Effects of Malaysian thermal spring water as adjunct therapy for mild to moderate acne vulgaris - a prospective, randomised, controlled, split face study

INTRODUCTION

Acne is a common skin disease with a high psychosocial burden, affecting mostly adolescents and youth worldwide. Management of acne is often challenged by cutaneous side effects that leads to therapeutic intolerance, poor compliance and impaired efficacy.

MATERIALS AND METHODS

This was a single-centre, evaluatorblinded, split-face, randomised study investigating the effects of thermal spring water (TSW) in improving efficacy and tolerability of standard acne therapy. Total of 31 participants with mild-to-moderate acne were recruited and subjected to TSW spray to one side of the face 4 times daily for 6 weeks in addition to standard therapy. The other side received standard therapy only.

RESULTS

Six (19.4%) males and 25 (80.6%) female with mean age 25.1±6.13 participated, 15 (48.4%) had mild acne while 16 (51.6%) had moderate acne. Seven (22.6%) were on oral antibiotics, 25 (80.6%) used adapalene, 6 (19.4%) tretinoin and 21 (67.7%) benzoyl peroxide. Skin hydration improved and better on spring water treated side with mean difference12.41±30.31, p = 0.04 at the forehead, 39.52±65.14, p < 0.01 at the cheek and 42.172±71.71, p < 0.01 at the jaw at week 6. Participants also report significant reduction in dryness at the treated side at week 6, mean difference 0.93±0.10, p < 0.001. TEWL, sebum and pH were comparable on both sides with no significant differences. Tolerability towards standard therapy improved as early week 2 with reduction of stinging following application of topical therapy (mean difference 0.62±1.43, p = 0.03), increase in skin feeling good (-1.79±1.70, p < 0.001) and skin suppleness (0.62±1.43, p < 0.001). These improvements were significantly maintained till week 6. Cardiff acne disability index significantly improved at week 6 (p<0.001) despite no significant changes in Comprehensive Acne Severity Scale score before and after treatment.

CONCLUSION

TSW may have a role as an adjunct to standard acne therapy by improving hydration, acne disability index and tolerability towards standard topical treatment.

Isolation and In Silico Characterization of Defensin Genes from Some Indigenous Plant Species of Pakistan

Aims: Damage of crop plants due to pathogenic attacks, postharvest crops spoilage and lethal effects of chemical pesticides has enforced scientists to find some potential natural alternative. Plants produce different types of antimicrobial peptides including defensins in response to biotic and abiotic stresses. Defensins are small cysteine rich, cationic peptide with 40-45 amino acid residues with a variety of biological activities. Hence defensins have pharmaceutical and agricultural significance especially wide range of antifungal activities. Methodology: Nine plant species viz Brassica napus, Brassica nigra, Conyza bonariensis, Alhagi marorum, Sonchus arvensis, Brassica compestris, Eruca sativa, Cirsium arvensis and Brassica juncea were selected for the study. Four set of primers were applied on extracted genomic DNAs and four amplified genes were isolated from different plants species by PCR. The amplified genes were cloned via pTZ57R/T in E.coli. The cloned fragments were sequenced and characterized by different bioinformatics tool such as coding length and peptide sequence, site of cell aggregation, peptide physico-chemical properties, antimicrobial properties and gene expression pattern. Result: The amplified products from B. napus, B. nigra, B. compestris, E. sativa and B. juncea were about 330 bp in length and showed upto 85% nucleotide homology to the reported defensins. Deduced amino acid sequence from Bn-Def, Es-Def Bj-Def and Bc- Def showed the conserved defensin domain. These sequences were also characterized for different characteristic like charged amino acids, pI value, shelflife and stability.  Sonchus arvensis didn’t give any specific product by prescribed set of primers. However the products from Alhagi marorum was about 770 bp and B. napus was of 270 bp but both give homology below 30%. Conclusion: This study showed that in silico characterization of deduced antimicrobial peptides from different plant species has depicted these as an effective alternative to communal therapeutics. However, further work is needed to verify defensins specific activity at protein level.

Epidemiology and clinical profiles of cutaneous graft versus host disease in allogeneic peripheral blood stem cell transplantation

INTRODUCTION

The epidemiology of cutaneous graft versus host disease (GVHD) in allogeneic peripheral blood stem cell transplantation (PBSCT) in Malaysia has not been described.

MATERIALS AND METHODS

We retrospectively analysed 691 allogeneic PBSCT patients between 2010-2017 in two centers.

RESULTS

The prevalence of cutaneous GVHD was 31.4% (217/691). No associations were detected with race, age or gender of donor and recipients. Cutaneous GVHD was associated with host cytomegalovirus (CMV) seropositivity (p<0.01), conditioning (p<0.01), GVHD prophylaxis (p=0.046) and survival (p<0.01). Majority developed the acute form (58.1%;126/217). Biopsies in 20.7% (45/217) showed 55.6% positivity for GVHD. Overall, involvement was non-severe. A majority demonstrated complete response (CR) to first-line corticosteroids (70.0%;152/217). Secondline therapies (extracorporeal phototherapy (ECP), psolaren ultraviolet A (PUVA), mycophenolate, tumour necrosis factor (TNF) inhibitors, interleukins inhibitors, or CD20 monoclonal antibodies) were required in 65/217, with 38.5% CR. Second-line therapy was associated with gender (p=0.042), extra-cutaneous GVHD (p=0.021), treatment outcomes (p=0.026) and survival (p=0.048). Mortality in cutaneous GVHD was 24.0% with severe sepsis being the leading cause at Day 100 (7.8%) and 5-years (7.8%), and relapsed disease at 2-years (32.7%). In steroid refractoriness, severe GVHD caused 30.8% mortality. In cutaneous GVHD, survival at Day 100 was 95.4%; 80.2% at 2-years and 73.1% at 5-years. The median survival in cutaneous GVHD was significantly shorter at 55 months, compared to those without GVHD at 69 months (p=0.001).

CONCLUSION

Cutaneous involvement is the commonest clinical manifestation of GVHD. A larger national study is warranted to further analyse severity and outcome of multiorgan GVHD, and factors associated with steroid refractoriness.

Lymphocutaneous sporotrichosis of the abdominal wall: A lesson in lymphatic drainage

Cutaneous sporotrichosis (CS) presents as asymptomatic lesions of varied morphology. The most common variant is the lymphocutaneous type which typically progresses from a papule to an ulcer and then forms nodules along the superficial lymphatic channels. Diagnosis CS may be challenging when the lesion presents at an uncommon site where the superficial lymphatic drainage is unfamiliar. We present here a case of sporotrichosis of the abdominal wall which was initially misdiagnosed as an abscess but later confirmed by culture and managed successfully.

POS0723 HERPES ZOSTER IN A MULTI-ETHNIC SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) COHORT: CLINICAL FEATURES AND RISK FACTORS

Background:

Systemic Lupus Erythematosus (SLE) patients are at risk of Herpes Zoster (HZ) infection due to the underlying immunosuppressed state. The reported incidence of HZ in SLE is 6 to 10-times higher than the general population.

Objectives:

To determine the clinical characteristics of SLE patients who develop Herpes Zoster (HZ) infection and their associated risk factors.

Methods:

Medical records review was performed on consecutive SLE patients in Universiti Kebangsaan Malaysia Medical Centre (UKMMC) from 2018 until 2019. Previous history of HZ and their demographic characteristics, clinical and medications used at the time of infection were recorded. Univariate and multivariate analyses were performed to compare the clinical and treatment characteristics between SLE patients with history of HZ and patients who had never had experienced HZ.

Results:

A total of 229 patients with predominantly Malay patients (n=123, 53.7%), followed by Chinese (n=90, 39.3%) and others (n=16, 7.0%) were included. A total of 37 patients had history of HZ (16.2%). Their mean age during HZ episode was 34.4 ± 13.8 years and their SLE disease duration was 68.7 ±57.1 months. More than half of them (n=21, 56.8%) developed HZ when the SLE disease was active with the mean dose of prednisolone at the time of infection was 20.7 ± 9.2 mg daily. A total of 21 HZ patients (56.8%) had ever received cyclophosphamide with the median interval of the last infusion was 6 (0.2-84) months. Almost half of the HZ patients (n=18, 48.6%) developed the infection while on cyclosporine A. Meanwhile, 4 (10.8%) were on azathioprine and mycophenolate mofetil respectively. Chinese patients tend to have HZ as compared to other ethnics (27% vs 41.7%), p=0.07. HZ occurred in a higher proportion among male patients (29%) as compared to female patients (14.1%), p=0.05. The use of azathioprine (10.8% vs 55.2%, p<0.01) and mycophenolate mofetil (10.8% vs 31.8%, p=0.009) were less associated with HZ. On the other hand, the use of cyclosporine A (48.6% vs 32.3%, p=0.05) and prednisolone ≥ 60mg daily (44.4% vs 28%, p=0.04) were associated with HZ. Higher HZ patients had hematological manifestation (81.1% vs 62.5%, p=0.04) and positive lupus anticoagulant (LA), 32.4% vs 14.6%, p=0.02. A forward logistic regression which included all factors with p<0.1 in the univariate analyses revealed that the use of prednisolone ≥ 60mg daily and hematological manifestation were the independent predictors of HZ with OR= 2.28 (95% C.I = 1.01-5.17), p=0.049 and OR= 2.78 (95% C.I = 1.09-7.04), p=0.03 respectively. The use of azathioprine was associated with a lower risk of HZ with OR 0.08 (95% C. I= 0.03-0.25), p=<0.01.

Conclusion:

Our study demonstrated the possible influence of male gender, Chinese ethnicity and disease characteristics such as hematological manifestation and lupus anticoagulant positivity with the occurrence of HZ. In addition, the use high dose oral prednisolone ≥ 60mg daily was the independent predictor of HZ while on the other hand, the use of azathioprine was associated with a lower risk of developing HZ as compared to other immunosuppressive agents. Further larger studies are needed to confirm these associations.

References:

[1]Chen D, Li H, Xie J, Zhan Z, Liang L, Yang X. Herpes zoster in patients with systemic lupus erythematosus: Clinical features, complications and risk factors. Exp Ther Med. 2017;14(6):6222-6228.

Disclosure of Interests:

None declared

Towards a large-scale integration of renewable energies in Morocco

Renewable energies are a sustainable, unlimited and decarbonised solution to address future energy challenges. In this context, Morocco has a considerable advantage to position itself on this promising market. Furthermore, renewable energies have been highlighted as a key strategic source for the country's green growth. Morocco has adopted the renewable energy path through a strategy targeted on the development of solar, wind and hydroelectric power to boost its energy policy by adapting it to the challenges posed by today's world. Nowadays, Morocco is facing a challenge to reach 52% by 2030 of its total renewable energy capacity, which will exceed 42% by the end of 2020. The main objective of this paper is to study a scenario for 2030 for the Moroccan electricity system and to identify the challenges that need to be addressed in order to accelerate the integration of renewable energies in the Moroccan energy mix and to achieve a possible export of such green energy towards Europe.

Comparison of transepidermal water loss and skin hydration in diabetics and nondiabetics

BACKGROUND

Pruritus is common in patients with diabetes mellitus (DM), and may lead to complex dermatological conditions if left untreated. Pruritus can be caused by increased transepidermal water loss (TEWL) and reduced skin hydration.

AIMS

To compare TEWL and skin hydration in patients with DM and controls, and to investigate associations between TEWL and skin hydration with glycated haemoglobin (HbA1c), fasting blood sugar (FBS), treatment, peripheral neuropathy (PN) and age in patients with diabetes.

METHODS

This was a prospective, case-control study carried out at a tertiary medical centre in Kuala Lumpur, Malaysia. TEWL and skin hydration measurements were taken at six different body sites in both groups.

RESULTS

In total, 146 patients (73 cases, 73 controls) were included (24 men and 49 women in each group). No significant difference in TEWL or skin hydration was seen between patients with DM and controls, but there were significant reductions in skin hydration in patients with DM who had FBS > 7 mmol/L (P < 0.01) or PN (P < 0.01). There was a reduction in TEWL over the anterior shin in patients with HbA1c levels > 6.5% (P < 0.02) and an increase in TEWL on the flank in patients on insulin injections at doses of > 1 U/kg/day (P < 0.01). In participants > 45 years old, there was a significant reduction in TEWL (P = 0.04) and hydration (P < 0.04) in the DM and control groups, respectively.

CONCLUSION

There was no difference in TEWL and skin hydration in patients with DM compared with controls. In the DM group, reduction in skin hydration was associated with uncontrolled FBS and PN but not with HbA1c or DM treatment, whereas TEWL was lower in patients with FBS > 8 mmol/L and increased in patients with higher insulin requirement.

Merkel cell carcinoma: Preparing to go the distance

INTRODUCTION

Merkel cell carcinoma (MCC) is a rare and aggressive malignancy of the skin, with poor clinical outcomes. Typical conditions include a rapidly growing, solitary dome-shaped, violaceous nodule. Several root causes have been identified - sun exposure, age, lighter skin, immunocompromised state, and polyomavirus infection. Wide local excision is the best treatment. The tumour is radiotherapy-responsive. However, the success rate of the treatment with chemotherapy is rather limited. Immunotherapy has shown promising results. Early detection is important to prevent morbidity and mortality.

CASE REPORT

In this literature work, we reported on a particular case of MCC, as exhibited by an 84-year-old Chinese woman, and discussed the clinical features and management of MCC.

DISCUSSION

We highlighted that MCC cases have a link to the polyomavirus 5. Patients who were identified with the Polyomavirus 5, and underwent immunotherapy, were seen to depict much better prognosis.

Measurement of the Spectral Shape of the β-Decay of ^{137}Xe to the Ground State of ^{137}Cs in EXO-200 and Comparison with Theory

We report on a comparison between the theoretically predicted and experimentally measured spectra of the first-forbidden nonunique β-decay transition ^{137}Xe(7/2^{-})→^{137}Cs(7/2^{+}). The experimental data were acquired by the EXO-200 experiment during a deployment of an AmBe neutron source. The ultralow background environment of EXO-200, together with dedicated source deployment and analysis procedures, allowed for collection of a pure sample of the decays, with an estimated signal to background ratio of more than 99 to 1 in the energy range from 1075 to 4175 keV. In addition to providing a rare and accurate measurement of the first-forbidden nonunique β-decay shape, this work constitutes a novel test of the calculated electron spectral shapes in the context of the reactor antineutrino anomaly and spectral bump.

Search for Neutrinoless Double-β Decay with the Complete EXO-200 Dataset

A search for neutrinoless double-β decay (0νββ) in ^{136}Xe is performed with the full EXO-200 dataset using a deep neural network to discriminate between 0νββ and background events. Relative to previous analyses, the signal detection efficiency has been raised from 80.8% to 96.4±3.0%, and the energy resolution of the detector at the Q value of ^{136}Xe 0νββ has been improved from σ/E=1.23% to 1.15±0.02% with the upgraded detector. Accounting for the new data, the median 90% confidence level 0νββ half-life sensitivity for this analysis is 5.0×10^{25}  yr with a total ^{136}Xe exposure of 234.1 kg yr. No statistically significant evidence for 0νββ is observed, leading to a lower limit on the 0νββ half-life of 3.5×10^{25}  yr at the 90% confidence level.

THE CONSISTENCY OF EXPOSURE INDICATOR VALUES IN DIGITAL RADIOGRAPHY SYSTEMS

After years of establishment of computed radiography (CR) and digital radiography (DR), manufacturers have introduced exposure indicator/index (EI) as a feedback mechanism for patient dose. However, EI consistency is uncertain for CR. Most manufacturers recommended EI values in a range of numbers for all examination, instead of giving the exact range for a specific body part, raising a concern of inappropriate exposure given to the patient in clinical practice. The aims of this study were to investigate the EI consistency in DR systems produced in constant exposure parameters and clinical condition, and to determine the interaction between the anatomical part and EI. A phantom study of skull, chest, abdomen and hand was carried out and four systems were used for comparison-Fuji CR, Carestream CR, Siemens DR and Carestream DR. For each projection, the phantom positioning and exposure parameters were set according to the standard clinical practice. All exposure parameters and clinical conditions were kept constant. Twenty (20) exposures were taken for each projection and the EI was recorded. Findings showed that EI is not consistent in DR systems despite constant exposure parameters and clinical condition except in Siemens DR, through skull examination. Statistical analysis showed a significant interaction between anatomical parts and EI values (P < 0.05). EI alone was proven to be less reliable to provide technologist a correct feedback on exposure level. The interaction between anatomical parts and EI values intensifies the need for an anatomical-specific EI values set by all manufacturers for accurate feedback on the exposure parameters used and the detector entrance dose.

Systemic lupus erythematosus among male patients in Malaysia: how are we different from other geographical regions?

BACKGROUND

Systemic lupus erythematosus (SLE) is an autoimmune disease which predominantly affects females. The disease characteristics in male SLE patients are reported to be distinct and may vary across ethnicities and geographical regions.

OBJECTIVE

To determine and compare the clinical phenotype and organ damage between male and female patients with SLE in Malaysia.

METHODOLOGY

This was a cross-sectional study involving SLE patients from Universiti Kebangsaan Malaysia Medical Centre from June 2016 until June 2017. Information on their socio-demographics and disease characteristics were obtained from the clinical records. Disease damage was assessed using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage index (SDI) scores. The disease characteristics, autoantibody profiles and organ damage were compared between male and female patients, and multivariable analysis using male sex as dependent variable was then performed.

RESULTS

A total of 418 patients were recruited and a total of 59 (14.1%) patients were male. Male patients presented with lower SLE ACR criteria at initial presentation but a significantly higher number of them had renal involvement (lupus nephritis) (78.0% versus 63.8%, p = 0.04). Male patients had less musculoskeletal involvement (45.8% versus 63.0%, p = 0.02) and tended to have lesser mucocutaneous involvement. Immunologic profile revealed that a lower number of male patients had positive anti-Ro antibody (22.7% versus 44.7%, p = 0.04) and they tended to have positive lupus anticoagulant antibody (27.6% versus 14.3%, p = 0.06). Presence of organ damage (SDI score ≥ 1) was significantly higher among males (55.9% versus 39.6%, p = 0.02) with higher renal damage (25.4% versus 9.2%, p = 0.004) and cardiovascular event of ischaemic heart disease or stroke (20.3% versus 7.0%, p = 0.004). They were also inclined to develop damage much earlier as compared to female patients, 3 (interquartile range (IQR) 7.5) versus 5 (IQR 7) years, p = 0.08. The occurrence of disease damage was independently associated with male gender with odds ratio of 1.9 (95% confidence interval 1.1-3.5), p = 0.02.

CONCLUSION

Male patients with SLE have more severe disease with renal damage and cardiovascular event.

Electrospun probiotics: an alternative for encapsulation

Electrospinning has emerged as a potential method to fabricate nonwoven nanofibers. It has application in different fields of biomedicine as it has potential to carry antimicrobial and bioactive agents. The present investigation was conducted to optimize the process conditions and determine the viability of probiotics after being electrospun in fibers. Poly(vinyl alcohol) (PVA) was utilized as electrospun material because it possesses generally recognized as safe (GRAS) status and in dry form it acts as a high oxygen barrier and has high water solubility. This characteristic allows the easy recovery of the bacteria from electrospun fibers. The viability tests, carried out at three different temperatures (room temperature, 4°C and -20°C) showed Bifidobacterium animalis subsp. Lactis Bb12 (probiotic 1) and combination of Streptococcus thermophilus (TH-4®), Lactobacillus paracasei 431® and Bb-12 (probiotic 2) within the electrospun PVOH fibers remained viable after 1 week at room temperature and refrigeration temperature. The nanofibers containing probiotics prepared with 9% poly venyl alcohol showed homogenous, uniform, bead-free and smooth texture. Probiotic 1 demonstrated growth as 1.85×108, 1.57×108 and 1.71×108 before, 0 hour and after 1 week of encapsulation. While probiotic 2 exhibited a growth of 2.1×108 before electrospinning, 1.3 ×108 at 0 hour and 1.97×108 after one week of electrospinning. There was no change in CFU/mL count and remained 108 CFU/mL. The encapsulation efficiency was 84.07% and 85.73% at 0 and one week, respectively, for Probiotic 1, while probitic 2 showed 90.09% and 93.59 % encapsulation efficiency before and after one week, respectively. Considering the prolonged viability of nanofibers containing probiotics noted at room temperature, this technology can be implemented for prolonged viability of probiotics.

Photoprotection awareness and practices among patients with systemic lupus erythematosus and its association with disease activity and severity

Objective The objective of this paper is to determine photoprotection awareness, knowledge, practices, and its relationship with disease activity and damage in patients with systemic lupus erythematosus (SLE). Methods A cross-sectional study was performed. Data were acquired from in-person interviews and medical records. Results A total of 199 (89.6%) females and 23 (10.4%) males were recruited. Median age was 39.00 (interquartile range (IQR) 18) years, disease duration 12.12 (IQR 8) years, Fitzpatrick skin phototype III 119 (53.6%) and IV 81 (36.5%). Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K) was 2.95 (IQR 4) while Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC-ACR DI) was 1.20 (IQR 2). The majority 205 (92.3%) were aware of sun exposure effects on SLE. Photoprotection methods were shade seeking 209 (94.1%), sun avoidance 212 (95.5%), long pants 168 (75.7%), long sleeves 155 (69.8%), sunscreen 116 (52.3%), sunglasses 114 (51.4%) and head cover 103 (46.4%). Significantly higher photoprotection practice scores (PPS) were observed in females, Malays, and individuals with higher education level and internet accessibility. PPS were not significantly correlated with SLICC-ACR DI and SLEDAI-2 K. Independent predictors for good photoprotection practice (GPP) were ethnicity (OR = 3.66, 95% CI 1.78-7.53), awareness (OR = 3.77, 95% CI 1.09-13.08) and cutaneous involvement (OR = 2.43, 95% CI 1.11-5.28). Photoprotection methods and GPP were not predictors for disease activity or damage. Conclusion Photoprotection awareness and knowledge was good. Shade seeking and sun avoidance were the common photoprotection methods practised. The use of sunscreen requires improvement. Photoprotection awareness and cutaneous manifestation were predictors for GPP. Neither photoprotection methods nor GPP were associated with disease activity or damage.

Association of BCL-2 with oxidative stress and total antioxidant status in pediatric acute lymphoblastic leukemia

B-Cell Lymphoma protein-2 (BCL-2) is one of the most studied proteins with substantial regulatory potential for both apoptosis and autophagy. BCL-2 confer chemoresistance through influencing cancer pathophysiology. Serum level of lactate dehydrogenase (LDH) predicts increased anaerobic glycolysis and is associated with metabolic modulation in cancer cells. In the present research, the interplay of BCL-2, total oxidative status (TOS) and LDH was investigated in patients with acute lymphoblastic leukemia (ALL). The studied parameters, BCL-2 protein (p less than 0.001), TOS (p less than 0.001) and LDH (p less than 0.001) were significantly elevated in the ALL group compared to the normal group (N-group). However, the total antioxidant status (TAS) was reduced significantly (p less than 0.01) in ALL patients. In the ALL group, the TOS had significant negative correlation with TAS (p less than 0.01). Furthermore, non-significant positive correlations were found between BCL-2 and LDH, BCL-2 and TAS and LDH and TAS (each with; p>0.05). However, a negative non-significant correlation was observed between BCL-2 and TOS and LDH and TOS (each with; p>0.05).

In vitro antioxidant potential of selected aphrodisiac medicinal plants

The present study aimed to evaluate the antioxidant activity of six selected aphrodisiac medicinal plants. Useful parts of the selected medicinal plants were collected and extracted in methanolic solvent. The antioxidant activity of selected plant extract was determined through different antioxidant assays, namely DPPH radical scavenging assay and ferric reducing antioxidant assay. Moreover, antioxidant compounds, like total phenolics and total flavonoids contents, were also determined. Results showed that Mucuna pruriens seed extract displayed high contents of phenolic compounds with total phenolic content of 683.15±4.28 mg GAE/g dry plant material while the least phenolic content was observed in Asparagus racemosus (195.5±3.02 mg GAE/g dry plant material). Highest total flavonoids content was found in Anacyclus pyrethrum roots (156.58±4.01 μg CE/g) and the least content was found in Asparagus racemosus roots. Among the studied plant extracts, the highest radical scavenging activity was shown by Mucuna pruriens seed extract (82.05±0.55%) and the least percent scavenging activity was observed in Tribulus terrestris extract (36.40±2.01%). Vitamin C was used as positive control for antioxidant assays showing 93.54±0.9% radical scavenging activity. The plant extract also exhibited a strong reducing potential against free radicals. Therefore, the present study concluded that all the studied medicinal plants possess varying concentrations of secondary active metabolites responsible for the antioxidant properties of the tested plant extracts.

Evaluation of foot and mouth vaccination for yak (Bos grunniens) in Pakistan

In northern Pakistan, many farming communities rely on domestic yak (Bos grunniens) as a principle source of income. A 2006 participatory disease surveillance report from this region indicated that foot-and-mouth disease (FMD) is the most prevalent annual disease of yak. Our objectives of this study were to determine exposure levels of yak to FMD virus; implement a vaccination program based on current, regional FMD virus serotypes and subtypes; and quantify immune responses following vaccination. Blood samples were used to determine pre-vaccination exposure of animals to FMD virus by antibody presence to non-structural proteins of FMD virus using a 3-ABC trapping indirect ELISA. Vaccine used consisted of FMD serotypes 'O' (PanAsia-2), 'A' (Iran-05), and 'Asia-1' (Shamir), but changed later during the study to match newly circulating viruses in the country ('O'-PanAsia-2; 'A'-Turk-06 and Asia-1-Sindh-08). Three hundred sixty-three blood samples were tested from selected villages to determine pre-vaccination FMD virus exposure in yak with an average of 37.7%. Immune responses from initial vaccination and booster dose 30 days later showed clear protective levels (as mean percent inhibition) of antibodies against structural proteins of serotypes 'O,' 'A,' and 'Asia-1.' These responses remained above threshold positive level even at day 210 following initial vaccination. Results of sero-surveillance and anecdotal information of repeated FMD outbreaks demonstrate the persistence of FMD virus of yak in northern Pakistan. Laboratory results and field observations clearly indicated that yak can be protected against FMD with a good quality vaccine with FMD serotype(s) matching current, regionally circulating FMD virus.

Single-dose systemic methotrexate vs expectant management for treatment of tubal ectopic pregnancy: a placebo-controlled randomized trial

OBJECTIVE

Methotrexate is used routinely worldwide for the medical treatment of clinically stable women with a tubal ectopic pregnancy. This is despite the lack of robust evidence to show its superior effectiveness over expectant management. The aim of our multicenter randomized controlled trial was to compare success rates of methotrexate against placebo for the conservative treatment of tubal ectopic pregnancy.

METHODS

This study took place in two early-pregnancy units in the UK between August 2005 and June 2014. Inclusion criteria were clinically stable women with a conclusive ultrasound diagnosis of a tubal ectopic pregnancy, presenting with a low serum beta human chorionic gonadotropin (β-hCG) level of < 1500 IU/L. Women were assigned randomly to a single systemic injection of either 50 mg/m² methotrexate or placebo. The primary outcome was a binary indicator for success of conservative management, defined as resolution of clinical symptoms and decline of serum β-hCG to < 20 IU/L or a negative urine pregnancy test without the need for any additional medical intervention. An intention-to-treat analysis was followed.

RESULTS

We recruited a total of 80 women, 42 of whom were assigned to methotrexate and 38 to placebo. The arms of the study were matched in terms of age, ethnicity, obstetric history, pregnancy characteristics and serum levels of β-hCG and progesterone. The rates of success were similar for the two study arms: 83% with methotrexate and 76% with placebo. On univariate analysis, this difference was not statistically significant (χ² (1 degree of freedom) = 0.53; P = 0.47). On multivariate logistic regression, the serum level of β-hCG was the only covariate found to be significantly associated with outcome. The odds of failure increased by 0.15% for each unit increase in β-hCG (odds ratio, 1.0015 (95% CI, 1.0002-1.003); P = 0.02). In 14 women presenting with serum β-hCG of 1000-1500 IU/L, the success rate was 33% in those managed expectantly compared with 62% in those receiving methotrexate. This difference was not statistically significant and a larger sample size would be needed to give sufficient power to detect a difference in the subgroup of women with higher β-hCG. In women with successful conservative treatment, there was no significant difference in median β-hCG resolution times between study arms (17.5 (interquartile range (IQR), 14-28.0) days (n = 30) in the methotrexate group vs 14 (IQR, 7-29.5) days (n = 25) in the placebo group; P = 0.73).

CONCLUSIONS

The results of our study do not support the routine use of methotrexate for the treatment of clinically stable women diagnosed with tubal ectopic pregnancy presenting with low serum β-hCG (< 1500 IU/L). Further work is required to identify a subgroup of women with tubal ectopic pregnancy and β-hCG ≥ 1500 IU/L in whom methotrexate may offer a safe and cost-effective alternative to surgery. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Comparación entre una sola dosis de metotrexate sistémico y la conducta expectante en el tratamiento de casos de embarazo ectópico tubárico: un ensayo aleatorio controlado con placebo RESUMEN OBJETIVO: El metotrexate se utiliza de modo rutinario en todo el mundo para el tratamiento de las mujeres clínicamente estables con un embarazo ectópico tubárico. Esto sucede a pesar de la falta de evidencia rigurosa que demuestre que su eficacia es superior a la conducta expectante. El objetivo de este ensayo controlado aleatorio multicéntrico fue comparar las tasas de éxito del metotrexate con las de un placebo para el tratamiento cauteloso del embarazo ectópico tubárico. MÉTODOS: Este estudio se llevó a cabo en dos clínicas de control de gestación temprana en el Reino Unido entre agosto de 2005 y junio de 2014. Los criterios de inclusión fueron mujeres clínicamente estables con un diagnóstico ecográfico concluyente de embarazo ectópico tubárico, las cuáles presentaban una concentración sérica baja de la β hormona coriónica gonadotrópica (β-hCG) inferior a 1500 UI/L. Las mujeres fueron asignadas aleatoriamente a una sola inyección sistémica de 50 mg/m2 de metotrexate o a placebo. El resultado primario fue un indicador binario del éxito del tratamiento conservador, definido como la resolución de los síntomas clínicos y la disminución en el suero de la β-hCG a <20 UI/L o una prueba de embarazo negativa en orina sin la necesidad de ninguna intervención médica adicional. Se hizo un análisis por intención de tratar.

RESULTADOS

Se reclutó un total de 80 mujeres; a 42 de ellas se les asignó el metotrexate y a 38 el placebo. Los grupos del estudio se realizaron en función de la edad, el origen étnico, los antecedentes obstétricos, las características del embarazo y los niveles séricos de la β-hCG y la progesterona. Las tasas de éxito fueron similares para los dos grupos de estudio: 83% con metotrexate y 76% con placebo. En el análisis univariante, esta diferencia no fue estadísticamente significativa (χ2 (1 grado de libertad) = 0,53; P = 0,47). En la regresión logística multivariante, el nivel sérico de la β-hCG fue la única covariable que se encontró significativamente asociada con el resultado. Las probabilidades de fracaso aumentaron en un 0,15% por cada unidad de aumento de la β-hCG (cociente de probabilidad 1,0015 (IC 95%, 1,0002-1,003); P = 0,02). La tasa de éxito en las 14 mujeres con un nivel sérico de la β-hCG de 1000-1500 UI/L fue del 33% en las tratadas con conducta expectante frente al 62% en las que recibieron metotrexate. Esta diferencia no fue estadísticamente significativa, por lo que se necesitaría un tamaño de muestra mayor, lo suficiente como para poder detectar diferencias en el subgrupo de mujeres con una β-hCG más elevada. En las mujeres en las que el tratamiento conservador tuvo éxito, no hubo una diferencia significativa en la mediana de los tiempos de resolución de la ß-hCG entre los grupos del estudio (17,5 (amplitud intercuartílica (IQR), 14-28,0) días (n = 30) en el grupo de metotrexate frente a 14 (IQR, 7-29.5) días (n = 25) en el grupo de placebo; P = 0,73).

CONCLUSIONES

Los resultados de este estudio no apoyan el uso rutinario de metotrexate para el tratamiento de las mujeres clínicamente estables diagnosticadas con un embarazo ectópico tubárico que presenta un nivel sérico bajo la β-hCG (<1500 UI/L). Serán necesarios estudios adicionales para identificar un subgrupo de mujeres con embarazo ectópico tubárico y β-hCG ≥1500 UI/L para quienes el metotrexate puede ofrecer una alternativa segura y rentable en comparación con la cirugía. : : ,,。。 : 2005820146,2。,,β(beta human chorionic gonadotropin,β-hCG)<1500 IU/L。,(50 mg/m² )。,β-hCG<20 IU/L,。。 : 80,42,38。2、、、β-hCG。2:83%,76%。,[χ² (1)=0.53;P=0.47]。logistic,β-hCG。β-hCG,0.15%[,1.0015(95% CI,1.0002~1.003);P=0.02]。14β-hCG1000~1500 IU/L,33%,62%。,β-hCG。,2β-hCG(P=0.73),17.5[(interquartile range,IQR),14~28.0](n=30),14 (IQR,7~29.5)(n=25)。 : 、、β-hCG(<1500 IU/L)。,β-hCG>1500 IU/L、。.

Diagnosis and management of intramural ectopic pregnancy

Intramural pregnancy is a rare form of ectopic pregnancy, and little is known about its etiology, prevalence and natural history. There is no consensus regarding the ultrasound criteria necessary for the diagnosis of intramural pregnancy, and management strategies vary depending on the severity of clinical presentation, exact location of the pregnancy, viability and gestational age at diagnosis. We present four cases of intramural pregnancy diagnosed in a single institution that illustrate variability in their clinical presentation and difficulty in reaching the correct diagnosis. We also propose a set of ultrasound criteria to facilitate differential diagnosis between intramural and other types of uterine ectopic pregnancy.

Efficacy and safety of a clinical protocol for expectant management of selected women diagnosed with a tubal ectopic pregnancy

OBJECTIVE

To validate the efficacy and safety of our clinical protocol for expectant management of selected women diagnosed with tubal ectopic pregnancy.

METHODS

This was a prospective observational study carried out in the early pregnancy unit of a London inner-city university teaching hospital from 1(st) January 2008 to 31(st) May 2011. All women presenting with suspected early pregnancy complications were assessed clinically and by transvaginal ultrasound. Those with a conclusive ultrasound diagnosis of tubal ectopic pregnancy were selected for either surgical or expectant management. Selection criteria for expectant management were clinical stability with no or minimal abdominal pain, no evidence of significant hemoperitoneum on ultrasound scan, ectopic pregnancy measuring < 30 mm in mean diameter with no evidence of embryonic cardiac activity, serum β-human chorionic gonadotropin (β-hCG) < 1500 IU/L and the woman's consent. All women selected for expectant management were followed up as outpatients until the ectopic pregnancy regressed spontaneously (resolution of clinical symptoms, serum β-hCG < 20 IU/L/negative urine pregnancy test) or surgical intervention was required. We recorded the rate of interventions, complications and length of follow-up.

RESULTS

During the study period 339/11 520 (2.9% (95% CI, 2.59-3.21%)) women were diagnosed with tubal ectopic pregnancy. Six women opted to participate in an ongoing randomized controlled trial and were excluded from further analysis. One hundred and sixty-five (49.5% (95% CI, 44.2-55.0%)) of the 333 remaining women met the criteria for expectant management; 146/333 (43.8% (95% CI, 38.5-49.1%)) of them opted for expectant management and 104/333 (31.2% (95% CI, 26.2-36.2%)) of all tubal ectopics resolved without requiring any intervention. All women with failed expectant management were treated by laparoscopic salpingectomy/salpingotomy and none of them required a blood transfusion.

CONCLUSION

Our clinical protocol for expectant management of tubal ectopic pregnancies eliminates the need for medical or surgical treatment in more than a third of women diagnosed with tubal ectopic pregnancy with a minimum risk of adverse outcome.

Mismanagement of cat bite wound: lessons to learn

Animal inflicted wounds, left untreated may result in chronic bacterial or fungal infection. Clinical features of these infections may overlap leading to a delay in diagnosis and treatment. We report a case of chronic non-healing cat bite wound treated with several antibiotics without improvement. Later patient developed the classical "sporotrichoid spread" and a presumptive diagnosis of sporotrichosis was made. Laboratory investigation for fungal culture and skin biopsy failed to identify the underlying pathogen. A trial of oral antifungal agent resulted in complete recovery of the lesions implicating fungus as the causative pathogen. Physicians should have a high index of suspicion for fungal infections when managing animal inflicted wounds.

Allogeneic stem cell transplantation for Glanzmann thrombasthenia

Glanzmann thrombasthenia (GT) is a rare autosomal recessive bleeding disorder characterized by normal platelet count, but lack of platelet aggregation. The molecular basis is linked to quantitative and/or qualitative abnormalities of the membrane glycoprotein IIb/IIIa complexes. Usually it is associated with mild bleeding but may lead to severe and potentially fatal hemorrhages. Allogeneic hematopoietic stem cell transplantation (HSCT) is the only curative treatment. However, because of the risks associated with HSCT, it is generally not recommended unless there are life threatening hemorrhages, or the patient has developed refractoriness to platelet transfusion due to antibody formation. Herein, we report an 11-year-old female from United Arab Emirates (UAE) with severe GT and anti platelet alloimmunization successfully treated with HSCT from her HLA-identical sibling.

The Influence of Exogenous Multienzyme Preparation and Graded Levels of Digestible Lysine in Sunflower Meal-Based Diets on the Performance of Young Broiler Chicks Two Weeks Posthatching

The study was conducted to investigate the effect of adding multienzyme preparation (Rovabio Excel AP, Adisseo Asia Pacific Pte Ltd., Singapore) at 2 inclusion levels of sunflower meal (SFM; 20 and 30% of the diets) with 3 levels of digestible Lys (0.8, 0.9, and 1.0%) with and without enzyme in a 2 x 2 x 3 factorial arrangement. Each diet was offered to 4 replicates of 51 one-day-old straight-run Hubbard broiler chicks (n = 2448) in a practical vegetable-based mash diet having 2,750 kcal of ME/kg and 19% CP during 2 wk posthatching (1 to 14 d of age). Feed formulation was based on digestible amino acids, which were calculated from the CP and DM contents of each ingredient using AminoDat 2 (Degussa Corp., Allendale, NJ). The enzyme used in this study was authenticated by the supplier to have minimum level of endo-1,4-beta xylanase (22,000 visco units/g) and endo-1,3(4)-beta glucanase (2,000 AGL units/g) and was added at the rate of 50 mg/kg of finished diet. No significant effect of enzyme or level of SFM was observed on BW gain (BWG), feed intake, or mortality during the experimental period. The BWG and feed:gain for birds fed on 30% SFM with enzyme were comparable to those fed on 20% SFM without enzyme during 1 to 14 d of age. However, enzyme at 20% SFM depressed the BWG (P <or=0.006) and feed conversion ratio (P <or=0.027). A quadratic (P <or=0.036) response of digestible Lys was noted for BWG, whereas it was linear (P <or=0.001) for feed:gain during 1 to 7 and 1 to 14 d. A level of 1.0% digestible Lys was observed best for BWG and feed:gain. For BWG, 0.8 and 0.9% digestible Lys was comparable when it was used at 30% SFM, along with enzyme. In conclusion, enzyme supplementation during 2 wk posthatching has no remarkable effect when used in SFM-based diets. Moreover, digestible Lys may be lowered to 0.8% during the first week but not less than 1.0% during the second week post-hatching.

Interpretation of vitamin A status in apparently healthy Pakistani children by using markers of subclinical infection

BACKGROUND

Plasma retinol concentrations are depressed by infection but are commonly used to assess vitamin A status.

OBJECTIVE

We measured 2 acute phase proteins, alpha(1)-antichymotrypsin (ACT) and alpha(1)-acid glycoprotein (AGP), to determine whether they could be used to assist in interpreting vitamin A status.

DESIGN

In 1997, a 2-stage cluster-sampling procedure was used to select 3074 apparently healthy, 6-60-mo-old children from rural and urban areas of North West Frontier Province, Pakistan. Plasma retinol, ACT, AGP, and ferritin measurements and anthropometric measurements were obtained for 2519 children.

RESULTS

Median plasma retinol, ACT, AGP, and ferritin concentrations were 0.86 micromol/L, 0.39 g/L, 1.14 g/L, and 5.5 microg/L, respectively. There were no significant (P: > 0.05) differences in retinol, ACT, or AGP by sex or age. Some 797 children (32%) had retinol concentrations <0.7 micromol/L and 87 (4%) had retinol concentrations <0.35 micromol/L; 274 children (11%) had elevated ACT (>0.6 g/L) and 1141 (45%) had elevated AGP (>1.2 g/L). Retinol concentration correlated with ACT (r = -0.141), AGP (r = -0.138), and ferritin (r = -0.09) (all P: < 0.001), but stepwise multiple regression indicated that these 3 variables made a minimal although quantifiable contribution to the variance of retinol (ACT, r(2) = 0.02; all 3 variables, r(2) = 0.03).

CONCLUSIONS

The transient depression in plasma retinol produced by subclinical infection increased the number of at-risk children by 10% (76 of 797) and 56% (49 of 87) for plasma retinol concentrations <0.7 and <0.35 micromol/L, respectively. In addition, dietary inadequacy may be responsible for retinol concentrations being approximately 16% lower in Pakistani children than in children in the United Kingdom, where dietary vitamin A is adequate.

TEL/AML-1 fusion gene. its frequency and prognostic significance in childhood acute lymphoblastic leukemia

TEL gene rearrangement due to the 12;21 chromosome translocation is believed to be the most common molecular genetic abnormality in childhood acute lymphoblastic leukemia (ALL). A study was conducted to investigate the frequency and prognostic significance of TEL/AML-1 fusion gene resulting from a cryptic t(12;21)(p13;q22). Bone marrow samples from 86 patients diagnosed over the past 5 years at Columbus Children's Hospital were analyzed by fluorescence in situ hybridization (FISH) technique for TEL/AML-1 fusion gene, using LSI((R)) DNA probes. The positive cases were analyzed for clinical outcome. Patients in this study received treatment according to Children's Cancer Group (CCG) protocols. Fifteen of the 86 cases (17%) were positive for the fusion gene. All were B-cell lineage and except for one, all were CD10 positive. TEL/AML-1 was not found in any T-cell ALL. The mean overall survival (OS) following diagnosis for the TEL/AML-1-positive group was significantly longer than for the TEL/AML-1-negative group by log-rank = 7.84, P = 0.005. Similarly, the event-free survival (EFS) after remission for the positive group (median 94.5 months) was longer than the negative group (median 57 months) by log-rank = 7.19, P = 0.007. This study confirms that the TEL/AML-1 fusion gene may be the most common genetic event in childhood ALL, occurring in 17% of the patients. It appears restricted to the B-cell lineage. In this study, the presence of a TEL/AML-1 fusion gene was statistically significant in predicting both OS and EFS, indicating a favorable clinical outcome for these patients. Screening for TEL/AML-1 should become routine at diagnosis and a useful biological variable for risk stratification in future clinical trials.

Assembly of the cleavage and polyadenylation apparatus requires about 10 seconds in vivo and is faster for strong than for weak poly(A) sites

We have devised a cis-antisense rescue assay of cleavage and polyadenylation to determine how long it takes the simian virus 40 (SV40) early poly(A) signal to commit itself to processing in vivo. An inverted copy of the poly(A) signal placed immediately downstream of the authentic one inhibited processing by means of sense-antisense duplex formation in the RNA. The antisense inhibition was gradually relieved when the inverted signal was moved increasing distances downstream, presumably because cleavage and polyadenylation occur before the polymerase reaches the antisense sequence. Antisense inhibition was unaffected when the inverted signal was moved upstream. Based on the known rate of transcription, we estimate that the cleavage-polyadenylation process takes between 10 and 20 s for the SV40 early poly(A) site to complete in vivo. Relief from inhibition occurred earlier for shorter antisense sequences than for longer ones. This indicates that a brief period of assembly is sufficient for the poly(A) signal to shield itself from a short (50- to 70-nucleotide) antisense sequence but that more assembly time is required for the signal to become immune to the longer ones (approximately 200 nucleotides). The simplest explanation for this target size effect is that the assembly process progressively sequesters more and more of the RNA surrounding the poly(A) signal up to a maximum of about 200 nucleotides, which we infer to be the domain of the mature apparatus. We compared strong and weak poly(A) sites. The SV40 late poly(A) site, one of the strongest, assembles several times faster than the weaker SV40 early or synthetic poly(A) site.

Poly(A)-driven and poly(A)-assisted termination: two different modes of poly(A)-dependent transcription termination

We mapped the elements that mediate termination of transcription downstream of the chicken betaH- and betaA-globin gene poly(A) sites. We found no unique element and no segment of 3'-flanking DNA to be significantly more effective than any other. When we replaced the native 3'-flanking DNA with bacterial DNA, it too supported transcription termination. Termination in the bacterial DNA depended on a functional poly(A) signal, which apparently compelled termination to occur in the downstream DNA with little regard for its sequence. We also studied premature termination by poorly processive polymerases close to the promoter. The rate of premature termination varied for different DNA sequences. However, the efficiencies of poly(A)-driven termination and promoter-proximal premature termination varied similarly on different DNAs, suggesting that poly(A)-driven termination functions by returning the transcription complex to a form which resembles a prior state of low processivity. The poly(A)-driven termination described here differs dramatically from the poly(A)-assisted termination previously described for the simian virus 40 (SV40) early transcription unit. In the SV40 early transcription unit, essentially no termination occurs downstream of the poly(A) site unless a special termination element is present. The difference between the betaH-globin and SV40 modes of termination is governed by sequences in the upstream DNA. For maximum efficiency, the betaH-globin poly(A) signal required the assistance of upstream enhancing sequences. Moreover, the SV40 early poly(A) signal also drove termination in betaH-globin style when it was placed in a betaH-globin sequence context. These studies were facilitated by a rapid, improved method of run-on transcription analysis, based on the use of a vector containing two G-free cassettes.

Innovation in the management of soft tissue sarcomas in infants and young children: high-dose-rate brachytherapy

PURPOSE

Conventional low-dose-rate (LDR) brachytherapy is effective in treating childhood sarcomas, but often not practical (due to the associated radiation hazards) in the young children who require continuous observation and sedation. Fractionated high-dose-rate brachytherapy (HDR) was used to deliver adequate tumoricidal radiation while preserving bone and organ growth in children.

MATERIALS AND METHODS

Twelve children with diverse sarcomas were treated with fractionated HDR. The median age at diagnosis was 18 months (range, 1 to 42). Nine patients had rhabdomyosarcoma and three had other soft tissue sarcoma (STS) variants. Ten patients had microscopic residual disease at the time of brachytherapy. All patients were treated with appropriate chemotherapy and surgery. HDR was delivered in 3-Gy fractions twice a day to a total dose of 36 Gy in 8 days. External-beam radiation therapy (EBRT) was avoided. Patients were monitored for a median of 61 months (range, 30 to 78).

RESULTS

One patient developed local recurrence and distant metastases to the lungs. The 6-year actuarial local control and overall survival rates were 91% and 81%, respectively. Brachytherapy-related morbidity occurred in 50% of patients. The morbidity was mild to moderate in 42% of patients and consisted primarily of acute skin and mucosal reaction. One patient experienced severe (grade III to IV) toxicity. Another child, treated to the tongue, had delayed dentition only in the teeth adjacent to the brachytherapy site. The other children have exhibited only minimal or none of the bone growth retardation expected with EBRT.

CONCLUSION

The combination of conservative surgery, chemotherapy, and exclusive HDR to postchemotherapy tumor volume with a modest margin, avoiding EBRT, provided disease control in carefully selected young children, while preserving bone growth and organ function. The short duration of therapy and small volume irradiated allowed chemotherapy to be resumed shortly after brachytherapy. The use of HDR challenges the present philosophy of radiotherapy treatment volume, which holds that the prechemotherapy tumor volume should be treated with an acceptable margin. Brachytherapy should be included in multicentric clinical trials in young children.

Prevalence of anaemia in semi-urban areas of Peshawar, Pakistan: a challenge for health professionals and policy makers

Iron deficiency anaemia is a serious problem among Pakistani children. Pre-intervention haematological status of children under two years was assessed as part of a double-blind, randomized controlled community-based study conducted in two semi-urban areas of Peshawar. The primary objective was to assess the impact of iron deficiency anaemia and iron intervention on growth and morbidity. Three hundred and twenty children who met the criteria of a "healthy child" were recruited for the study. Blood samples were drawn from 275 children for haemoglobin (Hb) and serum ferritin (SF) analyses. The children were classified as anaemic (Hb < 11 g/dl); iron deficient (SF < 12 ng/ml) and iron deficient anaemic (Hb < 11 g/dl and SF < 12 ng/ml). Ninety percent of the children were anaemic, 67% iron deficient and 63% iron deficient anaemic. Anaemia was more prevalent in boys who had significantly lower Hb and SF values than girls. The magnitude of anaemia in these children tended to increase with age. The study demonstrates that iron deficiency is the predominant cause of anaemia (69%) in children under two years. Minimization of iron deficiency anaemia should be a public health priority in order to prevent suffering of children and avert the associated cognitive and physical deficits in child development.