oligonucleotide probes. Although normal stromal cells failed to show type XII collagen mRNA, normal endothelial cells contain mRNA for this collagen. These results indicate that endothelium of normal rabbit cornea has a potential to synthesize type XII collagen. During corneal wound healing, both endothelium-derived and stroma-derived cells in the developing scar tissue contained type XII mRNA. In view of the known presence of type XII collagen in corneal stromas from chick and mouse, the distribution of mRNA in normal cornea is puzzling.

Cloning and in situ hybridization of rabbit decorin in corneal tissues.

PURPOSE: To develop molecular probes and to identify the cell types responsible for decorin synthesis in healing cornea. METHODS: Adult rabbit cornea and rabbit corneal stromal cell (keratocyte) culture cDNA libraries were constructed. The libraries were screened with commercially available human cDNA and oligonucleotide probes. Positive clones were sequenced to obtain a full length rabbit decorin cDNA. Synthetic oligonucleotides for rabbit decorin were chosen as probes for Northern blot analysis and in situ hybridization of healing rabbit corneas. RESULTS: The cDNA sequences of the positive clones from the two libraries were identical in areas of overlap. The combined cDNA sequence indicated a 1.5-kb length with a complete open reading frame for decorin. The cDNA and deduced amino acid sequences are 90% and 88% identical, respectively, to previously reported human fibroblast and bovine bone decorin sequences. A hypervariable region near the N-terminal has little homology to decorins of other species or other rabbit protein. Northern blot analysis detected a 2.0-kb and a 2.3-kb band in mRNA from rabbit keratocyte cultures. Decorin mRNA was detected in keratocytes of normal and healing rabbit corneas by in situ hybridization. Label in the healing tissue was markedly increased above normal. Normal endothelium and epithelium in normal and healing cornea failed to show label. CONCLUSIONS: Decorin mRNA from normal adult rabbit cornea is identical to decorin mRNA from keratocytes in culture and is highly homologous to decorin from other animal species. In situ hybridization indicated an upregulation of decorin message in cells adjacent to and within the healing tissue. Both stroma-derived and endothelium-derived cells in the wound synthesize message for decorin.

Structure of corneal scar tissue: an X-ray diffraction study.

Full-thickness corneal wounds (2 mm diameter) were produced in rabbits at the Schepens Eye Research Institute, Boston. These wounds were allowed to heal for periods ranging from 3 weeks to 21 months. The scar tissue was examined using low- and wide-angle x-ray diffraction from which average values were calculated for 1) the center-to-center collagen fibril spacing, 2) the fibril diameter, 3) the collagen axial periodicity D, and 4) the intermolecular spacing within the collagen fibrils. Selected samples were processed for transmission electron microscopy. The results showed that the average spacing between collagen fibrils within the healing tissue remained slightly elevated after 21 months and there was a small increase in the fibril diameter. The collagen D-periodicity was unchanged. There was a significant drop in the intermolecular spacing in the scar tissues up to 6 weeks, but thereafter the spacing returned to normal. The first-order equatorial reflection in the low-angle pattern was visible after 3 weeks and became sharper and more intense with time, suggesting that, as healing progressed, the number of nearest neighbor fibrils increased and the distribution of nearest neighbor spacings reduced. This corresponded to the fibrils becoming more ordered although, even after 21 months, normal packing was not achieved. Ultrastructural changes in collagen fibril density measured from electron micrographs were consistent with the increased order of fibril packing measured by x-ray diffraction. The results suggest that collagen molecules have a normal axial and lateral arrangement within the fibrils of scar tissue. The gradual reduction in the spread of interfibrillar spacings may be related to the progressive decrease in the light scattered from the tissue as the wound heals.