Rural Doctors’ Views on and Experiences with Evidence-Based Medicine: The FrEEDoM Qualitative Study

Background

Evidence-based medicine is the integration of individual clinical expertise, best external evidence and patient values which was introduced more than two decades ago. Yet, primary care physicians in Malaysia face unique barriers in accessing scientific literature and applying it to their clinical practice.

Aim

This study aimed to explore the views and experiences of rural doctors’ about evidence-based medicine in their daily clinical practice in a rural primary care setting.

Methods

Qualitative methodology was used. The interviews were conducted in June 2013 in two rural health clinics in Malaysia. The participants were recruited using purposive sampling. Four focus group discussions with 15 medical officers and three individual in-depth interviews with family medicine specialists were carried out. All interviews were conducted using a topic guide and were audio-recorded, transcribed verbatim, checked and analyzed using a thematic approach.

Results

Key themes identified were: (1) doctors viewed evidence-based medicine mainly as statistics, research and guidelines, (2) reactions to evidence-based medicine were largely negative, (3) doctors relied on specialists, peers, guidelines and non-evidence based internet sources for information, (4) information sources were accessed using novel methods such as mobile applications and (5) there are several barriers to evidence-based practice, including doctor-, evidence-based medicine-, patient- and system-related factors. These included inadequacies in knowledge, attitude, management support, time and access to evidence-based information sources. Participants recommended the use of online services to support evidence-based practice in the rural settings.

Conclusion

The level of evidence-based practice is low in the rural setting due to poor awareness, knowledge, attitude and resources. Doctors use non-evidence based sources and access them through new methods such as messaging applications. Further research is recommended to develop and evaluate interventions to overcome the identified barriers.     

Widefield Two-Photon Excitation without Scanning: Live Cell Microscopy with High Time Resolution and Low Photo-Bleaching

We demonstrate fluorescence imaging by two-photon excitation without scanning in biological specimens as previously described by Hwang and co-workers, but with an increased field size and with framing rates of up to 100 Hz. During recordings of synaptically-driven Ca²⁺ events in primary rat hippocampal neurone cultures loaded with the fluorescent Ca²⁺ indicator Fluo-4 AM, we have observed greatly reduced photo-bleaching in comparison with single-photon excitation. This method, which requires no costly additions to the microscope, promises to be useful for work where high time-resolution is required.     

Some anthropometric studies of the femur of the male West Malaysian Chinese

Measurements and indices were made on 120 male West Malaysian Chinese femora. The findings are compared with appropriate ones from some Eastern and Western series. The Chinese femur is smaller than all the other groups listed except for the Japanese femur. There is a high degree of significance between the maximum and bicondylar lengths of the Chinese femur against those of the Australian aborigine, Maori and White American. The head of the femur is greater in the Maori and White American than the Chinese. The platymeric index is nearly as high as the White American. The difference in the robusticity index of the femur between the Australian aborigine, Maori, White American and the present series is small. The collodiaphyseal angle of the Chinese femur is large being greater than the Australian aborigine, Finn and White American. The angle of torsion of 11.8° is within the range for Westerners with a high incidence of retroversion unlike the Australian aborigine and Maori where no retroversion is seen. Although most of the means of the measurements and indices of the femur show a highly significant difference between the present series and some of the other groups listed there is a wide overlap for measurements of the Chinese femur to be used for racial identification.     

Pig intestinal microvillar maltase-glucoamylase. Structure and membrane insertion

The NH2-terminal sequence (25 residues) of amphiphilic single polypeptide chain maltase-glucoamylase (EC 3.2.1.20) was determined by gas-phase sequencing. The result indicates that the NH2-terminal segment anchors the enzyme to the microvillar membrane. The single-chain form and the proteolytically processed two-chain form have two distinct active sites differing in heat stability. However, both sites are sensitive to chonduritol B-epoxide and have similar substrate specificity. The amphiphilic single-chain maltase-glucoamylase and the amphiphilic proteolytically processed form were inserted into liposomes and studied by electron microscopy. The results showed that the enzyme is predominantly present as a homodimeric complex in the membrane.     

Biosynthesis of intestinal microvillar proteins. Pulse-chase labelling studies on maltase-glucoamylase, aminopeptidase A and dipeptidyl peptidase IV

The biogenesis of three intestinal microvillar enzymes, maltase-glucoamylase (EC 3.2.1.20), aminopeptidase A (aspartate aminopeptidase, EC 3.4.11.7) and dipeptidyl peptidase IV (EC 3.4.14.5), was studied by pulse-chase labelling of pig small-intestinal explants kept in organ culture. The earliest detectable forms of the enzymes were polypeptides of Mr 225000, 140000 and 115000 respectively. These were found to represent the enzymes in a 'high-mannose' state of glycosylation, as judged by their susceptibility to treatment with endo-beta-N-acetylglucosaminidase H (EC 3.2.1.96). After about 40-60 min of chase, maltase-glucoamylase, aminopeptidase A and dipeptidyl peptidase IV were further modified to yield the mature polypeptides of Mr 245000, 170000 and 137000 respectively, which were expressed at the microvillar membrane after 60-90 min of chase. The fact that the enzymes before reaching the microvillar membrane were found in a Ca2+-precipitated membrane fraction (intracellular and basolateral membranes), but not in soluble form, indicates that during biogenesis maltase-glucoamylase, aminopeptidase A and dipeptidyl peptidase IV are transported and assembled in a membrane-bound state.     

Proteins of the kidney microvillar membrane. Aspartate aminopeptidase: purification by immunoadsorbent chromatography and properties of the detergent- and proteinase-solubilized forms.

Aminopeptidase A (aspartate aminopeptidase, EC 3.4.11.7) was purified 2000-fold from pig kidney cortex. The essential step in the purification was chromatography on an immunoadsorbent column prepared from a rabbit antiserum raised against pig intestinal aminopeptidase A. Glutamyl and aspartyl substrate were attacked most rapidly and their hydrolyses were stimulated by Ca2+. The 2-naphthylamide derivatives of neutral and basic amino acids were also hydrolysed by aminopeptidase A, but at rates about two orders of magnitude lower, and Ca2+ was inhibitory. The possibility that these atypical substrates were hydrolysed by traces of aminopeptidase M (EC 3.4.11.2) contaminating the preparation could be excluded on several grounds. Aminopeptidase A was sensitive to inhibition by chelating agents and the inactive enzyme could be reactivated by Ca2+ or Mn2+. Atomic absorption spectrophotometry revealed 1 g-atom of Ca/143000 g of protein. Two forms of the enzyme were purified: an amphipathic form solubilized from the membrane by Triton X-100 (detergent form) and a hydrophilic form released by incubation with trypsin (proteinase form). The detergent form exhibited charge-shift in crossed immunoelectrophoresis when anionic or cationic detergents were present. On gel filtration, mol.wts. of 350000--400000 and 270000 were calculated for the detergent and proteinase forms. Electron microscopy after negative staining of the proteinase form revealed a dimeric structure. Electrophoresis of either form in the presence of sodium dodecyl sulphate revealed four polypeptides with mobilities corresponding to apparent mol.wts. of 155000, 110000, 90000 and 45000. All four bands stained positively for carbohydrate. Pig serum possesses weak aminopeptidase A activity; immunological experiments showed it to be a similar protein.     

Ca2+-binding protein from human kidney. Purification and properties.

A Ca2+-binding protein (CaBP) from human kidney was purified by two different procedures. The first involved heat-precipitation of a kidney cytosol fraction followed by gel filtration and chromatofocusing. This resulted in a 200-fold increase in the specific Ca2+-binding activity with a yield of 10%. A specific antibody was raised against the purified CaBP, as demonstrated by one precipitate in crossed immunoelectrophoresis of a kidney cytosol fraction. The antibody was coupled to Sepharose 4B and CaBP was then purified by immunoadsorbent chromatography. Applying this technique, a 500-fold purification of CaBP with a yield of 50% was obtained. Both preparations appeared homogeneous in crossed immunoelectrophoresis against a polyvalent antiserum and migrated as a single band corresponding to a mol.wt. of 26000 on sodium dodecyl sulphate/polyacrylamide-gel electrophoresis. In gel filtration under non-denaturing conditions CaBP was eluted corresponding to a mol.wt. of 28000. The association constant for the high-affinity Ca2+-binding sites of CaBP was estimated by gel filtration to be 0.1 X 10(6)M-1, and the protein displayed Ca2+-dependent electrophoretic mobility, with more rapid anodic migration in the presence of EDTA. The protein eluted at a position corresponding to a pI of 4.5 in chromatofocusing. Immunochemical experiments with the specific antibody showed no cross-reaction between renal and intestinal CaBP.     

Effect of ragi and Lxxx-lactate-producing cultures on enteric pathogens in a rice-based weaning food

The use of the Southeast-Asian starter culture ragi in enhancing the safety of a rice-based model weaning food is described and compared with the use of diastatic malt extract. Ragi was shown to be an effective saccharifying agent convenient for use in weaning-food preparation on a domestic scale. Saccharification and fermentation with ragi alone produced some antimicrobial effect against the three enteric bacterial pathogens tested but this was much improved when ragi was used in conjunction with the Lxxx-lactate-producing Lactococcus lactis or Lactobacillus bavaricus. The latter showed the greatest inhibition of pathogens, reducing viable numbers by more than a factor of 10⁴ within 4 h. The antibacterial effects observed correlated with the total acid produced (ragi alone giving 0.2%; ragi with Lc. lactis giving 0.3% and ragi with Lb. bavaricus giving 0.4%). The proportion of the physiological Lxxx-lactate isomer was highest in Lc. lactis fermentations (>99% compared with 80% with Lb. bavaricus). There was no evidence of any pronounced antimicrobial effect due to the nisin produced during fermentation by Lc. lactis (150 IU/g). Whereas bacteriocin production may play little role in pathogen control, it may be desirable as a way of preventing fermentations conducted non-aseptically from becoming dominated by lactic acid bacteria producing unacceptable amounts of Dxxx-lactate.R.M. Yusof is with the Department of Nutrition and Community Health, Faculty of Human Ecology, University Pertanian Malaysia, 43400 UPM, Serdang, Selangor, Malaysia. T.A. Baker, J.B. Morgan and M.R. Adams are with the School of Biological Sciences, University of Surrey, Guildford, Surrey GU2 5XH, UK.     

Potential dermatological application on Asian plants

Skin diseases are among some of the most common types of health problems faced in Malaysia, as reported by the World Health Organization (WHO). Correspondingly, research into the use of medicinal plants for skin disease treatment has become important. Through the ages, medicinal plants have been used widely to treat a variety of skin diseases. The demand for plant-based medicines is growing, as they are generally considered to be safer and less harmful than conventional allopathic drugs. This article reviews the potential of Asian plants to be epidermal protecting agents. There are eleven remarkable Asian plants that are known for their skin barrier protecting agent properties. Important studies have shown that natural products offer a rich potential source of epidermal protecting agents. Nevertheless, further surveys and clinical evidence are needed to establish the potential of identified species in contributing to the treatment of skin disease, especially atopic eczema.     

Carnosine exhibits significant antiviral activity against Dengue and Zika virus

Dengue virus (DENV) and Zika virus (ZIKV) are flaviviruses transmitted to humans by their common vector, Aedes mosquitoes. DENV infection represents one of the most widely spread mosquito‐borne diseases whereas ZIKV infection occasionally re‐emerged in the past causing outbreaks. Although there have been considerable advances in understanding the pathophysiology of these viruses, no effective vaccines or antiviral drugs are currently available. In this study, we evaluated the antiviral activity of carnosine, an endogenous dipeptide (β‐alanyl‐l ‐histidine), against DENV serotype 2 (DENV2) and ZIKV infection in human liver cells (Huh7). Computational studies were performed to predict the potential interactions between carnosine and viral proteins. Biochemical and cell‐based assays were performed to validate the computational results. Mode‐of‐inhibition, plaque reduction, and immunostaining assays were performed to determine the antiviral activity of carnosine. Exogenous carnosine showed minimal cytotoxicity in Huh7 cells and rescued the viability of infected cells with EC₅₀ values of 52.3 and 59.5 μM for DENV2 and ZIKV infection, respectively. Based on the mode‐of‐inhibition assays, carnosine inhibited DENV2 mainly by inhibiting viral genome replication and interfering with virus entry. Carnosine antiviral activity was verified with immunostaining assay where carnosine treatment diminished viral fluorescence signal. In conclusion, carnosine exhibited significant inhibitory effects against DENV2 and ZIKV replication in human liver cells and could be utilized as a lead peptide for the development of effective and safe antiviral agents against DENV and ZIKV.