Economics of primary healthcare: cost estimation of clinical services at primary care facilities in the six countries of the Gulf Cooperation Council.

OBJECTIVE: While the Gulf Cooperation Council (GCC) countries have demonstrated a strong commitment to strengthening primary healthcare (PHC), the costs of delivering these services in this region remain relatively unexplored. Understanding the costs of PHC delivery is essential for effective resource allocation and health system efficiency. DESIGN: We used an ingredient-based method to estimate the cost of delivering a selection of services at PHC facilities in the six GCC countries in 2019. Services were categorised into eight programmes: immunisation; non-communicable diseases (NCDs); oral and dental care; child health; nutrition; mental health; reproductive, maternal, neonatal and child health and general practice. The cost estimation focused on two key ingredients: the costs of drugs and supplies and the healthcare workforce cost. The coverage rates of specific types of health services, including screening and mental health services, were also estimated. Data for the analysis were obtained from ministries of health, health statistics reports, online databases, national surveys and scientific literature. RESULTS: The estimated costs of delivering the selected services at public PHC facilities in the six GCC countries totalled US$5.7 billion in 2019, representing 0.34% of the combined 2019 GDP. The per capita costs varied from US$69 to US$272. General practice and NCD programmes constituted 79% of the total costs modelled while mental health ranged between 0.0% and 0.3%. Over 8 million individuals did not receive NCD screening services, and over 30 million did not receive needed mental health services in public PHC facilities across the region. CONCLUSIONS: To our knowledge, this is the first study to estimate the costs of services delivered at PHC facilities in the GCC countries. Identifying the main cost drivers and the services which individuals did not receive can be used to help strengthen PHC to improve efficiency and scale up needed services for better health outcomes.

A comparative study of early functional outcomes in undisplaced neck of femur fracture treated with partially threaded and fully threaded cannulated screw fixation in patients above 60 years age.

Objective: To compare the partially threaded versus fully threaded cannulated screw fixation methods in stable neck of femur fracture in terms of early functional outcomes in patients of age 60 and above. Methods: A randomized controlled trial was conducted at Orthopedic Unit-II, Mayo Hospital Lahore, Pakistan from July 2021 to July 2022. A total of 82 (41 in each group) patients of both genders, aged 60 or above were included. All patients had garden Type-I or II and were mobile before they fractured the femoral neck were included. In Group-A, cannulated screw fixation (cancellous screws 6 mm) was done using partially threaded screws while fully threaded screws (cancellous screws 6 mm) were used in Group-B. Patients were followed up at six weeks, three months and six months interval for "Radiographic Union Scale for Hip (RUSH)" and "Harris Hip score". Results: In a total of 82 (41 in each group) patients, 66 (80.5%) we male. At 6th week (p=0540) and 3rd month (p=0.653) postoperatively, no significant differences were seen between groups for Hip Harris score. However, at 6th month, functional outcome of Group-B patients was significantly better as compared to Group-A (p=0.038). Mean RUSH score in Group-A and in Group-B at 6th month postoperative was 25.45±2.73 and 30.52±2.39 (p<0.001). Conclusion: Fully threaded cannulated screw fixation is better in treating undisplaced neck of femur fracture as compared to partially threaded cannulated screw fixation in terms of early functional outcomes among the age group of 60 years and above.RCT Registration number: NCT05587660.

Genomic profiling and sites of metastasis in non-small cell lung cancer.

Background: We investigated the biological predisposition to site of metastasis in patients with NSCLC based on their molecular profiling and program death ligand PD-L1 status. We sought to identify any association between metastatic site and molecular profile in NSCLC patients. Methods: This was a retrospective analysis of patients with stage IV NSCLC who were newly diagnosed from January 2014 to June 2022. Clinical characteristics, pathology, molecular reports, and imaging were retrieved and analyzed. Results: A total of 143 patients were included in the study. Median age was 65 years, with an equal number of men (n=71) and women (n=72). The most common histology was adenocarcinoma (81.8%). At least one genetic mutation was discovered in 100 patients. Mutations with a targetable drug were found in 86 patients. The most common mutations were TP53 (25.2%), EGFR (24.5%), KRAS/NRAS (20.3%), and CDKN2A/2B (7.7%). Patients with any mutation were significantly more likely to have metastatic disease to the brain (57% vs. 37%, p=0.03), but there was no difference in metastatic disease to bone (34% vs. 26%, p=0.32). Patients without a discoverable mutation were significantly more likely to have metastatic disease to other sites (e.g., adrenal gland 91% vs. liver 66%, p=0.002). There was no difference in progression-free survival (PFS) or overall survival (OS) between those with versus without mutations. Median PFS and OS were significantly longer in patients with an EGFR mutation than those with KRAS/NRAS or TP53 mutations. Patients with PD-L1 >1% or TP53 were significantly more likely to have metastatic disease to organs other than bone or brain (p=0.047 and p=0.023, respectively). We identified four prognostic groups in metastatic NSCLC. Patients with PD-L1 <1% and no actionable mutations have the poorest prognosis, with median survival of around 20 months. Conclusion: Patients with mutations discoverable on NGS are more likely to have metastatic disease to the brain. KRAS/NRAS in particular has a predilection to metastasize to the brain and bone. PD-L1 expression and a TP53 mutation, on the other hand, tend to lead to metastasis of NSCLC to organs other than brain or bone. These results need to be corroborated in larger prospective studies.

Nitrogen optimization coupled with alternate wetting and drying practice enhances rhizospheric nitrifier and denitrifier abundance and rice productivity.

Optimizing nitrogen (N) fertilization without sacrificing grain yield is a major concern of rice production system because most of the applied N has been depleted from the soil and creating environmental consequences. Hence, limited information is available about nutrient management (NM) performance at a specific site under alternate wetting and drying (AWD) irrigation compared to conventional permanent flooding (PF). We aimed to inquire about the performance of NM practices compared to the farmer's fertilizer practice (FFP) under PF and AWD on rhizospheric nitrifier and denitrifier abundance, rice yield, plant growth, and photosynthetic parameters. Two improved NM practices; nutrient management by pig manure (NMPM); 40% chemical N replaced by pig manure (organic N), and nutrient management by organic slow-release fertilizer (NMSR); 40% chemical N replaced by organic slow-release N were compared. The results showed an increased total grain yield (16.06%) during AWD compared to PF. Compared to conventional FFP, NMPM, and NMSR significantly increased the yields by 53.84 and 29.67%, respectively, during AWD. Meanwhile, PF prompted a yield increase of 45.07 and 28.75% for NMPM and NMSR, respectively, (p < 0.05) compared to FFP. Besides, a significant correlation was observed between grain yield and nitrogen content during AWD (R 2 = 0.58, p < 0.01), but no significant correlation was observed during PF. The NMPM contributed to photosynthetic attributes and the relative chlorophyll content under both watering events. Moreover, relatively higher abundances of ammonia-oxidizing bacteria (AOB) and ammonia-oxidizing archaea (AOA) were observed during AWD, and the highest value was found after the late panicle stage. Our results suggest that the AWD-NMPM model is the best option to stimulate nitrifier and denitrifier gene abundance and promote rice production.

Nitrogen deficiency regulates premature senescence by modulating flag leaf function, ROS homeostasis, and intercellular sugar concentration in rice during grain filling.

BACKGROUND: Leaf senescence occurs in an age-dependent manner, but the rate and timing of leaf senescence may be influenced by various biotic and abiotic factors. In the course of stress, the function, composition, and different components of photosynthetic apparatus occur to be synthesized homogeneously or degraded paradoxically due to different senescence-related processes. Nitrogen (N) deficiency is one of the critical environmental factors that induce leaf senescence, and its incidence may curtail leaf photosynthetic function and markedly alter the genetic information of plants that might result in low grain yield. However, the physiological and genetic mechanism underlying N deficiency regulates premature senescence, and flag leaf function, ROS homeostasis, and intercellular sugar concentration in rice during grain filling are not well understood. In this paper, Zhehui7954 an excellent indica restorer line (wildtype) and its corresponding mutant (psf) with the premature senescence of flag leaves were used to study the effect of different N supplies in the alteration of physiological and biochemical components of flag leaf organ and its functions during grain filling. RESULTS: The results showed that the psf mutant appeared to be more susceptible to the varying N supply levels than WT. For instance, the psf mutant showed considerably lower Pn, Chl a, Chl b, and Car contents than its WT. N deficiency (LN) decreased leaves photosynthetic activities, N metabolites, but significantly burst O2•-, H2O2, and relative conductivity (R1/R2) concentrations, which was consistent with the expression levels of senescence-associated genes. Sucrose, glucose, and C/N ratio concentrations increased with a decrease in N level, which was closely associated with N and non-structural carbohydrate translocation rates. Increases in POD activity were positively linked with the senescence-related enhancement of ROS generation under LN conditions, whereas, SOD, CAT, and APX activities showed opposite trends. High N (HN) supply significantly inhibits the transcripts of carbohydrate biosynthesis genes, while N assimilation gene transcripts gradually increased along with leaf senescence. The psf mutant had a relatively higher grain yield under HN treatment than LN, while WT had a higher grain yield under MN than HN and LN. CONCLUSIONS: This work revealed that the C/N ratio and ROS undergo a gradual increase driven by interlinking positive feedback, providing a physiological framework connecting the participation of sugars and N assimilation in the regulation of leaf senescence. These results could be useful for achieving a higher yield of rice production by appropriate N supply and plant senescence regulation.

Ethylene participates in zinc oxide nanoparticles induced biochemical, molecular and ultrastructural changes in rice seedlings.

Nowadays, the applications of engineered nanoparticles (ENPs) have been significantly increased, thereby negatively affecting crop production and ultimately contaminating the food chain worldwide. Zinc oxide nanoparticles (ZnO NPs) induced oxidative stress has been clarified in previous studies. But until now, it has not been investigated that how ethylene mediates or participates in ZnO NPs-induced toxicity and related cellular ultrastructural changes in rice seedlings. Here, we reported that 500 mg/L of ZnO NPs reduced the fresh weight (54.75% and 55.64%) and dry weight (40.33% and 47.83%) in shoot and root respectively as compared to control. Furthermore, ZnO NPs (500 mg/L) reduced chlorophyll content (72% Chla, 70% Chlb), induced the stomatal closure and ultrastructural damages by causing oxidative stress in rice seedlings. These cellular damages were significantly increased by exogenous applications of ethylene biosynthesis precursor (ACC) in the presence of ZnO NPs. In contrary, ZnO NPs induced damages on the above-mentioned attributes were reversed through the exogenous supply of ethylene signaling and biosynthesis antagonists such as silver (Ag) and cobalt (Co) respectively. Interestingly, ZnO NPs accelerate ethylene biosynthesis by up-regulating the transcriptome of ethylene biosynthesis responsive genes. The antioxidant enzymes activities and related gene expressions were further increased in ethylene signaling and biosynthesis associated antagonists (Ag and Co) treated seedlings as compared to sole ZnO NPs treatments. In contrary, the above-reported attributes were further decreased by ACC together with ZnO NPs. In a nutshell, ethylene effectively contributes in ZnO NPs induced toxicity and causing ultrastructural and stomatal damage in rice seedlings. Such findings could have potential implications in producing genetic engineered crops, which will be able to tolerate nanoparticles toxicity in the environment.

Comparative study of the genetic basis of nitrogen use efficiency in wild and cultivated barley.

To curb the increasing demand for nitrogenous fertilizers, it is imperative to develop new cultivars with comparatively greater nitrogen use efficiency (NUE). Nonetheless, so far very meager information is available concerning the variances among barley (Hordeum vulgare L.) varieties for their response to nitrogen deprivation. The current study was carried out to explore the potential of barley genotypes for higher NUE. A hydroponic experiment was conducted at seedling stage to compare the performance of four barley genotypes, ZD9 and XZ149 (with higher NUE) and HXRL and XZ56 (with lower NUE) in response to low (0.1 mM) and normal nitrogen (2 mM) levels. Under low N, all the genotypes expressed less number of tillers, decreased soluble proteins, chlorophyll and N concentrations in both roots and shoots, in comparison with normal N supply. However, significant differences were found among the genotypes. The genotypes with high NUE (ZD9 and XZ149) showed higher N concentration, increased number of tillers, improved chlorophyll and soluble proteins in both roots and shoots as compared to the inefficient ones (HXRL and XZ56). Furthermore, nitrate transporter gene (NRT2.1) showed higher expression under low N, both in roots and leaves of N efficient genotypes, as compared to the N inefficient ones. However, N assimilatory genes (GS1 and GS2) showed higher expression under normal and low N level, in leaves and roots respectively. The outcome of the study revealed that genotypes with higher NUE (ZD9 and XZ149) performed better under reduced N supply, and may require relatively less N fertilizer for normal growth and development, as compared to those with lower NUE. The study also revealed a time-specific expression pattern of studied genes, indicating the duration of low N stress. The current study suggested that future work must involve the time course as a key factor while studying expression patterns of these genes to better understand the genetic basis of low-N tolerance.

Anthocyanin Accumulation in Black Kernel Mutant Rice and its Contribution to ROS Detoxification in Response to High Temperature at the Filling Stage.

Effect of high temperature (HT) on anthocyanin (ANS) accumulation and its relationship with reactive oxygen species (ROS) generation in color rice kernel was investigated by using a black kernel mutant (9311bk) and its wildtype (WT). 9311bk showed strikingly higher ANS content in the kernel than WT. Just like the starch accumulation in rice kernels, ANS accumulation in the 9311bk kernel increased progressively along with kernel development, with the highest level of ANS at kernel maturity. HT exposure evidently decreased ANS accumulation in 9311bk kernel, but it increased ROS and MDA concentrations. The extent of HT-induced decline in kernel starch accumulation was genotype-dependent, which was much larger for WT than 9311bk. Under HT exposure, 9311bk had a relatively lower increase in ROS and MDA contents than its WT. This occurrence was just opposite to the genotype-dependent alteration in the activities of antioxidant enzymes (SOD, CAT and APX) in response to HT exposure, suggesting more efficiently ROS detoxification and relatively stronger heat tolerance for 9311bk than its WT. Hence, the extent of HT-induced declines in grain weight and kernel starch content was much smaller for 9311bk relative to its WT. HT exposure suppressed the transcripts of OsCHS, OsF3'H, OsDFR and OsANS and impaired the ANS biosynthesis in rice kernel, which was strongly responsible for HT-induced decline in the accumulation of ANS, C3G, and P3G in 9311bk kernels. These results could provide valuable information to cope with global warming and achieving high quality for color rice production.

Senescence-specific change in ROS scavenging enzyme activities and regulation of various SOD isozymes to ROS levels in psf mutant rice leaves.

To clarify the interaction between different antioxidant enzymes for monitoring oxidative stress and ROS burst in rice senescent leaves, we investigated the genotype-dependent alteration in temporal patterns of the O2•- production rate, H2O2 content, and ROS-scavenging enzyme activities during leaf senescence in two rice genotypes, namely, the premature senescence of flag leaf (psf) mutant and its wild type. Results showed that the psf mutant differed obviously from its wild type in leaf O2•- generation rate and H2O2 content accumulation, and the decreased activities of SOD, CAT, and APX in the psf leaves were strongly responsible for the increased ROS level and the accelerated leaf senescence. By contrast, the increase in POD activity was positively correlated with the senescence-related enhancement in O2•- generation in rice leaves. Among various SOD isoforms, Mn-SOD responded sensitively to the increasing O2•- generation rate, whereas Cu/Zn-SOD remained stable with the progression of leaf senescence. These findings suggest that the senescence-related decline in total SOD activity was mostly attributable to the downregulation of both the translation and transcription of Mn-SOD isoform. This occurrence finally resulted in the collapse of SOD defense system and accelerated leaf senescence for the psf mutant. Furthermore, we presented the possible contribution of several Cu/Zn-SOD expression patterns to the senescence-related O2•- detoxification in different cell compartments.

Involvement of Abscisic Acid in PSII Photodamage and D1 Protein Turnover for Light-Induced Premature Senescence of Rice Flag Leaves.

D1 protein in the PSII reaction center is the major target of photodamage, and it exhibits the highest turnover rate among all the thylakoid proteins. In this paper, rice psf (premature senescence of flag leaves) mutant and its wild type were used to investigate the genotype-dependent alteration in PSII photo-damage and D1 protein turnover during leaf senescence and its relation to ABA accumulation in senescent leaves. The symptom and extent of leaf senescence of the psf mutant appeared to be sunlight-dependent under natural field condition. The psf also displayed significantly higher levels of ABA accumulation in senescent leaves than the wild type. However, the premature senescence lesion of psf leaves could be alleviated by shaded treatment, concomitantly with the strikingly suppressed ABA level in the shaded areas of flag leaves. The change in ABA concentration contributed to the regulation of shade-delayed leaf senescence. The participation of ABA in the timing of senescence initiation and in the subsequent rate of leaf senescence was closely associated with PSII photodamage and D1 protein turnover during leaf senescence, in which the transcriptional expression of several key genes (psbA, psbB, psbC and OsFtsH2) involved in D1 protein biosynthesis and PSII repair cycle was seriously suppressed by the significantly increased ABA level. This response resulted in the low rate of D1 protein synthesis and impaired repair recovery in the presence of ABA. The psf showed evidently decreased D1 protein amount in the senescent leaves. Both the inhibition of de novo synthesized D1 protein and the slow rate of proteolytic removal for the photodamaged D1 protein was among the most crucial steps for the linkage between light-dependent leaf senescence and the varying ABA concentration in psf mutant leaves. OsFtsH2 transcriptional expression possibly played an important role in the regulation of D1 protein turnover and PSII repair cycle in relation to ABA mediated leaf senescence.