Health system barriers and enablers to early access to breast cancer screening, detection, and diagnosis: a global analysis applied to the MENA region.

OBJECTIVES: To identify barriers and enablers that impact access to early screening, detection, and diagnosis of breast cancer both globally and more specifically in the Middle East and North Africa (MENA) region (with a specific focus on Egypt, Jordan, Oman, Saudi Arabia, United Arab Emirates [UAE], and Kuwait) with a specific focus on the health system. STUDY DESIGN: A systematic review of literature. METHODS: We conducted a systematic reviewing using the PRISMA methodology. We searched PubMed, Global Index Medicus, and EMBASE for studies on 'breast cancer', 'breast neoplasm,' or 'screening, early detection, and early diagnosis' as well as key words related to the following barriers: religion, culture, health literacy, lack of knowledge/awareness/understanding, attitudes, fatalism/fear, shame/embarrassment, and physician gender from January 1, 2000 until September 1, 2016. Two independent reviewers screened both titles and abstracts. The application of inclusion and exclusion criteria yielded a final list of articles. A conceptual framework was used to guide the thematic analysis and examine health system barriers and enablers to breast cancer screening at the broader macro health system level, at the health provider level, and the individual level. The analysis was conducted globally and in the MENA region. RESULTS: A total of 11,936 references were identified through the initial search strategy, of which 55 were included in the final thematic analysis. The results found the following barriers and enablers to access to breast cancer screening at the health system level, the health provider level, and the individual level: health system structures such as health insurance and care coordination systems, costs, time concerns, provider characteristics including gender of the provider, quality of care issues, medical concerns, and fear. In addition, the following seven barriers and enablers were identified at the health system or provider level as significantly impacting screening for breast cancer: (1) access to insurance, (2) physician recommendation, (3) physician gender, (4) provider characteristics, (5) having a regular provider, (6) fear of the system or procedure, and (7) knowledge of the health system. More specifically, the largest increased odds for having a mammogram was from having insurance, having a physician recommendation, type of provider (mainly gynecologist), and having regular contact with a physician. Clinical breast examinations were increased by having insurance and having regular contact with a physician. The eight studies identified from the MENA region identified barriers to breast cancer screening related to service quality, fear of pain and of cancer itself, female versus male provider, having a physician recommend the screen, cost issues as well as time and convenience of the services. CONCLUSIONS: There are a number of system changes that can be made to remove barriers to breast cancer screening. Some of these system changes apply directly to MENA countries. A larger health system assessment of a country is warranted to determine which health system changes should be made to most efficiently and effectively improve access to breast cancer screening.

Isolated node engineering of neuronal systems using laser direct write.

Current limitations to the engineering of ex vivo and in vitro neural environments are hampering the ability to understand underlying neurophysiology. High levels of spatial specificity, reproducibility and viability have been previously reported using laser direct write (LDW) to print cells. However, despite the significant need no one has yet reported laser assisted printing of primary mammalian neuronal cells, an inherently sensitive but critically important population. Herein, we describe the use of LDW to reproducibly and accurately pattern viable dorsal root ganglion (DRG) neurons and supportive cells capable of neural outgrowth and network formation. Our demonstrated ability to engineer and control distinct micro-environmental components unlocks the potential for high throughput experiments to both understand underlying physiology and investigate therapeutic interventions.

Tobacco availability and point of sale marketing in demographically contrasting districts of Massachusetts.

OBJECTIVE: To assess the prevalence and characteristics of tobacco sales and point-of-sale promotions and advertising in predominantly Latino business districts, and in comparison districts; and the economic importance of tobacco sales and marketing to Latino owned small businesses. DESIGN: Observational surveys of retail establishments and interviews with store managers. SETTING: Demographically contrasting business districts of eastern Massachusetts. MAIN OUTCOME MEASURES: Percentage of businesses selling tobacco, numbers and characteristics of exterior and interior tobacco advertisements per store, merchant reports of promotional allowances received from tobacco distributors. RESULTS: The proportion of businesses selling tobacco, and hence having storefront tobacco advertising, is strongly negatively correlated with per capita income in the census tracts where businesses are located (Spearman's rho = -0.794, p = 0.006). Mentholated brands are marketed disproportionately in low income, urban communities. Latino merchants are highly dependent on tobacco sales, but would require relatively modest compensation to forego tobacco promotional allowances. CONCLUSIONS: Storefront tobacco advertising is far more prevalent in predominantly minority, low income communities than in non-minority, higher income communities, principally because of the differing mix of kinds of businesses in the two types of communities, and the greater prevalence of tobacco vendors in lower income neighbourhoods. Tobacco companies obtain this advertising at little cost.

Pore-forming proteins and their application in biotechnology.

Proteins and peptides that form membrane-spanning pores and channels comprise a diverse class of molecules ranging from short peptides that are unregulated and create non-selective pathways to large ion channel proteins that are highly regulated and exhibit exquisite selectivity for particular ions. The diversity of regulation and selectivity, together with recent advances in protein "re-engineering" technology, provide a strong framework on which to build custom molecules with wide-ranging biotechnological application. Here we review a selection of pore-forming peptides and proteins from a number of different species to highlight their structural and functional diversity. The current and potential uses of native and re-engineered molecules are discussed together with a novel strategy to re-engineer alpha-hemolysin to create targeted and regulable cell-killing agents termed proimmunolysins. Numerous pore-forming peptides are currently in development as antimicrobial agents with potential application as anti-tumorigenic agents. In addition to their roles as biotherapeutic agents, pore-forming proteins are also being developed as biosensors for a range of different analytes. Recent examples of this technology include the use of alpha-hemolysin with an adapter molecule to create sensors for organic molecules and gramicidin as a general-purpose sensor for a range of analytes. These approaches promise to deliver a configurable binding site for analytes encoded in a readily measured electrical signal. The number of applications for pore-forming molecules is sure to grow in both quantity and diversity with increased knowledge of the fundamental structure and function of pores.

Gene transfer: manipulating and monitoring function in cells and tissues.

1. The ectopic expression of genes has proven to be an extremely valuable tool for biologists. The most widely used systems involve electrically or chemically mediated transfer of genes to immortalized cell lines and, at the other end of the spectrum, transgenic animal models. As would be expected, there are compromises to be made when using either of these broad approaches. Immortalized cell lines have limited "physiological relevance" and transgenic approaches are costly and out of the reach of many laboratories. There is also significant time required for the de novo generation of a transgenic animal. 2. As a viable alternative to these approaches, we describe the use of recombinant adenovirus and Sindbis virus to deliver genes to cells and tissues. 3. We exemplify this approach with studies from our laboratories: (i) an investigation of Ca2+ handling deficits in cardiac myocytes of hypertrophied hearts using infection with recombinant adenovirus encoding either green fluorescent protein (GFP) or the sarcoplasmic/endoplasmic reticulum calcium-ATPase (Serca2a); (ii) a study of the mechanism of macrophage/microglial migration by infection of embryonic phagocytes with a GFP-encoding virus and coculture with brain slices to then track the movement of labelled cells; and (iii) we are also exploiting the natural tropism of the Sindbis virus to label neurons in hippocampal brain slices in culture to resolve high-resolution structure and to map neuronal connectivity. 4. Further development of these approaches should open new avenues of investigation for the study of physiology in a range of cells and tissues.

Mutant GABA(A) receptor gamma2-subunit in childhood absence epilepsy and febrile seizures.

Epilepsies affect at least 2% of the population at some time in life, and many forms have genetic determinants. We have found a mutation in a gene encoding a GABA(A) receptor subunit in a large family with epilepsy. The two main phenotypes were childhood absence epilepsy (CAE) and febrile seizures (FS). There is a recognized genetic relationship between FS and CAE, yet the two syndromes have different ages of onset, and the physiology of absences and convulsions is distinct. This suggests the mutation has age-dependent effects on different neuronal networks that influence the expression of these clinically distinct, but genetically related, epilepsy phenotypes. We found that the mutation in GABRG2 (encoding the gamma2-subunit) abolished in vitro sensitivity to diazepam, raising the possibility that endozepines do in fact exist and have a physiological role in preventing seizures.

Taking antiretroviral therapy for HIV infection: learning from patients' stories.

OBJECTIVE: To describe how people with HIV understand and experience the problem of adhering to antiretroviral medication regimens. DESIGN: We performed a qualitative study based on interviews with HIV-infected patients, including 46 clients of AIDS service organizations, who were sampled according to age, ethnicity, and injection drug use history, and a convenience sample of 15 patients. Interviews were conducted in English or Spanish and were audiotaped and transcribed. PARTICIPANTS: Of 52 respondents who had prescriptions for antiretroviral therapy, 25 were randomly selected for in-depth analysis. Of these, 5 reported having an AIDS diagnosis, 15 reported symptoms they attributed to HIV, and 5 reported having no symptoms of HIV disease. MEASUREMENTS AND MAIN RESULTS: Investigators prepared structured abstracts of interviews to extract adherence-related data. One investigator compared the abstracts with the original transcripts to confirm the interpretations, and used the abstracts to organize and classify the findings. Most subjects (84%) reported recent nonadherent behavior, including ceasing treatment, medication "holidays," sleeping through doses, forgetting doses, skipping doses due to side effects, and following highly asymmetric schedules. Initially, most reported that they were not significantly nonadherent, and many did not consider their behavior nonadherent. Only a minority clearly understood the possible consequences of missing doses. Most said they had not discussed their nonadherence with their physicians. CONCLUSIONS: Many people rationalize their difficulty in adhering to HIV treatment by deciding that the standard of adherence they can readily achieve is appropriate. Physicians should inquire about adherence-related behavior in specific detail, and ensure that patients understand the consequences of not meeting an appropriate standard.

Genetically targeted calcium sensors enhance the study of organelle function in living cells.

1. Understanding the regulation of calcium (Ca2+), the most common of the mineral ions within the human body, has always been of extreme interest to physiologists. While the importance of Ca2+ in contributing to physiological events through regulation of levels has been significantly established, seldom is consideration given to the intricacies of this ion and its mechanics in producing such diverse physiological responses in different regions of the cell. 2. The present review will summarize new methodologies used in our laboratories for the study of two major intracellular organelles, mitochondria and the nucleus. These techniques are based predominantly on the use of molecular biological approaches to both create and then target protein-based sensor molecules to specific intracellular locations. 3. The regulation of Ca2+ in the mitochondria and nucleus is of particular interest to us because of the central involvement of these organelles in: (i) cardiac cell responses during ischaemia/reperfusion; and (ii) the control of gene expression, respectively.

Chloromethyl-X-rosamine (MitoTracker Red) photosensitises mitochondria and induces apoptosis in intact human cells.

We report that chloromethyl-X-rosamine (MitoTracker Red), a mitochondrion-selective fluorescent probe, has a strong photosensitising action. Photoirradiation of intact cells loaded with chloromethyl-X-rosamine induces depolarisation of the inner mitochondrial membrane and swelling of mitochondria, subsequently resulting in apoptosis. We have studied human osteosarcoma 143B TK-(rho+) cells and the derived (rho)0 206 cell line devoid of mitochondrial DNA. Colony formation tests revealed that chloromethyl-X-rosamine itself has no toxicity to either cell line in the concentration range 100-250 nM (unless photoirradiated). Chloromethyl-X-rosamine has potent phototoxicity such that almost quantitative cell killing was achieved at light doses of >2 J/cm2. These photodamaged cells initially showed swollen degenerative mitochondria and, later, uptake of propidium iodide in their apoptotic nuclei was observed. When cells were loaded with chloromethyl-X-rosamine (100 nM) and imaged by laser scanning confocal microscopy, photoirradiation by the laser beam under routine scanning conditions was sufficient to induce mitochondrial damage in both cell lines. This was evidenced by a rapid decrease of fluorescence intensity of co-loaded rhodamine 123 (indicative of mitochondrial depolarisation). Globular swelling of mitochondria took place within 15 minutes, imaged by the residual fluorescence of chloromethyl-X-rosamine itself, which also markedly decreased in intensity after imaging. Mitochondrial membrane depolarisation of cells loaded with chloromethyl-X-rosamine after photoirradiation using a measured dose of visible light was independently confirmed in 143B TK- and (rho)0 206 cells, by the significant decrease in uptake into cells of [3H]methyltriphenylphosphonium ions. Photoactivation of chloromethyl-X-rosamine in 143B TK-(rho+) cells, whose mitochondria had previously been loaded with calcein, caused rapid release of the mitochondrially entrapped calcein into the cytosol and nucleus. This major change in permeability of the mitochondrial inner membrane could not be prevented by cyclosporin A. Immunohistochemical study of cytochrome c revealed its diffuse redistribution into the cytoplasm in chloromethyl-X-rosamine-loaded cells after irradiation, as opposed to its specific mitochondrial localisation in non-irradiated cells. As a photosensitiser specifically targeted to mitochondria, and also a reporter of membrane potential and morphology, chloromethyl-X-rosamine may provide versatile new applications in studies of mitochondrial roles in cell death.

Induction of metallothionein and heme oxygenase in rats after inhalation of endotoxin.

Various stress proteins appear to play a role in injury and repair produced by inhaled pollutants. The present study examined the effect of inhaled endotoxin on the expression of the metallothionein and heme oxygenase genes. Rats were exposed to saline or endotoxin aerosols for 3 h and sacrificed up to 3 d following exposure. The significant induction of metallothionein mRNA in both the lung (fourfold increase) and liver (one-fold) were greatest at 3 h and returned to basal levels by 24 h after endotoxin exposure. Similarly, the increase in tissue metallothionein was greater in the lung. In situ hybridization in mice showed large increases in the relative abundance of metallothionein transcripts in epithelial cells of the conducting airways, in surrounding airway tissue, and in the nearby gas exchange region. While an endotoxin-induced significant increase in heme oxygenase mRNA followed a time course similar to that observed for metallo thionein, the relative magnitude was reversed for the lung and liver. Heme oxygenase mRNA was induced greater in the liver (twofold) than in the lung (60% above control). Our findings demonstrate that metallothionein and heme oxygenase are early response genes that are rapidly activated after inhalation of occupationally relevant concentrations of endotoxin.

Mitochondrial permeability transition and swelling can occur reversibly without inducing cell death in intact human cells.

Severe disruption of mitochondrial function is generally considered to provide a powerful trigger for apoptosis in mammalian cells. We report here that intact cells may undergo the mitochondrial permeability transition and mitochondria swell in a fully reversible manner, without inducing cell death. Cultured human osteosarcoma cells (143B TK-) stained with JC-1, MitoTracker dyes, or calcein plus Co2+ were imaged by confocal microscopy to visualize changes of mitochondrial membrane potential (DeltaPsim), morphology, and permeability transition, respectively, during treatment with a protonophore, carbonyl cyanide m-chlorophenylhydrazone (CCCP). Cells rapidly exhibited mitochondrial permeability transition and swelling after addition of CCCP, but the swelling subsided within hours, leaving mitochondria that appeared in punctate form, not filamentous as before CCCP treatment. Cyclosporin A impeded the permeability transition and swelling, although complete inhibition was not observed. Cells survived the dissipation of DeltaPsim by CCCP for up to 6 h without developing any obvious cell damage or signs of apoptosis. With the restoration of DeltaPsim after removal of CCCP (following 6 h of CCCP treatment), permeability transition pores were closed. These results suggest that none of the following events represent a point of no return in the process of apoptotic cell death: loss of DeltaPsim, mitochondrial permeability transition, or mitochondrial swelling.

Role of mitochondria in calcium regulation of spontaneously contracting cardiac muscle cells.

Mitochondrial involvement in the regulation of cytosolic calcium concentration ([Ca2+]i) in cardiac myocytes has been largely discounted by many authors. However, recent evidence, including the results of this study, has forced a reappraisal of this role. [Ca2+]i and Ca2+ in the mitochondria ([Ca2+]m) were measured in this study with specific fluorescent probes, fluo-3 and di-hydro-rhod-2, respectively; mitochondrial membrane potential (DeltaPsim) was monitored with JC-1. Addition of uncouplers or inhibitors of the mitochondrial respiratory chain was found to cause a twofold decrease in the rate of removal of Ca2+ from the cytosol after a spontaneously generated Ca2+ wave. These agents also caused a progressive elevation of [Ca2+]i, an increase in the number of hotspots of Ca2+ release (Ca2+ sparks), and depression of mitochondrial potential. The Ca2+-indicative fluorophore dihydro-rhod-2 has a net positive charge that contributes to selective accumulation by mitochondria, as supported by its co-localization with other mitochondrial-specific probes (MitoTracker Green). Treatment of dihydro-rhod-2-loaded cells with NaCN resulted in rapid formation of "black holes" in the otherwise uniformly banded pattern. These are likely to represent individual or small groups of mitochondria that have depressed mitochondrial potential, or have lost accumulated rhod-2 and/or Ca2+; all of these eventualities are possible upon onset of the mitochondrial permeability transition. Release of Ca2+ from the sarcoplasmic reticulum and the resultant spontaneous contractility of cardiac muscle are proposed to be triggered by the induction of the mitochondrial permeability transition and the subsequent loss of [Ca2+]m.

Microemboli during carotid angiography. Association with stroke risk factors or subsequent magnetic resonance imaging changes?

BACKGROUND AND PURPOSE: Carotid angiography is associated with a 1% risk of major stroke. Recently, transcranial Doppler ultrasonography (TCD) has shown cerebral microemboli during carotid angiography. To determine their significance, we correlated the number of microemboli during angiography with clinical characteristics, angiography findings, and preangiography and postangiography cerebral magnetic resonance imaging (MRI). METHODS: One middle cerebral artery was monitored with TCD in 24 patients during angiography for carotid territory ischemia. The number of microemboli was correlated with angiographic and clinical characteristics. T2-weighted cerebral MRI was performed before and < or = 48 hours after angiography, and the number of new ischemic lesions was determined in a blinded review. RESULTS: Microemboli were seen in all patients, with an average of 51 per procedure (range, 12 to 154). The majority of microemboli had signal characteristics typical of air. Sixteen of the 24 patients had both preangiography and postangiography MRI. One of 24 patients had an angiographic stroke, with a single new thalamic lesion on MRI. No other patient had a new lesion. The microembolus count correlated with the angiographic contrast volume (P < .001) but not with any other radiological or clinical characteristic. CONCLUSIONS: This study confirmed the presence of numerous cerebral microemboli during carotid angiography. The microembolic signal characteristics and the correlation with contrast volume indicate that introduced air is the cause. These microemboli are usually clinically silent and do not lead to new changes on cerebral MRI.

Immunotoxicity of low level cadmium exposure in fish: an alternative animal model for immunotoxicological studies.

Cadmium represents a major aquatic pollutant in many parts of the world. Yet, despite the fact that cadmium accumulates in high concentrations in fish tissues, is found in polluted aquatic environments, and is carcinogenic and immunotoxic in a variety of mammalian species, the effects of cadmium on the immune responses of directly exposed aquatic species have not been clearly defined. This study was designed to assess the effects of in vivo cadmium exposure, at a concentration found in contaminated aquatic environments, on the immune defense mechanisms of fish. In this study, no effects were observed upon body weight, lysozyme activity, of cell viability, despite the high concentration of accumulated cadmium in the gills and liver. Furthermore, in the absence of any clinical manifestations or overt toxicity, exposure of rainbow trout to waterborne cadmium at 2 ppb altered macrophage-mediated immune functions, including phagocytosis and free radical production, in a time-dependent manner. Similar immunotoxic effects of cadmium have also been observed in mammals. Although interspecies comparisons between mammalian and fish immune responses are extremely complicated and need to be approached with caution, results from this study suggest the applicability of fish as an additional/alternative animal model for immunotoxicological studies.

Soybean agglutinin-positive natural suppressor cells in mouse bone marrow inhibit interleukin 2 production and utilization in mixed lymphocyte reactions.

Although natural suppressor (NS) cells resident in bone marrow (BM) have been the subject of intensive study, the exact nature and mode of action of these potentially important immunoregulatory cells are still uncertain. Here we show that NS cells with potent inhibitory effects on mixed lymphocyte reactions (MLRs) can be isolated from BM of normal adult mice by agglutination with the plant lectin soybean agglutinin (SBA). Complement-dependent lysis of SBA receptor-bearing BM cells with antibodies to asialoGM1, Mac-1, Thy-1.2, J11d.2, and 2C1 phenotypic markers reveals the presence of at least two distinct populations of BM NS cells. Most of the SBA-binding BM cells with NS capacity have the null phenotype and resemble hematopoietic stem cells, and some inhibitory SBA+ BM cells express the 2C1 marker found on pregnancy-associated splenic NS cells and the J11d.2 antigen characteristic of B cells and immature T cells. Results of positive selective experiments confirmed these findings. The mechanism of natural suppression was also studied. Evidence is presented that SBA+ BM cells exert NS activity in MLRs by interfering with the production and utilization of interleukin 2. Indomethacin does not relieve natural suppression associated with SBA+ BM cells, indicating that prostaglandin synthesis is not a requirement for inhibitory function. However, neutralizing antibodies to transforming growth factor beta (TGF-beta) partially reverse the suppression mediated by SBA+ BM cells, suggesting that some BM NS cells may act through the release of an immunosuppressive molecule related to TGF beta.

Development of fish peritoneal macrophages as a model for higher vertebrates in immunotoxicological studies. I. Characterization of trout macrophage morphological, functional, and biochemical properties.

The immune defense mechanisms of fish are not as well characterized as those of mammals but seem to be related and similarly competent. Because of this, there is an increased interest in the immune responses of fish as models for higher vertebrates in immunotoxicological studies. Prior to such studies, baseline criteria for specific components of the immune response needed to be established. For this study, we have examined trout macrophage morphology using light and scanning electron microscopy, phagocytic activity, random and stimulus-directed migration, and superoxide anion radical (O2-) production for resident and lipopolysacharide (LPS) or Aeromonas salmonicidae-elicited rainbow trout (Oncorhynchus mykiss) peritoneal macrophages (M phi). Following peritoneal lavage, greater than 89% of the cells were M phi as determined by differential counts and nonspecific esterase staining. Immunization with LPS and A. salmonicidae increased M phi number approximately 5 and 13-fold, respectively, and overall size. Trout M phi were phagocytically active engulfing serum opsonized latex particles and were mobile, migrating both randomly and in a directed fashion towards formyl-methionine-L-leucine-L-phenylalanine (FMLP) and trout serum-derived complement fragment C5a. Concentrations of FMLP (100 nM) and C5a (0.01-1%) effective for attracting trout M phi are the same as those used to attract rabbit M phi. Resident trout M phi produced negligable quantities of .O2- following stimulation with 1 micrograms/ml phorbol myristate acetate; Aeromonas-elicited M phi produced .O2- in a time-dependent manner which peaked after 60 min at 2.9 nmol per 2 x 10(5) cells and then declined. The results of this study provide a data base for future toxicological studies with trout peritoneal M phi and indicate the usefulness of this system for immunotoxicological studies.

Immunogenicity of ribosomal preparations from Neisseria gonorrhoeae.

Protection against gonococcal infection was obtained by immunization with ribosomal preparations from Neisseria gonorrhoeae. Ribosomes were isolated from disrupted cells by differential ultracentrifugation and treatment of the microsomal fraction with 0.25% sodium dodecyl sulfate. The isolated ribosomal preparations contained 55% ribonucleic acid, 39% protein, and 0.35% carbohydrate. The ribosomal preparations contained small amounts of endotoxin as determined by thiobarbituric acid- and lead acetate-sensitized mice assays. Guinea pigs immunized subcutaneously with ribosomal preparations were challenged intrachamberially with 10(7) colony-forming units of N. gonorrhoeae, and protection was assessed by clearance of the organism from subcutaneous chambers. The ribosomal preparations elicited significant protection, which was enhanced by incoporation of the immunogen into adjuvant. This protection was comparable to that obtained with whole cells. Treatment with proteolytic enzymes destroyed the protective effect of the ribosomal preparations, but ribonuclease had no measurable effect. Passive hemagglutination and immunodiffusion tests with sera from immunized animals demonstrated the presence of antibody to the ribosomal antigens. Results of adsorption of antiribosomal sera with enzyme-treated ribosomal preparations also indicated the protein nature of the immunogen. These results indicate that protein associated with the gonococcal ribosomal preparation is the major protective immunogen. The role of endotoxin contamination in the immunogenicity of gonococcal ribosomal preparations warrants further investigation.