Strategies for Effective Stakeholder Engagement in Strengthening Referral Networks for Management of Hypertension Across Health Systems in Kenya

BackgroundIneffective referral networks in low- and middle-income countries hinders access to evidence-based therapies by hypertensive patients, leading to high cardiovascular mortality and morbidity. The STRENGTHS (Strengthening Referral Networks for Management of Hypertension Across Health Systems) study evaluates strategies to improve referral processes utilizing the International Association of Public Participation framework to engage stakeholders.ObjectivesThis study sought to identify and engage key stakeholders involved in referral of patients in the Ministry of Health, western Kenya.MethodsKey stakeholders involved in policy formulation, provision, or consumption of public health care service were mapped out and contacted by phone, letters, and emissaries to schedule meetings, explain research objectives, and obtain feedback.ResultsKey stakeholders identified were the Ministry of Health, the Academic Model Providing Access to Healthcare, health professionals, communities and their leadership, and patients. Engaging them resulted in permission to contact research in their areas of jurisdiction and enabled collaboration in updating care protocols with emphasis on timely and appropriate referrals.ConclusionsEarly stakeholder identification and engagement using the International Association of Public Participation model eased explanation of research objectives, building consensus, and shaping the interventions to improve the referral process.     

Human donor bone marrow cells induce in vitro "suppressor T cells" that functionally suppress autologous B cells

We have reported a beneficial effect of donor vertebral body bone marrow cells (DBMC) infusions in cadaver renal allograft recipients in a 6-year follow-up, but with a transient increase in early (6 month) postoperative CMV infections and concomitant suppressed immunoglobulins (Ig) production. We also found that although there was no difference between the DBMC-infused and non-infused (control) groups in the development of donor-specific antibody, we now describe an additional difference seen in the percent reactive antibody (PRA) reactivity against a panel of HLA antigens that developed postoperatively. We hypothesize that (allogeneic) antigen presenting cells in the DBMC, systemically infused, caused the generation of recipient T suppressor (T4-suppressor) cells, thereby "inducing" a negative influence on B cell Ig production. We tested this notion in vitro by incubating PBL from CMV IgG positive laboratory volunteers with either (allogeneic) T-cell depleted DBMC or donor spleen cells (DSPC) from (the same) cadaver donors. After 7 days, the (responding) T cells were collected using magnetic beads and placed in culture with purified B cells freshly obtained from the same (autologous) CMV positive volunteer. To these cultures were added either media or 40 ng of CMV antigen. After 3, 5, 7, and 9 days, the expression of surface anti-CMV Ig was measured by flow cytometry using a panel of fluorescent markers double-labeled for activated B cells (CD20, CD19, and HLA DRw) and CMV-FITC. We also determined the phenotype of the cultured T cells using anti-CD3, CD4, and CD62L specific monoclonal antibodies. B cells that had been in contact with autologous T cells derived from DBMC cultures (TBM) were less likely to express anti-CMV surface Ig than those cultured with DSPC (TSP). The flow cytometry analysis revealed an increase in the number of T4 suppressor cells (CD3+, CD4+, CD62L+) in the TBM group, whereas the T4 helper phenotype (CD3+, CD4+, CD62L-) predominated in the TSP group. These in vitro findings support the notion that (allogeneic) DBMC infusions can induce a T4 suppressor (regulatory) influence and thereby indirectly affect B-cell function.     

Brain death determination: the imperative for policy and legal initiatives in Sub-Saharan Africa

The concept of brain death (BD), defined as irreversible loss of function of the brain including the brainstem, is accepted in the medical literature and in legislative policy worldwide. However, in most of Sub-Saharan Africa (SSA) there are no legal guidelines regarding BD. Hypothetical scenarios based on our collective experience are presented which underscore the consequences of the absence of BD policies in resource-limited countries (RLCs). Barriers to the development of BD laws exist in an RLC such as Kenya. Cultural, ethnic, and religious diversity creates a complex perspective about death challenging the development of uniform guidelines for BD. The history of the medical legal process in the USA provides a potential way forward. Uniform guidelines for legislation at the state level included special consideration for ethnic or religious preferences in specific states. In SSA, medical and social consensus on the definition of BD is a prerequisite for the development BD legislation. Legislative policy will (1) limit prolonged and futile interventions; (2) mitigate the suffering of families; (3) standardise clinical practice; and (4) facilitate better allocation of scarce critical care resources in RLCs. There is a clear-cut need for these policies, and previous successful policies can serve to guide these efforts.     

Ramadan Fasting during Pregnancy and Health Outcomes in Offspring: A Systematic Review

Ramadan is one of the five pillars of Islam, during which fasting is obligatory for all healthy individuals. Although pregnant women are exempt from this Islamic law, the majority nevertheless choose to fast. This review aims to identify the effects of Ramadan fasting on the offspring of Muslim mothers, particularly on fetal growth, birth indices, cognitive effects and long-term effects. A systematic literature search was conducted until March 2020 in Web of Science, Pubmed, Cochrane Library, Embase and Google Scholar. Studies were evaluated based on a pre-defined quality score ranging from 0 (low quality) to 10 (high quality), and 43 articles were included. The study quality ranged from 2 to 9 with a mean quality score of 5.4. Only 3 studies had a high quality score (>7), of which one found a lower birth weight among fasting women. Few medium quality studies found a significant negative effect on fetal growth or birth indices. The quality of articles that investigated cognitive and long-term effects was poor. The association between Ramadan fasting and health outcomes of offspring is not supported by strong evidence. To further elucidate the effects of Ramadan fasting, larger prospective and retrospective studies with novel designs are needed.     

The correlation between plasma levels of oxytocin and betatrophin in non-diabetic and diabetic metabolic syndrome patients: A cross sectional study from Jordan

Background

Oxytocin (OXT) is a neurohypophyseal hormone that has been recently shown to possess a number of beneficial effects in diabetes and obesity. Betatrophin is a protein expressed in fat and liver that regulates lipid metabolism and promotes pancreatic β-cell proliferation. It is not investigated yet whether OXT and betatrophin levels correlate in metabolic syndrome (MS) or diabetes patients.

Medicinal plants from Jordan in the treatment of cancer: traditional uses vs. in vitro and in vivo evaluations--part 1

Plant species have long been used as principal ingredients in traditional medicine. Different surveys showed that ethnomedicinal plant species used by the inhabitants of Jordan for the treatment of cancer are inadequately screened for their therapeutic/chemopreventive potential and phytochemical findings. In this mini review, traditional herbal medicines pursued indigenously with their methods of preparation and active constituents are listed. Studies of random screening for selective cytotoxicity and antiproliferative activity of local spices, domesticated greens, or wild plants are briefly discussed. Recommended future directives for the design and conduct of comprehensive trials are pointed out to validate the usefulness of these active plants or bioactive phytoconstituents either alone or in combination with existing therapies or complementing pharmacologies.     

Medicinal plants from Jordan in the treatment of diabetes: traditional uses vs. in vitro and in vivo evaluations--part 2

Diabetes mellitus is the most common metabolic disorder affecting millions worldwide. It is recognized as a global major health problem. As alternatives to the available orthodox medicines, plants are considered a potential source for the treatment of diabetes within traditional ethnomedicine practices. In the Jordanian traditional medicine a significant selection of ethnobotanicals is promoted for their antidiabetic activity. Literature surveys demonstrate the benefit of several ethnobotanicals as antidiabetic agents evaluated in in vitro and in vivo systems in the form of their crude extracts and/or isolated pure compounds with varying degrees of hypoglycemic or antihyperglycemic bioactivities. This mini review discusses the preparatory forms in which these plants are consumed, their reported phytoconstituents, and the results of their reported antidiabetic bioactivity.