Effect of a patient-centered hypertension delivery strategy on all-cause mortality: Secondary analysis of SEARCH,a community-randomized trial in rural Kenya and Uganda

BackgroundHypertension treatment reduces morbidity and mortality yet has not been broadly implemented in many low-resource settings, including sub-Saharan Africa (SSA). We hypothesized that a patient-centered integrated chronic disease model that included hypertension treatment and leveraged the HIV care system would reduce mortality among adults with uncontrolled hypertension in rural Kenya and Uganda.Methods and findingsThis is a secondary analysis of the SEARCH trial (NCT:01864603), in which 32 communities underwent baseline population-based multidisease testing, including hypertension screening, and were randomized to standard country-guided treatment or to a patient-centered integrated chronic care model including treatment for hypertension, diabetes, and HIV. Patient-centered care included on-site introduction to clinic staff at screening, nursing triage to expedite visits, reduced visit frequency, flexible clinic hours, and a welcoming clinic environment. The analytic population included nonpregnant adults (≥18 years) with baseline uncontrolled hypertension (blood pressure ≥140/90 mm Hg). The primary outcome was 3-year all-cause mortality with comprehensive population-level assessment. Secondary outcomes included hypertension control assessed at a population level at year 3 (defined per country guidelines as at least 1 blood pressure measure <140/90 mm Hg on 3 repeated measures). Between-arm comparisons used cluster-level targeted maximum likelihood estimation.Among 86,078 adults screened at study baseline (June 2013 to July 2014), 10,928 (13%) had uncontrolled hypertension. Median age was 53 years (25th to 75th percentile 40 to 66); 6,058 (55%) were female; 677 (6%) were HIV infected; and 477 (4%) had diabetes mellitus. Overall, 174 participants (3.2%) in the intervention group and 225 participants (4.1%) in the control group died during 3 years of follow-up (adjusted relative risk (aRR) 0.79, 95% confidence interval (CI) 0.64 to 0.97, p = 0.028). Among those with baseline grade 3 hypertension (≥180/110 mm Hg), 22 (4.9%) in the intervention group and 42 (7.9%) in the control group died during 3 years of follow-up (aRR 0.62, 95% CI 0.39 to 0.97, p = 0.038). Estimated population-level hypertension control at year 3 was 53% in intervention and 44% in control communities (aRR 1.22, 95% CI 1.12 to 1.33, p < 0.001). Study limitations include inability to identify specific causes of death and control conditions that exceeded current standard hypertension care.ConclusionsIn this cluster randomized comparison where both arms received population-level hypertension screening, implementation of a patient-centered hypertension care model was associated with a 21% reduction in all-cause mortality and a 22% improvement in hypertension control compared to standard care among adults with baseline uncontrolled hypertension. Patient-centered chronic care programs for HIV can be leveraged to reduce the overall burden of cardiovascular mortality in SSA.Trial registrationClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01864603","term_id":"NCT01864603"}}NCT01864603.

Matthew Hickey and co-workers report on outcomes of the SEARCH trial of hypertension screening and care in sub-Saharan Africa.     

The small mammal community of Mukogodo Forest, Kenya

Species richness and diversity of rodents and insectivores were investigated at relict forest patches of Mukogodo, Laikipia, Kenya using Sherman's live traps and pitfall traps. Two hundred and nineteen individuals were captured in 3021 trap‐nights. There were eleven species in two taxonomic groups, Rodentia and Insectivora. Two other rodent species were sighted but not captured. Thirteen bats belonging to four species (Epomophorous wahlbergi, Pipistrellus kuhlii, Scotophilus dingani and Nycteris thebaica) were opportunistically trapped using mist nets. Two of the four species accumulation curves for forest patches did not reach an asymptote. Species richness and diversity were highest at Kurikuri compared with other patches because of habitat variability. The results support the prediction that forest disturbance and degradation lead to an increase in generalist species as compared with specialists and highlight the importance of relict afromontane forests in the conservation of small mammals in Kenya.     

Normal nonmetastatic human trophoblast cells share in vitro invasive properties of malignant cells

First-trimester normal human trophoblast cells show some phenotypic similarities to malignant cells, e.g., rapid proliferation and ability to invade neighboring tissue, including basement membrane in situ, but do not have the ability for unlimited growth or metastasis. The present study examined whether the invasive ability of normal trophoblast cells is an intrinsic property of these cells, independent of the microenvironment provided by the pregnant uterus, and if so, whether they share some of the molecular mechanisms of invasion exercized by metastatic malignant cells. The ability of in vitro grown human trophoblast lines to invade an epithelium-free human amniotic membrane was measured from the temporal kinetics of retention of radioactivity within this membrane resulting from a penetration by 125I-iododeoxyuridine-labeled trophoblast cells. The magnitude of this invasion was compared to that of the highly metastatic human JAR-choriocarcinoma cell line and murine B16F10 melanoma line. Trophoblasts were found to share some of the same molecular mechanisms of invasion with the metastatic cell lines. Inhibitors of collagenase, plasmin, plasminogen, and plasminogen activators completely prevented invasion of the amnion by the trophoblast lines as well as by the metastatic JAR and B16F10 lines. Mersalyl, a compound known to activate collagenase, stimulated invasion by all cell lines tested, including under conditions in which plasmin activity was inhibited. In addition, trophoblasts produced significant levels of type IV collagenase and laminin, both of which appear to be important products of metastatic tumor cells required for basement membrane invasion. It may be concluded from these findings that the invasive property of first trimester human trophoblasts is genetically determined; that the magnitude of amnion invasion cannot differentiate between metastatic cell lines and invasive but nonmetastatic cell lines; and that invasiveness is not a sufficient prerequisite for metastatic ability.     

Further studies of primer-independent phosphorylase isozymes in the algae

Both Oscillatoria princeps and Cyanidium caldarium contain phosphorylase isozymes that can cause the synthesis of polyglucan from glucose-1-phosphate in the absence of added maltodextrin ‘primer’. In addition, O. princeps contains a primer-dependent phosphorylase isozyme. When the phosphorylase fractions isolated from extracts of the algae were treated with α-amylase, the primer-independent isozyme became primer-dependent and shifted from the position it was normally found at after polyacrylamide gel electrophoresis. This primer-independent isozyme became less mobile towards the anode, and was found at the locus usually occupied by the primer-dependent isozyme. It was not possible to restore its mobility towards the anode and its primer-independent properties by preincubation with maltoheptaose. The indication is that this isozyme is a glucoprotein and that the glucan component is chemically bonded to the protein.     

The effect of diamide and glutathione on the uptake of α-methyl-d-glucoside by slices of rat kidney cortex

The uptake of α-methyl-d-glucoside was stimulated in slices of rat kidney cortex by pretreatment with reduced glutathione. Diamide, an oxidizing agent with high specificity for GSH, caused an inhibition of α-methyl-d-glucoside uptake. These effects appeared to be related specifically to GSH, since dithiothreitol and mercaptoethanol did not increase α-methyl-d-glucoside uptake, and were not as effective as GSH in reversing the effects of diamide. GSH and diamide had no effect on the uptake of another sugar analog, $\text{3-O-}\text{methylglucose}$, which is not actively transported. Kinetic studies indicated that GSH increased the apparent $\text{V}$ without affecting $\text{K}{}_{\mathrm{<mtext>m</mtext>}}$. The results are discussed in terms of the possible role of GSH in the process of sugar transport.     

The effect of some alkyl derivatives of cholesterol on the permeability properties and microviscosities of model membranes

The properties of lecithin liposomes or vesicles containing a variety of sterols have been studied by measuring either the release of entrapped glucose or determining microviscosity by fluorescence depolarization of the probe diphenylhexatriene. Sterols containing alkyl substituents at C₃, C₄, or C₁₄ were less effective in reducing glucose permeability or increasing microviscosity than cholesterol. 19-Norcholesterol was also less effective than cholesterol in raising membrane viscosity. These results support the hypothesis that the selective biological demethylation of lanosterol to a planar (α-face) structure optimizes the ability of the sterol molecule to condense the lipid phase of the membrane bilayer. Removal of an angular methyl group (C₁₉), a rare event in biological systems, has the opposite effect.     

Effect of environment pH on storage glucan synthesis in three thermophilic algae

Plectonema nostocorum, a thermophilic cyanophyte which lives under alkaline conditions at pHs approaching 13, forms a storage glucan showing a maximum absorption of its iodine complex almost identical with that of another thermophilic cyanophyte, Oscillatoria princeps, which exists at a more neutral pH, and with that of the acidophilic thermophile, Cyanidium caldarium. Gel electrophoretic patterns of the storage glucan-forming isozymes of Plectonema do not differ essentially from those of Oscillatoria. The a₂ phosphorylase isozyme appears to be primer-independent, and resembles the a₂ isozymes of both Oscillatoria and Cyanidium. The isozymes responsible for forming α-1,6-glucosidic branched linkages in Plectonema are of the b.e. type (able to further branch amylopectin), rather than of the Q type (able to branch amylose only to amylopectin).     

Preferential conformation of the endogenous opiate-like pentapeptide met-enkephalin in DMSO-d6 solution determined by high field 1H NMR

A preferential conformation of the endogenous opiate-like pentapeptide Met-Enkephalin in DMSO-d₆ solution was proposed from high field ¹H NMR experiments at variable temperature and complete analysis of the coupling constants in relation with conformational energy steric maps.This conformation is characterized by a highly folded secondary structure with a β_I turn involving a head-to-tail interaction and a quasi-axial position of the methionine side chain. The N-terminal Tyr-Gly moiety which exhibits a relative degree of freedom shows all the steric requirements found in opiates for a stereospecific interaction with the receptor. All these results are discussed in relation with the physicochemical and biological properties of opiate-like peptides.     

Fluid shear-induced mechanical signaling in MC3T3-E1 osteoblasts requires cytoskeleton-integrin interactions

Mechanical stimulation of bone induces new bone formation invivo and increases the metabolic activity and gene expression ofosteoblasts in culture. We investigated the role of the actin cytoskeleton and actin-membrane interactions in the transmission ofmechanical signals leading to altered gene expression in cultured MC3T3-E1 osteoblasts. Application of fluid shear to osteoblasts causedreorganization of actin filaments into contractile stress fibers andinvolved recruitment of₁-integrins and -actinin tofocal adhesions. Fluid shear also increased expression of two proteinslinked to mechanotransduction in vivo, cyclooxygenase-2 (COX-2) and theearly response gene product c-fos. Inhibition of actin stress fiberdevelopment by treatment of cells with cytochalasin D, by expression ofa dominant negative form of the small GTPase Rho, or by microinjectioninto cells of a proteolytic fragment of -actinin that inhibits-actinin-mediated anchoring of actin filaments to integrins at theplasma membrane each blocked fluid-shear-induced gene expression inosteoblasts. We conclude that fluid shear-induced mechanical signalingin osteoblasts leads to increased expression of COX-2 and c-Fos througha mechanism that involves reorganization of the actin cytoskeleton.Thus Rho-mediated stress fiber formation and the -actinin-dependentanchorage of stress fibers to integrins in focal adhesions may promotefluid shear-induced metabolic changes in bone cells.