The Amount of Folic Acid in Weekly Iron-Folic Acid Supplements Should Be Increased From 0.4 to 2,8 mg to Reduce Neural Tube Defects (NTD)

Objectives

Weekly iron–folic acid (IFA) supplements are recommended for all menstruating women in countries where anaemia prevalence is > 20%. Anaemia caused by folate deficiency is low worldwide, and the need to include folic acid is in question. Including folic acid might reduce the risk of a neural tube defect (NTD) should a woman become pregnant. Most weekly supplements contain 0.4 mg folic acid; however, WHO recommends 2.8 mg because it is seven times the daily dose effective in reducing NTDs. There is a reluctance to switch to supplements containing 2.8 mg of folic acid because of a lack of evidence that this dose would prevent NTDs. Our aim was to investigate the effect of two doses of folic acid, compared with placebo, on red blood cell (RBC) folate, a biomarker of NTD risk.

Methods

We conducted a three-arm double-blind efficacy trial in Malaysia. Non-pregnant women (n = 331) were randomized to receive 60 mg iron and either 0, 0.4, or 2.8 mg folic acid once weekly for 16 weeks.

Results

At 16 weeks, women receiving 0.4 mg and 2.8 mg folic acid per week had a higher mean RBC folate than those receiving 0 mg (mean difference (95% CI) 84 (54 to 113) and 355 (316 to 394) nmol/L, respectively). Women receiving 2.8 mg folic acid had a mean RBC folate 271 (234 to 309) nmol/L greater mean RBC folate than those receiving 0.4 mg. Moreover, women in the 2.8 mg group were seven times (RR 7.3, 95% CI 3.9 to 13.7) more likely to achieve an RBC folate > 748 nmol/L, a concentration associated with a low risk of NTD, compared with the 0.4 mg group.

Conclusions

IFA supplements containing 2.8 mg folic acid increases RBC folate more than those containing 0.4 mg. Increased availability and access to the 2.8 mg formulation is needed.

Funding Sources

Nutrition International (Ottawa, Ontario).

Performance-based technical support for drug-resistant TB responses: lessons from the Green Light Committee

Drug-resistant tuberculosis (DR-TB) constitutes a global threat and a major contributor to deaths related to antimicrobial resistance. Despite progress in DR-TB detection and treatment over the last decade, huge gaps remain in treatment coverage, access to quality care and treatment outcome. Global Fund investments have been critical to scaling up the existing and new diagnostic tools, treatment coverage and people-centred service delivery. The United Nations General Assembly (UNGA) high-level meeting represents unprecedented opportunities to accelerate towards addressing DR-TB. Established in 2000 and funded by the Global Fund since 2009, the Green Light Committee (GLC) mechanism has evolved from project approval to providing demand-based technical assistance to countries to scale up response to DR-TB based on their need and priorities. Lessons learnt from the GLC mechanism over 10 years demonstrate that a result-based, systematic and accountable technical assistance model to support scale-up of DR-TB response is critically important. Meeting the UNGA declaration targets requires major scale-up of current efforts and new tools, and hence the need for predictable, consistent and sustained technical support to countries, including through the regional GLC mechanism. The application of the principles and processes of this model could be adapted and replicated to design a similar performance-based and quality-assured technical support mechanism.

Prevalence, Severity, and Type of Anaemia Among Malaysian Women of Reproductive Age

Objectives

Globally, anaemia affects approximately one third of adolescent girls and women of reproductive age. Anaemia can lead to severe health consequences and can negatively impact social and economic development. Our aim was to understand the prevalence, severity and types of anaemia among Malaysian women.

Methods

A total of n = 331 Malaysian women (18–45 y) who were recruited for a trial on the effects of once weekly iron folic acid supplementation on blood folate levels were included in the analyses for this objective. Fasting venous blood was collected and a complete blood count was conducted using an automated haematology analyser.

Results

The mean ± SD age of participants was 19.0 ± 2.3 years. Eighty-nine % of participants were Malay (n = 295); the remainder identified as Chinese, Indian, or of another ethnicity (11%; n = 36). The mean ± SD body mass index (BMI) of participants was 22.4 ± 4.8 kg/m2, with 60% (n = 199) having a normal BMI (BMI between 18.5–24.9 kg/m2). Overall, the mean ± SD haemoglobin (Hb) concentration was 128.5 ± 11.5 g/L, with 17.5% (n = 58) women presenting as anaemic (Hb < 120 g/L). Of the 58 women with anaemia, 59% (n = 40) had mild anaemia (Hb 110–119 g/L), 29% (n = 17) had moderate anaemia (Hb 80–109 g/L), and ∼2% (n = 1) had severe anaemia (Hb < 80 g/L). Among the participants with anaemia, 52% (n = 30) presented with microcytic cells (mean corpuscular volume < 78 fL), and 72% (n = 42) presented with hypochromic cells (mean corpuscular haemoglobin < 27 pg). None of the women with Hb < 120 g/L had macrocytic or hyperchromic cells.

Conclusions

Anaemia prevalence among Malaysian women of reproductive age in our study was lower than previously reported in a national survey (17.5% vs. 25%, respectively). The majority of anaemia was microcytic, which may be an indication of iron deficiency and/or genetic haemoglobin disorders, both of which are known to be prevalent in Southeast Asia.

Funding Sources

Nutrition International.

Impact of Modifiable Risk Factors on Bone Loss During Periodontal Maintenance

Objectives:

The aim of this study was to analyze modifiable patient risk factors from dental chart histories and radiographs for progressive mild-moderate periodontitis during periodontal maintenance (PM).

Methods and Materials:

Bitewing radiographs of 442 elderly periodontal maintenance patients were taken before and after two years of periodontal maintenance. Each progressive periodontitis (PP) patient (with at least one site of posterior interproximal bone loss of ≥2 mm, n=71) was matched to a periodontitis stable (PS) patient (no sites with bone loss, n=71) of the same gender and age (±five years) to control for these variables and was compared for measurements of general patient (medical history, smoking, hygiene and compliance habits) and tooth-related (bone loss, overhangs, interproximal dimensions) factors at baseline. Fisher exact and t-tests were used to compare groups.

Results:

While the elderly PM patients with mild-moderate periodontitis were generally stable, 71 of 442 were PP patients. No significant differences from PS patients were observed at baseline with regard to the systemic factors measured. However, the PP group had less cementoenamel junction to bone length (bone loss p<0.0001) and more interproximal width (2.3±1.0 mm) than did the PS group (1.7±0.6 mm, p=0.0016). This was reflected in more open sites without adjacent tooth contact in PP (42% vs 15%, p=0.0006).

Conclusions:

In the short term, systemic and behavior factors are of limited value in identifying mild-moderate periodontitis patients on PM at increased risk of bone loss. However, interproximal width and lack of adjacent tooth contacts are related to the likelihood of losing interproximal bone during periodontal maintenance, suggesting the need for restorative therapy.

Capture-recapture method to assess the prevalence of disabled leprosy patients

The capture-recapture technique was applied in estimating the prevalence of disabled leprosy patients in four States in Northern Nigeria. A two-sample capture-recapture method, using data from hospital admissions during 1997 and 1998 in three leprosy referral hospitals, and from a sample survey on leprosy patients with disabilities in the clinics in 1999. In the sample, 1395 (ex) leprosy patients were found, 393 with a disability. Of these 393 patients, 47 had been admitted during 1997 and 1998 to one of three leprosy referral hospitals. In these hospitals, 151 individuals from the 24 study Local Government Areas (LGA) in four states of Northern Nigeria were admitted in 1997 and 1998. Using the Peterson estimator, we calculated the number of unknown disabled leprosy patients in the studied LGAs to be 1262 (95% confidence interval 991-1533). This was nearly four times greater than the field reported figure. The capture-recapture method can be applied in a leprosy care programme. Limitations of the method are the completeness of reporting after invitation in the field, as well as the probable biased sample of leprosy patients admitted to hospital. Our finding implies that relying on patients to report for prevention of disabilities and rehabilitation to the clinics, causes the real size of the problem to be underestimated by a factor of 3-4. We recommend the use of a special 'care' register for disabled leprosy patients to better address their needs for prevention of disabilities and rehabilitation.

Nonresponsiveness of the metastatic human lung carcinoma MV522 xenograft to conventional anticancer agents

The human lung carcinoma cell line MV522 was previously noted to produce extensive metastasis to the lungs, spleen and lymph nodes after subcutaneous transplantation into athymic nude mice. Animals eventually succumb to these metastases, and not primary tumor growth. The ability to produce extensive metastasis after a simple subcutaneous injection in 100% of animals (> 100 tested to date) would be an advantage when screening compounds for anticancer activity. To validate the utility of this xenograft model for testing anticancer agents, we tested the ability of 10 anticancer drugs to either inhibit primary tumor growth and/or prolong life span of MV522-bearing animals. Among the 10 antitumor conventional agents, only mitomycin C and taxol demonstrated primary tumor growth inhibition. Mitomycin C produced a mild increase in median life span of 41% to 63%, while taxol had inconsistent effects. The metastatic MV522 carcinoma model appears to reflect clinical resistance of primary non-small cell lung cancer to conventional chemotherapeutic agents and should be useful for testing new anti-cancer drugs.

Characterization of illudin S sensitivity in DNA repair-deficient Chinese hamster cells. Unusually high sensitivity of ERCC2 and ERCC3 DNA helicase-deficient mutants in comparison to other chemotherapeutic agents

Illudins, novel natural products with a structure unrelated to any other known chemical, display potent in vitro and in vivo anti-cancer activity against even multi-drug resistant tumors, and are metabolically activated to an unstable intermediate that binds to DNA. The DNA damage produced by illudins, however, appears to differ from that of other known DNA damaging toxins. The sensitivity pattern of the various UV-sensitive cell lines differs from previously studied DNA cross-linking agents. Normally, the ERCC1- (excision repair cross complementing) and ERCC4-deficient cell lines are most sensitive to DNA cross-linking agents, with ERCC2-, ERCC3- and ERCC5-deficient cell lines having minimal sensitivity. With illudins the pattern is reversed, with ERCC2 and ERCC3 being the most sensitive. The sensitivity to illudins in complementation groups 1 through 3 is due to a deficiency of the ERCC1-3 gene products, as cellular drug accumulation studies revealed no differences in transport capacity or total drug accumulation. Also, a transgenic cell line in which ERCC2 activity was expressed through an expression vector regained its relative resistance to the illudins. The EM9 cell line, which displays sensitivity to monoadduct producing chemicals, was not sensitive. Thus, excision repair is involved in repair of illudin-induced damage and, unlike other anti-cancer agents, the involvement of ERCC2 and ERCC3 helicases is critical for repair to occur. The requirement for ERCC2 and ERCC3, combined with the finding that ERCC1 but not ERCC2 is upregulated in drug-resistant tumors, may explain the efficacy of illudins against drug-resistant tumors. The inhibition of DNA synthesis in cells within minutes after exposure to illudins at nanomolar concentrations may be related to the finding that the ERCC3 gene product is actually the p89 helicase component of the BTF2 (TFII) basic transcription factor and the high sensitivity of ERCC3-deficient cells to illudins.

Epidemic of "shocks" in telephone operators: lessons for the medical community

In January 1986 two brief power failures occurring within an hour of each other affected the operation of visual display terminals in a section of the Manitoba Telephone System. After the power failures three operators reported an alarming tingling sensation in their arms and one side of their body, which they called "shocks". Other operators then began to report incidents of numbness and tingling in their limbs, face or head as well as other, diffuse symptoms. During the next 2 weeks 92 such incidents were reported by 55 operators. The media carried alarming headlines, and medical practitioners perpetuated the label of "electric shock". Despite extensive investigation, which revealed no electrical fault, the section was closed by the regulatory authority, and an independent medical panel was convened to review the findings. The panel concluded that there was no immediate hazard to life or health and recommended continued workplace assessment and follow-up of affected operators; however, because the panel lacked electrical engineering expertise, uncertainty persisted as to the cause of the events. The reports of incidents persisted, peaking in association with continued rumours of diagnoses of "nerve damage". In the fall of 1987 a multidisciplinary committee ruled out as causative factors all known hazards other than electrostatic shock and occupational stress. This costly and lengthy investigation underlines the danger in regarding collective stress reaction as a diagnosis of exclusion. It highlights the need to scrutinize objective evidence before validating potentially unfounded concerns and underlines the desirability of considering the psychosocial effects of technology and regimented tasks.