Multi-level change strategies for health: learning from people-centered advocacy in Uganda.

BACKGROUND: The paper analyzes how the Accountability Can Transform Health (ACT Health) program activated bottom-up citizen action to secure government responses and more accountable health services in Uganda. The ACT Health program had two phases-Phase 1 focused on a community-level intervention studied with a randomized control trial, and Phase 2 supported citizen-led advocacy targeting government officials across multiple levels. The focus of this paper is an analysis of Phase 2, when the "people-centered advocacy" approach supported almost 400 community advocates representing 98 health facilities to organize, identify joint advocacy priorities, directly monitor health services, and collaborate on health advocacy campaigns in 18 districts. Most district campaigns focused on the complex, power-laden issue of health worker absenteeism. With a few notable exceptions, iterative cycles of engagement between citizens and the state across multiple levels are infrequently discussed in the formal literature on health accountability. METHODS: This paper is based on a comparative, inductive, practitioner-led analysis of program monitoring data from 18 multi-level health advocacy campaigns. The findings emerge from analysis of a "Heat Map," capturing grounded accounts of government responses to community-led advocacy. RESULTS: Officials in eight out of 18 districts fulfilled or surpassed commitments made to community advocates. Government responses included: increased monitoring, more downward accountability, countering backlash against advocates, applying sanctions for absent health workers, and increased budget allocations. Advocates' bottom-up advocacy worked in part through triggering top-down responses and activating governmental checks and balances. CONCLUSIONS: Methodologically, this article demonstrates the value of analyzing process monitoring and program data to understand outcomes from direct engagement between citizens and the state to improve health services. Survey-based research methods and quantitative analysis may fail to capture signs of government responsiveness and relational outcomes (such as subtle signs of shifting power dynamics) many hope to see from citizen-led accountability efforts. Practitioners' perspectives on how accountability for health emerges in practice are important correctives to much positivist research on accountability, which has a tendency to ignore the complex dynamics and processes of building citizen power.

Social Accountability Reporting for Research (SAR4Research): checklist to strengthen reporting on studies on social accountability in the literature.

BACKGROUND: An increasing number of evaluations of social accountability (SA) interventions have been published in the past decade, however, reporting gaps make it difficult to summarize findings. We developed the Social Accountability Reporting for Research (SAR4Research) checklist to support researchers to improve the documentation of SA processes, context, study designs, and outcomes in the peer reviewed literature and to enhance application of findings. METHODS: We used a multi-step process, starting with an umbrella review of reviews on SA to identify reporting gaps. Next, we reviewed existing guidelines for reporting on behavioral interventions to determine whether one could be used in its current or adapted form. We received feedback from practitioners and researchers and tested the checklist through three worked examples using outcome papers from three SA projects. RESULTS: Our umbrella review of SA studies identified reporting gaps in all areas, including gaps in reporting on the context, intervention components, and study methods. Because no existing guidelines called for details on context and the complex processes in SA interventions, we used CONSORT-SPI as the basis for the SAR4Research checklist, and adapted it using other existing checklists to fill gaps. Feedback from practitioners, researchers and the worked examples suggested the need to eliminate redundancies, add explanations for items, and clarify reporting for quantitative and qualitative study components. CONCLUSIONS: Results of SA evaluations in the peer-reviewed literature will be more useful, facilitating learning and application of findings, when study designs, interventions and their context are described fully in one or a set of papers. This checklist will help authors report better in peer-reviewed journal articles. With sufficient information, readers will better understand whether the results can inform accountability strategies in their own contexts. As a field, we will be better able to identify emerging findings and gaps in our understanding of SA.

Reasons for delayed antiretroviral therapy (ART) initiation in the era of early ART initiation guidelines: a retrospective service evaluation.

Following changes in national antiretroviral therapy (ART) guidelines removing the CD4 threshold for initiation of ART, we evaluated the time to ART initiation and reasons for delayed or non-initiation. A retrospective notes review of 292 newly diagnosed HIV-positive individuals attending two London clinics between August 2015 and December 2016 was performed. Two hundred and fifty-four of 292 (87%) individuals started ART. Median time to ART initiation was 29 days (range: 0-514). Thirty of 292 (13%) did not start ART. Rates of virological suppression at six months were similar regardless of time to ART initiation. People who inject drugs (16.7% vs. 3.6%) (p = 0.009), having a higher median baseline CD4 cell count (500 vs. 388 cells/mm3, p = 0.001), and having gastrointestinal/liver co-morbidities (23% vs. 9%, p = 0.001) were associated with delayed ART initiation. The cohort not on ART had a higher median baseline CD4 cell count (500 vs. 388 cells/mm3, p < 0.001). Documented reasons for delayed or ART non-initiation included patient's choice, prolonged adjustment periods, and difficulty leaving work. We conclude that delayed or non-initiation of ART was associated with injecting drug use and prolonged adjustment to a new HIV diagnosis. Clinician factors may include lack of urgency with higher baseline CD4 cell counts. Improved linkage to care and drug services pathways may encourage timely ART initiation.

Supporting maintenance of sugar-sweetened beverage reduction using automated versus live telephone support: findings from a randomized control trial.

BACKGROUND: Although reducing sugar-sweetened beverage (SSB) intake is an important behavioral strategy to improve health, no known SSB-focused behavioral trial has examined maintenance of SSB behaviors after an initial reduction. Guided by the RE-AIM framework, this study examines 6-18 month and 0-18 month individual-level maintenance outcomes from an SSB reduction trial conducted in a medically-underserved, rural Appalachia region of Virginia. Reach and implementation indicators are also reported. METHODS: Following completion of a 6-month, multi-component, behavioral RCT to reduce SSB intake (SIPsmartER condition vs. comparison condition), participants were further randomized to one of three 12-month maintenance conditions. Each condition included monthly telephone calls, but varied in mode and content: 1) interactive voice response (IVR) behavior support, 2) human-delivered behavior support, or 3) IVR control condition. Assessments included the Beverage Intake Questionnaire (BEVQ-15), weight, BMI, and quality of life. Call completion rates and costs were tracked. Analysis included descriptive statistics and multilevel mixed-effects linear regression models using intent-to-treat procedures. RESULTS: Of 301 subjects enrolled in the 6-month RCT, 242 (80%) were randomized into the maintenance phase and 235 (78%) included in the analyses. SIPsmartER participants maintained significant 0-18 month decreases in SSB. For SSB, weight, BMI and quality of life, there were no significant 6-18 month changes among SIPsmartER participants, indicating post-program maintenance. The IVR-behavior participants reported greater reductions in SSB kcals/day during the 6-18 month maintenance phase, compared to the IVR control participants (- 98 SSB kcals/day, 95% CI = - 196, - 0.55, p < 0.05); yet the human-delivered behavior condition was not significantly different from either the IVR-behavior condition (27 SSB kcals/day, 95% CI = - 69, 125) or IVR control condition (- 70 SSB kcals/day, 95% CI = - 209, 64). Call completion rates were similar across maintenance conditions (4.2-4.6 out of 11 calls); however, loss to follow-up was greatest in the IVR control condition. Approximated costs of IVR and human-delivered calls were remarkably similar (i.e., $3.15/participant/month or $38/participant total for the 12-month maintenance phase), yet implications for scalability and sustainability differ. CONCLUSION: Overall, SIPsmartER participants maintained improvements in SSB behaviors. Using IVR to support SSB behaviors is effective and may offer advantages as a scalable maintenance strategy for real-world systems in rural regions to address excessive SSB consumption. TRIAL REGISTRY: Clinicaltrials.gov; NCT02193009 ; Registered 11 July 2014. Retrospectively registered.

Rural Cancer Screening and Faith Community Nursing in the Era of the Affordable Care Act.

Rural populations often face higher cancer rates and have lower cancer screening rates than urban populations. Screening disparities may be mediated by limited access to care, less knowledge of screening, and psychosocial factors. While the improved insurance rates and more comprehensive coverage under the Affordable Care Act may address some of these barriers, rural-urban disparities in cancer screening may not be fully attenuated. Faith-based interventions have been an effective approach to improving cancer screening among rural and underserved populations. Similarly, faith community nurses (FCNs) may be an effective agents for implementing evidence-based cancer screening strategies in rural communities. We provide a model for how FCNs standards of professional performance and practice can enable them to implement screening strategies. We also posit two recommendations of services that FCNs can provide to improve cancer screening in rural areas: educational messaging and patient navigation.

Changes in Anxiety and Depression Are Mediated by Changes in Pain Severity in Patients Undergoing Lower-Extremity Total Joint Arthroplasty.

BACKGROUND: Depression and anxiety are common comorbidities in chronic pain including osteoarthritis patients undergoing total joint arthroplasty (TJA). What is not clear is whether psychiatric comorbidity precedes the manifestation of painful states or represents a reaction to living with chronic pain and associated functional impairment. The objective of this research was to explore whether decreases in depressive and anxiety symptoms after lower-extremity TJA could be due to postsurgical reductions in pain. METHODS: We conducted a secondary analysis of data from 1448 TJA patients enrolled in the Analgesics Outcome Study. Patients completed measures of pain intensity, functional status, and depressive and anxiety symptoms preoperatively and at 3 and 6 months postoperatively. Data were analyzed using a structural equation modeling approach. RESULTS: We found that improvement in pain and physical function from baseline to 6 months postoperatively was associated with improvement in depression and anxiety symptoms. We also found that a change in overall body pain at 3 months after surgery significantly mediated changes in both the depression and anxiety scores at 6 months after surgery even when controlling for age, sex, baseline body pain, education, opioid use, and type of surgery. CONCLUSIONS: Presurgical affective symptoms not only have an effect on change in postsurgical pain, whereby lower preoperative scores on depression and anxiety were associated with lower postsurgical pain, but also postsurgical decreases in pain were associated with lower levels of depression and anxiety after surgery. Taking these points into consideration may prove useful in working toward better outcomes for TJA.

Are physician assistant and patient airway assessments reliable compared to anesthesiologist assessments in detecting difficult airways in general surgical patients?

BACKGROUND: Airway management remains one of the most important responsibilities of anesthesiologists. Prediction of difficult airway allows time for proper selection of equipment, technique, and personnel experienced in managing patients with difficult airway. Face to face preoperative anesthesia interviews are difficult to conduct as they necessitate patients traveling to the clinics, and, in practice, are usually conducted in the morning of the procedure by the anesthesiologist, when identification of predictors of difficult intubation may lead to schedule delays or case cancelations. We hypothesized that an airway assessment tool could be used by patients or physician assistants to accurately assess their airways. METHODS: We administered an airway assessment tool, which had been constructed in consultation with a psychometrician and revised after non-medical layperson feedback, to 215 patients presenting to the preoperative clinic for evaluation. Separately, patients had the airway exam performed by a physician assistant and an anesthesiologist. Agreement was compared using kappa. RESULTS: We found good agreement between observers only on "can you put three fingers in your mouth?" (three-way kappa = .733, p < 0.001) and poor agreement on Mallampati classification (three-way kappa = .195, p < 0.001) and "Can you fit three fingers between your chin and your Adam's Apple?" (three-way kappa = .216, p < 0.001). The agreements for the other questions were mostly fair. Agreements between patients and anesthesiologists were similar to those between physician assistants and anesthesiologists. CONCLUSIONS: Neither the patients' self-assessments nor the physician assistants' assessments were adequate to substitute for the anesthesiologists' airway assessments.

Effects of a behavioral and health literacy intervention to reduce sugar-sweetened beverages: a randomized-controlled trial.

BACKGROUND: Despite excessive consumption of sugar-sweetened beverages (SSB), little is known about behavioral interventions to reduce SSB intake among adults, particularly in medically-underserved rural communities. This type 1 effectiveness-implementation hybrid RCT, conducted in 2012-2014, applied the RE-AIM framework and was designed to assess the effectiveness of a behavioral intervention targeting SSB consumption (SIPsmartER) when compared to an intervention targeting physical activity (MoveMore) and to determine if health literacy influenced retention, engagement or outcomes. METHODS: Guided by the Theory of Planned Behavior and health literacy strategies, the 6 month multi-component intervention for both conditions included three small-group classes, one live teach-back call, and 11 interactive voice response calls. Validated measures were used to assess SSB consumption (primary outcome) and all secondary outcomes including physical activity behaviors, theory-based constructs, quality of life, media literacy, anthropometric, and biological outcomes. RESULTS: Targeting a medically-underserved rural region in southwest Virginia, 1056 adult participants were screened, 620 (59%) eligible, 301 (49%) enrolled and randomized, and 296 included in these 2015 analyses. Participants were 93% Caucasian, 81% female, 31 % ≤ high-school educated, 43% < $14,999 household income, and 33% low health literate. Retention rates (74%) and program engagement was not statistically different between conditions. Compared to MoveMore, SIPsmartER participants significantly decreased SSB kcals and BMI at 6 months. SIPsmartER participants significantly decreased SSB intake by 227 (95% CI = -326,-127, p < 0.001) kcals/day from baseline to 6 months when compared to the decrease of 53 (95% CI = -88,-17, p < 0.01) kcals/day among MoveMore participants (p < 0.001). SIPsmartER participants decreased BMI by 0.21 (95% CI = -0.35,-0.06; p < 0.01) kg/m(2) from baseline to 6 months when compared to the non-significant 0.10 (95 % CI = -0.23, 0.43; NS) kg/m(2) gain among MoveMore participants (p < 0.05). Significant 0-6 month effects were observed for about half of the theory-based constructs, but for no biological outcomes. Health literacy status did not influence retention rates, engagement or outcomes. CONCLUSIONS: SIPsmartER is an effective intervention to decrease SSB consumption among adults and is promising for translation into practice settings. SIPsmartER also yielded small, yet significant, improvements in BMI. By using health literacy-focused strategies, the intervention was robust in achieving reductions for participants of varying health literacy status. TRIAL REGISTRATION: Clinicaltrials.gov; ID: NCT02193009 .

Using Teach-Back to Understand Participant Behavioral Self-Monitoring Skills Across Health Literacy Level and Behavioral Condition.

OBJECTIVE: To assess differences, by health literacy status and behavioral condition, in participants' abilities to self-monitor behaviors accurately and recall key behavioral messages using data from a teach-back call. DESIGN: Cross-sectional. SETTING: Rural, southwestern Virginia. PARTICIPANTS: Adults (n = 301). The majority were female (81.1%), 31.9% had a high school education or less, 66.1% earned < $25,000/y, and 32.9% were low health literate. INTERVENTION: First class session of 2 community-based behavioral interventions: SIPsmartER (reduce sugar-sweetened beverage intake) or MoveMore (increase physical activity). MAIN OUTCOME MEASURES: Reported accuracy of behavioral diary completion, proportion of behavioral messages recalled during the first round of teach-back, and rounds of teach-back. ANALYSIS: Descriptive statistics and generalized linear model. RESULTS: Low health literate participants were significantly less accurate in diary completion (P < .001), recalled fewer behavioral messages correctly (P < .001), and needed more rounds of teach-back (P < .001) than high health literate participants. Compared with SIPsmartER participants, MoveMore participants more accurately completed diaries (P = .001) but recalled a lower proportion of behavioral messages correctly (P < .001) and required more rounds of teach-back (P < .001). CONCLUSIONS AND IMPLICATIONS: Health literacy status and behavioral target affect the ability to self-monitor and recall key concepts. Researchers should consider using teach-back early in the intervention to assess and reinforce participants' ability to self-monitor.

Associations among chronic disease status, participation in federal nutrition programs, food insecurity, and sugar-sweetened beverage and water intake among residents of a health-disparate region.

OBJECTIVE: To determine whether sociodemographic characteristics, food security status, participation in federal nutrition programs (Supplemental Nutrition Assistance Program [SNAP] or Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]), and chronic disease status were associated with adherence to water and sugar-sweetened beverage (SSB) intake recommendations. DESIGN: Cross-sectional, random-digit phone survey with questions from the Behavioral Risk Factor Surveillance System and beverage intake questionnaire. PARTICIPANTS: Residents of a medically underserved, rural area. MAIN OUTCOME MEASURES: Water and SSB intake. ANALYSIS: Descriptive statistics, chi-square and 1-way ANOVA, and linear and logistic regression. RESULTS: The sample consisted of 930 respondents (aged 56 ± 17 years; 35% non-white); reported food insecurity and SNAP and WIC participation were 37%, 29%, and 8%, respectively. Prevalent health conditions included overweight/obesity (69%), diabetes (19%), and hypertension (45%). Water recommendations were more likely to be met (72%; mean intake, 31 ± 19 fluid oz) than SSB (41%; mean intake, 246 ± 297 kcal). Food insecurity and SNAP/WIC participation were not associated with meeting recommendations, but those reporting ≥ 1 chronic disease were more likely to meet SSB recommendations (odds ratio, 2.42; P = .02). CONCLUSIONS AND IMPLICATIONS: Odds of achieving SSB but not water recommendations were greater among individuals with a chronic disease. Efforts to communicate beverage recommendations to at-risk groups are needed.

Genotype-phenotype correlations in recessive RYR1-related myopathies.

BACKGROUND: RYR1 mutations are typically associated with core myopathies and are the most common overall cause of congenital myopathy. Dominant mutations are most often associated with central core disease and malignant hyperthermia, and genotype-phenotype patterns have emerged from the study of these mutations that have contributed to the understanding of disease pathogenesis. The recent availability of genetic testing for the entire RYR1 coding sequence has led to a dramatic expansion in the identification of recessive mutations in core myopathies and other congenital myopathies. To date, no clear patterns have been identified in these recessive mutations, though no systematic examination has yet been performed. METHODS: In this study, we investigated genotype-phenotype correlations in a large combined cohort of unpublished (n = 14) and previously reported (n = 92) recessive RYR1 cases. RESULTS: Overall examination of this cohort revealed nearly 50% of cases to be non-core myopathy related. Our most significant finding was that hypomorphic mutations (mutations expected to diminish RyR1 expression) were enriched in patients with severe clinical phenotypes. We also determined that hypomorphic mutations were more likely to be encountered in non-central core myopathies. With analysis of the location of non-hypomorphic mutations, we found that missense mutations were generally enriched in the MH/CCD hotspots and specifically enriched in the selectivity filter of the channel pore. CONCLUSIONS: These results support a hypothesis that loss of protein function is a key predictive disease parameter. In addition, they suggest that decreased RyR1 expression may dictate non-core related pathology though, data on protein expression was limited and should be confirmed in a larger cohort. Lastly, the results implicate abnormal ion conductance through the channel pore in the pathogenesis in recessive core myopathies. Overall, our findings represent a comprehensive analysis of genotype-phenotype associations in recessive RYR1-myopathies.

The Aging Waistline: Impact of the Geriatric Obesity Epidemic on an Urban Emergency Department: Original Communication.

PURPOSE: Reviews adult emergency department (ED) visits for patients age 65 and older during one calendar year; determine the prevalence of weight classifications; identifies trends between BMI and discharge/admitting diagnoses, vital signs, and severity index. METHODS: The electronic medical records system and data from the ED billing service was reviewed for an urban academic institution with an annual volume of 125,000 for patients age > 65. Using a random number table, a retrospective cohort of 328 elderly patients was selected for review, representing a convenience sample of 2.6% of elderly ED visits. Body Mass Index (BMI) was calculated, using the Center for Disease Control (CDC) formula with underweight (<18.5), normal (18.5 - 24.9), overweight (25 - 29.9), and obese (≥30). RESULTS: The majority of the cohort in this study was African-American and Hispanic (60% and 27% respectively), and there were a higher percentage of females than males (60% and 40% respectively). Approximately 29% of the patients were classified as normal weight, 35% classified as overweight, and 36% as obese. The older the patient, the more likely that patient belonged to a lower weight classification (p < 0.01). Those presenting with neurological, pulmonary or gastrointestinal complaints were more likely to be of a higher weight classification (p < 0.05). Patients who were hypertensive on arrival to the ED were more likely to be in a higher weight classification (p < 0.01). CONCLUSION: Those patients with a higher weight classification had a strong correlation with selected abnormal vital signs and disease presentations. EDs are important sources of care for the elderly. EDs can serve as a previously untapped resource for screening and early referral exercise programs aimed at improving physical function/functional status and quality of life in the elderly patient population.

Barriers and opportunities for evidence-based health service planning: the example of developing a Decision Analytic Model to plan services for sexually transmitted infections in the UK.

BACKGROUND: Decision Analytic Models (DAMs) are established means of evidence-synthesis to differentiate between health interventions. They have mainly been used to inform clinical decisions and health technology assessment at the national level, yet could also inform local health service planning. For this, a DAM must take into account the needs of the local population, but also the needs of those planning its services. Drawing on our experiences from stakeholder consultations, where we presented the potential utility of a DAM for planning local health services for sexually transmitted infections (STIs) in the UK, and the evidence it could use to inform decisions regarding different combinations of service provision, in terms of their costs, cost-effectiveness, and public health outcomes, we discuss the barriers perceived by stakeholders to the use of DAMs to inform service planning for local populations, including (1) a tension between individual and population perspectives; (2) reductionism; and (3) a lack of transparency regarding models, their assumptions, and the motivations of those generating models. DISCUSSION: Technological advances, including improvements in computing capability, are facilitating the development and use of models such as DAMs for health service planning. However, given the current scepticism among many stakeholders, encouraging informed critique and promoting trust in models to aid health service planning is vital, for example by making available and explicit the methods and assumptions underlying each model, associated limitations, and the process of validation. This can be achieved by consultation and training with the intended users, and by allowing access to the workings of the models, and their underlying assumptions (e.g. via the internet), to show how they actually work. SUMMARY: Constructive discussion and education will help build a consensus on the purposes of STI services, the need for service planning to be evidence-based, and the potential for mathematical tools like DAMs to facilitate this.

Dental hygienists' perceptions of barriers to graduate education.

To advance the profession of dental hygiene, graduate education is necessary to support growth in research, education, administration, and practice in the discipline and to sustain credibility in a climate in which other health professions require entry-level master's and doctoral degrees. The purpose of this study was to explore what dental hygienists perceive as barriers to pursuing a graduate degree. A survey was developed based on the literature and other national surveys. Data were collected from 160 respondents to the survey: 50 percent held an entry-level baccalaureate degree in dental hygiene, while the rest held an entry-level associate degree (48 percent) or certificate (2 percent) in dental hygiene. All respondents had completed a bachelor's degree. The top five barriers these respondents identified in pursuing graduate education were as follows: 1) cost of graduate education, 2) family responsibilities are too great, 3) concerns about personal funding to pay for graduate education, 4) finding time for graduate school while working, and 5) fear of thesis research. Dental hygiene is one of the few health professions that still have entry-level degrees at the associate and baccalaureate levels. The profession needs to reduce such barriers to enable dental hygienists to pursue graduate education and thus ensure an adequate supply of future leaders, educators, and researchers.

A discrete event simulation model to evaluate operational performance of a colonoscopy suite.

BACKGROUND AND AIMS: Colorectal cancer, a leading cause of cancer death, is preventable with colonoscopic screening. Colonoscopy cost is high, and optimizing resource utilization for colonoscopy is important. This study's aim is to evaluate resource allocation for optimal use of facilities for colonoscopy screening. METHOD: The authors used data from a computerized colonoscopy database to develop a discrete event simulation model of a colonoscopy suite. Operational configurations were compared by varying the number of endoscopists, procedure rooms, the patient arrival times, and procedure room turnaround time. Performance measures included the number of patients served during the clinic day and utilization of key resources. Further analysis included considering patient waiting time tradeoffs as well as the sensitivity of the system to procedure room turnaround time. RESULTS: The maximum number of patients served is linearly related to the number of procedure rooms in the colonoscopy suite, with a fixed room to endoscopist ratio. Utilization of intake and recovery resources becomes more efficient as the number of procedure rooms increases, indicating the potential benefits of large colonoscopy suites. Procedure room turnaround time has a significant influence on patient throughput, procedure room utilization, and endoscopist utilization for varying ratios between 1:1 and 2:1 rooms per endoscopist. Finally, changes in the patient arrival schedule can reduce patient waiting time while not requiring a longer clinic day. CONCLUSIONS: Suite managers should keep a procedure room to endoscopist ratio between 1:1 and 2:1 while considering the utilization of related key resources as a decision factor as well. The sensitivity of the system to processes such as turnaround time should be evaluated before improvement efforts are made.

Solubilization of carotenoids from carrot juice and spinach in lipid phases: I. Modeling the gastric lumen.

Our understanding of the factors determining the bioavailability of carotenoids from fruits and vegetables is poor. The apolar nature of carotenoids precludes their simple diffusion from the food structure to the absorption site at the enterocyte. Therefore, there is interest in the potential pathways for solubilization in the gut before absorption. We have studied the transfer of carotenoids from carrot juice and homogenized spinach into lipid phases that mimic the intestinal lumen at the start of digestion. In this paper we report on their transfer into olive oil under conditions pertaining to the gastric environment. A comparison between preparations of raw spinach and of carrot, in which the intact cells have been largely broken, suggests that the membrane-bound carotenoids of spinach are more resistant to transfer than the crystalline carotenoids of carrot. Lowering the pH and pepsin treatment enhance the transfer from raw vegetables. The process of blanching and freezing spinach destroys the chloroplast ultrastructure and leads to (i) a substantial increase in transfer of the carotenoids to oil and (ii) an attenuation or reversal of the enhancement of transfer seen with reduced pH or with pepsin treatment. Similar effects are seen after blanching carrot juice. Our results show that removal of soluble protein and denaturation of membrane proteins enhances the partition of carotenoids into oil. For both vegetables there is no evidence of preference in the extent of transfer of one carotenoid over another. This suggests that partitioning into oil under gastric conditions is not the stage of digestion that could lead to differences in carotenoid bioavailability.

Alternative splicing as a mechanism for regulating 14-3-3 binding: interactions between hD53 (TPD52L1) and 14-3-3 proteins.

D52 (TPD52)-like proteins are coiled-coil motif-bearing proteins first identified through their expression in human breast carcinoma, which have been proposed to represent signalling intermediates and regulators of vesicle trafficking. D52-like gene transcripts are subject to alternative splicing, with sequences encoding a region termed insert 3 being affected in all three D52-like genes. We have now identified a 14-3-3 binding motif within one of two alternatively spliced exons encoding insert 3. As predicted from the distribution of 14-3-3 binding motifs in four hD52-like bait proteins tested, only a hD53 isoform encoding a 14-3-3 binding motif bound both 14-3-3beta and 14-3-3zeta preys in the yeast two-hybrid system. Since D53 proteins carrying 14-3-3 binding motifs are predicted to be widely expressed, polyclonal antisera were derived to specifically detect these isoforms. Using soluble protein extracts from breast carcinoma cell lines, pull-down assays replicated interactions between recombinant 14-3-3beta and 14-3-3zeta isoforms and exogenously expressed hD53, and co-immunoprecipitation analyses demonstrated interactions between endogenous 14-3-3 and both endogenously and exogenously-expressed hD53 protein. Co-expressed hD53 and 14-3-3 proteins were similarly demonstrated to co-localise within the cytoplasm of breast carcinoma cell lines. These results identify 14-3-3 proteins as partners for hD53, and alternative splicing as a mechanism for regulating 14-3-3 binding.