1
|
Sarfraz A, Jamil Z, Ahmed S, Umrani F, Qureshi AK, Jakhro S, Sajid M, Rahman N, Rizvi A, Ma JZ, Mallawaarachchi I, Iqbal NT, Syed S, Iqbal J, Sadiq K, Moore SR, Ali SA. Impact of diarrhoea and acute respiratory infection on environmental enteric dysfunction and growth of malnourished children in Pakistan: a longitudinal cohort study. Lancet Reg Health Southeast Asia 2023; 15:100212. [PMID: 37614352 PMCID: PMC10442970 DOI: 10.1016/j.lansea.2023.100212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 01/04/2023] [Accepted: 04/26/2023] [Indexed: 08/25/2023]
Abstract
Background Diarrhoea and acute respiratory infections (ARI) are assumed to be major drivers of growth and likely contribute to environmental enteric dysfunction (EED), which is a precursor to childhood malnutrition. In the present study, we checked the correlation between diarrhoeal/ARI burden and EED using a novel duodenal histological index. Methods Between November 2017 and July 2019, a total of 365 infants with weight-for-height Z scores (WHZ score) of <-2 were enrolled, and 51 infants with WHZ scores of >0 and height-for-age Z scores (HAZ scores) of >-1 were selected as age-matched healthy controls. Morbidity was assessed weekly and categorised as the total number of days with diarrhoea and acute respiratory infection (ARI) from enrolment until two years of age and was further divided into four quartiles in ascending order. Findings The HAZ declined until two years of age regardless of morbidity burden, and WHZ and weight-for-age Z scores (WAZ scores) were at their lowest at six months. Sixty-three subjects who had a WHZ score <-2 and failed to respond to nutritional and educational interventions were further selected at 15 months to investigate their EED histological scores with endoscopy further. EED histological scores of the subjects were higher with increasing diarrhoeal frequency yet remained statistically insignificant (p = 0.810). Interpretation There was not a clear correlation between diarrhoea and ARI frequency with growth faltering, however, children with the highest frequency of diarrhoea had the highest EED histological scores and growth faltering. Funding Bill and Melinda Gates Foundation and The National Institutes of Health.
Collapse
Affiliation(s)
- Azza Sarfraz
- Department of Pediatrics and Child Health, The Aga Khan University, Pakistan
| | - Zehra Jamil
- Department of Biological & Biomedical Sciences, The Aga Khan University, Pakistan
| | - Sheraz Ahmed
- Department of Pediatrics and Child Health, The Aga Khan University, Pakistan
| | - Fayaz Umrani
- Department of Pediatrics and Child Health, The Aga Khan University, Pakistan
| | | | - Sadaf Jakhro
- Department of Pediatrics and Child Health, The Aga Khan University, Pakistan
| | - Muhammad Sajid
- Department of Pediatrics and Child Health, The Aga Khan University, Pakistan
| | - Najeeb Rahman
- Department of Pediatrics and Child Health, The Aga Khan University, Pakistan
| | - Arjumand Rizvi
- Department of Pediatrics and Child Health, The Aga Khan University, Pakistan
| | - Jennie Z. Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | | | - Najeeha T. Iqbal
- Department of Pediatrics and Child Health, The Aga Khan University, Pakistan
- Department of Biological & Biomedical Sciences, The Aga Khan University, Pakistan
| | - Sana Syed
- Department of Pediatrics and Child Health, The Aga Khan University, Pakistan
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Junaid Iqbal
- Department of Pediatrics and Child Health, The Aga Khan University, Pakistan
- Department of Biological & Biomedical Sciences, The Aga Khan University, Pakistan
| | - Kamran Sadiq
- Department of Pediatrics and Child Health, The Aga Khan University, Pakistan
| | - Sean R. Moore
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Syed Asad Ali
- Department of Pediatrics and Child Health, The Aga Khan University, Pakistan
| |
Collapse
|
2
|
Cowardin CA, Syed S, Iqbal N, Jamil Z, Sadiq K, Iqbal J, Ali SA, Moore SR. Environmental enteric dysfunction: gut and microbiota adaptation in pregnancy and infancy. Nat Rev Gastroenterol Hepatol 2023; 20:223-237. [PMID: 36526906 PMCID: PMC10065936 DOI: 10.1038/s41575-022-00714-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 03/31/2023]
Abstract
Environmental enteric dysfunction (EED) is a subclinical syndrome of intestinal inflammation, malabsorption and barrier disruption that is highly prevalent in low- and middle-income countries in which poverty, food insecurity and frequent exposure to enteric pathogens impair growth, immunity and neurodevelopment in children. In this Review, we discuss advances in our understanding of EED, intestinal adaptation and the gut microbiome over the 'first 1,000 days' of life, spanning pregnancy and early childhood. Data on maternal EED are emerging, and they mirror earlier findings of increased risks for preterm birth and fetal growth restriction in mothers with either active inflammatory bowel disease or coeliac disease. The intense metabolic demands of pregnancy and lactation drive gut adaptation, including dramatic changes in the composition, function and mother-to-child transmission of the gut microbiota. We urgently need to elucidate the mechanisms by which EED undermines these critical processes so that we can improve global strategies to prevent and reverse intergenerational cycles of undernutrition.
Collapse
Affiliation(s)
- Carrie A Cowardin
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Child Health Research Center, University of Virginia, Charlottesville, VA, USA
| | - Sana Syed
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Child Health Research Center, University of Virginia, Charlottesville, VA, USA
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeha Iqbal
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zehra Jamil
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Kamran Sadiq
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Junaid Iqbal
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Syed Asad Ali
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sean R Moore
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Child Health Research Center, University of Virginia, Charlottesville, VA, USA.
| |
Collapse
|
3
|
Abtahi S, Sailer A, Roland JT, Haest X, Chanez-Paredes SD, Ahmad K, Sadiq K, Iqbal NT, Ali SA, Turner JR. Intestinal Epithelial Digestive, Transport, and Barrier Protein Expression Is Increased in Environmental Enteric Dysfunction. J Transl Med 2023; 103:100036. [PMID: 36870290 PMCID: PMC10121737 DOI: 10.1016/j.labinv.2022.100036] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/08/2022] [Accepted: 11/16/2022] [Indexed: 01/11/2023] Open
Abstract
Environmental enteric dysfunction (EED) is characterized by malabsorption and diarrhea that result in irreversible deficits in physical and intellectual growth. We sought to define the expression of transport and tight junction proteins by quantitative analysis of duodenal biopsies from patients with EED. Biopsies from Pakistani children with confirmed EED diagnoses were compared to those from age-matched North American healthy controls, patients with celiac disease, and patients with nonceliac disease with villous atrophy or intraepithelial lymphocytosis. Expression of brush border digestive and transport proteins and paracellular (tight junction) proteins was assessed by quantitative multiplex immunofluorescence microscopy. EED was characterized by partial villous atrophy and marked intraepithelial lymphocytosis. Epithelial proliferation and enteroendocrine, tuft, and Paneth cell numbers were unchanged, but there was significant goblet cell expansion in EED biopsies. Expression of proteins involved in nutrient and water absorption and that of the basolateral Cl- transport protein NKCC1 were also increased in EED. Finally, the barrier-forming tight junction protein claudin-4 (CLDN4) was significantly upregulated in EED, particularly within villous enterocytes. In contrast, expression of CFTR, CLDN2, CLDN15, JAM-A, occludin, ZO-1, and E-cadherin was unchanged. Upregulation of a barrier-forming tight junction protein and brush border and basolateral membrane proteins that support nutrient and water transport in EED is paradoxical, as their increased expression would be expected to be correlated with increased intestinal barrier function and enhanced absorption, respectively. These data suggest that EED activates adaptive intestinal epithelial responses to enhance nutrient absorption but that these changes are insufficient to restore health.
Collapse
Affiliation(s)
- Shabnam Abtahi
- Laboratory of Mucosal Barrier Pathobiology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anne Sailer
- Department of Pathology, University of Chicago, Chicago, Illinois
| | - Joseph T Roland
- Epithelial Biology Center, Vanderbilt University Medical Center; Nashville, Tennessee
| | - Xenia Haest
- Laboratory of Mucosal Barrier Pathobiology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sandra D Chanez-Paredes
- Laboratory of Mucosal Barrier Pathobiology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kumail Ahmad
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Kamran Sadiq
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeha Talat Iqbal
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - S Asad Ali
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Jerrold R Turner
- Laboratory of Mucosal Barrier Pathobiology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Pathology, University of Chicago, Chicago, Illinois.
| |
Collapse
|
4
|
Kabir F, Iqbal J, Jamil Z, Iqbal NT, Mallawaarachchi I, Aziz F, Kalam A, Muneer S, Hotwani A, Ahmed S, Umrani F, Syed S, Sadiq K, Ma JZ, Moore SR, Ali A. Impact of enteropathogens on faltering growth in a resource-limited setting. Front Nutr 2023; 9:1081833. [PMID: 36704796 PMCID: PMC9871909 DOI: 10.3389/fnut.2022.1081833] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/08/2022] [Indexed: 01/12/2023] Open
Abstract
Introduction Environmental enteropathy is an important contributor to childhood malnutrition in the developing world. Chronic exposure to fecal pathogens leads to alteration in intestinal structure and function, resulting in impaired gut immune function, malabsorption, and growth faltering leading to environmental enteropathy. Methods A community-based intervention study was carried out on children till 24 months of age in Matiari district, Pakistan. Blood and fecal specimens were collected from the enrolled children aged 3-6 and 9 months. A real-time PCR-based TaqMan array card (TAC) was used to detect enteropathogens. Results Giardia, Campylobacter spp., enteroaggregative Escherichia coli (EAEC), Enteropathogenic Escherichia coli (EPEC), Enterotoxigenic Escherichia coli (ETEC), and Cryptosporidium spp. were the most prevailing enteropathogens in terms of overall positivity at both time points. Detection of protozoa at enrollment and 9 months was negatively correlated with rate of change in height-for-age Z (ΔHAZ) scores during the first and second years of life. A positive association was found between Giardia, fecal lipocalin (LCN), and alpha 1-Acid Glycoprotein (AGP), while Campylobacter spp. showed positive associations with neopterin (NEO) and myeloperoxidase (MPO). Conclusion Protozoal colonization is associated with a decline in linear growth velocity during the first 2 years of life in children living in Environmental enteric dysfunction (EED) endemic settings. Mechanistic studies exploring the role of cumulative microbial colonization, their adaptations to undernutrition, and their influence on gut homeostasis are required to understand symptomatic enteropathogen-induced growth faltering.
Collapse
Affiliation(s)
- Furqan Kabir
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Junaid Iqbal
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan,Department of Biological and Biomedical Sciences, The Aga Khan University, Karachi, Pakistan
| | - Zehra Jamil
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan,Department of Biological and Biomedical Sciences, The Aga Khan University, Karachi, Pakistan
| | - Najeeha Talat Iqbal
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan,Department of Biological and Biomedical Sciences, The Aga Khan University, Karachi, Pakistan
| | - Indika Mallawaarachchi
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - Fatima Aziz
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Adil Kalam
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Sahrish Muneer
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Aneeta Hotwani
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Sheraz Ahmed
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Fayaz Umrani
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Sana Syed
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan,Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Virginia, Charlottesville, VA, United States
| | - Kamran Sadiq
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Jennie Z. Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - Sean R. Moore
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Virginia, Charlottesville, VA, United States,*Correspondence: Sean R. Moore,
| | - Asad Ali
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan,Asad Ali,
| |
Collapse
|
5
|
Memon IA, Parkash A, Sadiq K, Kamal NM, El-Shabrawi MH. The Asia Pacific Pediatric Association (APPA) position statement on the MAFLD definition of fatty liver disease. Ther Adv Chronic Dis 2023; 14:20406223231164523. [PMID: 37051073 PMCID: PMC10084573 DOI: 10.1177/20406223231164523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Affiliation(s)
- Iqbal A. Memon
- University of Texas, Galveston, TX, USA
- Asia Pacific Pediatric Association, Kuala Lumpur, Malaysia
- Asian Pan Pacific Societies of Pediatric Gastroenterology, Hepatology & Nutrition (APPSPGHAN), Seoul, Republic of Korea
- Asian Society of Pediatric Infectious Diseases (ASPID)
- Sir Syed College of Medical Sciences for Girls, Karachi, Pakistan
| | - Arit Parkash
- Pediatric Gastroenterology & Hepatology, National Institute of Child Health, Karachi, Pakistan
| | - Kamran Sadiq
- British Columbia Children’s Hospital, Vancouver, BC, Canada
- Agha Khan University Hospital, Karachi, Pakistan
| | - Naglaa M. Kamal
- Kasr Alainy Faculty of Medicine, Cairo University, Giza, Egypt
- University of Maine, Orono, ME, USA
- Alhada Armed Forces Hospital, Taif, Saudi Arabia
| | - Mortada H.F. El-Shabrawi
- Kasr Alainy Faculty of Medicine, Cairo University, Giza, Egypt
- International Society of tropical pediatrics (ISTP)
| |
Collapse
|
6
|
Farooqui N, Mir F, Siddiqui D, Hotwani A, Nathwani AA, Mahmood SF, Sadiq K, Kayani HA, Sheikh SA, Shah SA, Ferrand RA, Abidi SH. Phylogenetic and drug- and vaccine-resistance profiles of Hepatitis B Virus among children with HIV co-infection in Pakistan. Infect Genet Evol 2022; 105:105371. [PMID: 36179949 PMCID: PMC9614405 DOI: 10.1016/j.meegid.2022.105371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/25/2022] [Accepted: 09/26/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION HIV-1 and hepatitis B virus (HBV) share common routes of transmission and therefore co-infection is common. In 2019, an HIV-1 outbreak that resulted in >1000 children being infected, predominantly through nosocomial transmission, occurred in Sindh, Pakistan. We conducted a phylogenetic and drug resistance analysis of the HBV Reverse Transcriptase (RT) gene in children with HIV-1 and HBV co-infection. METHODOLOGY Blood samples were collected from 321 children with HIV who were recruited as part of a study to investigate the HIV-1 outbreak. All samples were tested for HBV surface antigen (HBsAg) using an ELISA assay, and positive samples were used to amplify and sequence the HBV RT gene. The phylogenetic relationship between sequences was analyzed, and drug- and vaccine- resistance mutations in the RT gene were explored. RESULTS Of 321 samples, 23% (n = 75) were positive for HBsAg on ELISA. Phylogenetic analysis of the sequences revealed that 63.5% of HBV sequences were sub-genotype D1, while the rest were sub-genotype D2. Cluster analysis revealed grouping of sub-genotype D1 sequences exclusively with Pakistani sequences, while clustering of sub-genotypes D2 predominantly with global sequences. The 236Y mutation associated with resistance to tenofovir was observed in 2.8% of HBV sequences. Additionally, seven vaccine escape mutations were observed, the most common being 128 V. CONCLUSION Our study suggests ongoing transmission of HBV D1 and D2 sub-genotypes in the HIV-1 co-infected population, likely nosocomially, given common routes of HVB and HIV-1 transmission. The prevalence of major HBV drug- and vaccine-resistant mutations remains low. Surveillance for further transmissions and the possible emergence of major drug- or vaccine-resistant variants is required.
Collapse
Affiliation(s)
- Nida Farooqui
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan; Department of Biosciences, The Shaheed Zulfikar Ali Bhutto Institute of Science and Technology, Karachi, Pakistan
| | - Fatima Mir
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Dilsha Siddiqui
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Aneeta Hotwani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Apsara Ali Nathwani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Kamran Sadiq
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Hammad Afzal Kayani
- Department of Biosciences, The Shaheed Zulfikar Ali Bhutto Institute of Science and Technology, Karachi, Pakistan
| | | | | | - Rashida Abbas Ferrand
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Syed Hani Abidi
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan; Department of Biomedical Sciences, Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan.
| |
Collapse
|
7
|
Abtahi S, Sailer A, Sadiq K, Iqbal N, Ahmed K, Kabir F, Ali SA, Turner JR. Abnormal transporter and tight junction protein expression in environmental enteric dysfunction. FASEB J 2022. [DOI: 10.1096/fasebj.2022.36.s1.r5615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Shabnam Abtahi
- PathologyBrigham and women's Hospital, Harvard Medical SchoolBostonMA
| | | | - Kamran Sadiq
- Department of Paediatrics and Child HealthAga Khan UniversityKarachi
| | - Najeeha Iqbal
- Department of Paediatrics and Child HealthAga Khan UniversityKarachi
| | - Kumail Ahmed
- Department of Paediatrics and Child HealthAga Khan UniversityKarachi
| | - Furqan Kabir
- Department of Paediatrics and Child HealthAga Khan UniversityKarachi
| | - S A. Ali
- Department of Paediatrics and Child HealthAga Khan UniversityKarachi
| | - Jerrold R. Turner
- PathologyUniversity of ChicagoChicagoIL
- Brigham and Women's Hospital, Harvard Medical SchoolBostonMA
| |
Collapse
|
8
|
Abstract
Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder in which there is development of multiple venous malformations and haemangiomas in the skin and visceral organs. The lesions mostly involve the skin and gastrointestinal systems but other organs, including the liver, muscles, and the central nervous system, can also be involved. If untreated, affected individuals develop severe anaemia. Most cases are managed with iron supplementation and blood transfusions but some may require surgical resection, endoscopic sclerosis and laser photocoagulation. Here, we present a case of BRBNS in a four-year-old girl with multiple cutaneous lesions, melena and severe anaemia. Review of South Asian literature showed that only two cases (besides ours) have been reported from Pakistan and the rest were from India. This highlights the lack of awareness of BRBNS among physicians in Pakistan and the rest of South Asian countries.
Collapse
Affiliation(s)
- Habib Qaiser
- Department of Paediatrics and Child Health, Aga Khan University Hospital,Karachi, Pakistan
| | - Kamran Sadiq
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Bushra Afroze
- Department of Paediatrics & Child Health, The Aga Khan University Hospital, Karachi, Pakistan
| |
Collapse
|
9
|
Sadiq K, Mir F, Jiwani U, Chanar S, Nathwani A, Jawwad M, Hussain A, Rizvi A, Muhammad S, Habib MA, Soofi SB, Ariff S, Bhutta ZA. OUP accepted manuscript. Int Health 2022; 15:281-288. [PMID: 35567792 PMCID: PMC10153564 DOI: 10.1093/inthealth/ihac022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/16/2022] [Accepted: 04/01/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Diarrhoea is a leading cause of preventable childhood morbidity and mortality worldwide. Unfortunately, Pakistan has the third-highest burden of diarrhoea-related deaths in children <5 y of age. Therefore we aimed to evaluate factors associated with diarrhoea among Pakistani children. METHODS A retrospective 1:2 matched case-control study nested in a baseline cross-sectional survey was conducted from October to December 2018 in Taluka Kotri, a two-thirds urban locality in the Jamshoro district. Children between the ages of 0 and 23 months with a history of diarrhoea in the 2 weeks preceding the survey were labelled as cases. Age-matched controls were children without symptoms of diarrhoea. Univariate and multivariable conditional logistic regression was performed to identify diarrhoea-related factors. RESULTS A total of 1558 cases were matched with 3116 controls. Factors significantly associated with lower odds of diarrhoea in the multivariate analysis included increasing maternal age (odds ratio [OR] 0.78 [95% confidence interval {CI} 0.67 to 0.90]), breastfeeding (OR 0.77 [95% CI 0.66 to 0.90]), higher paternal education (OR 0.79 [95% CI 0.65 to 0.97]) and belonging to the rich (OR 0.66 [95% CI 0.54 to 0.80]) and richest quintiles (OR 0.54 [95% CI 0.44 to 0.66]). CONCLUSIONS This study identifies risk factors associated with diarrhoea in children <23 months of age, including younger maternal age, higher paternal education, not breastfeeding and poverty, which has implications for developing preventive programs and strategies that target populations with a higher risk of diarrhoea.
Collapse
Affiliation(s)
| | | | | | - Suhail Chanar
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi 74800, Pakistan
| | - Apsara Nathwani
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi 74800, Pakistan
| | - Muhammad Jawwad
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Amjad Hussain
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Arjumand Rizvi
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shah Muhammad
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Muhammad Atif Habib
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi 74800, Pakistan
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sajid Bashir Soofi
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi 74800, Pakistan
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shabina Ariff
- Corresponding author: Tel: +92 21 3486 4357; E-mail:
| | - Zulfiqar A Bhutta
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| |
Collapse
|
10
|
Zhao X, Setchell KDR, Huang R, Mallawaarachchi I, Ehsan L, Dobrzykowski III E, Zhao J, Syed S, Ma JZ, Iqbal NT, Iqbal J, Sadiq K, Ahmed S, Haberman Y, Denson LA, Ali SA, Moore SR. Bile Acid Profiling Reveals Distinct Signatures in Undernourished Children with Environmental Enteric Dysfunction. J Nutr 2021; 151:3689-3700. [PMID: 34718665 PMCID: PMC8643614 DOI: 10.1093/jn/nxab321] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/20/2021] [Accepted: 08/30/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Intestinal inflammation and malabsorption in environmental enteric dysfunction (EED) are associated with early childhood growth faltering in impoverished settings worldwide. OBJECTIVES The goal of this study was to identify candidate biomarkers associated with inflammation, EED histology, and as predictors of later growth outcomes by focusing on the liver-gut axis by investigating the bile acid metabolome. METHODS Undernourished rural Pakistani infants (n = 365) with weight-for-height Z score (WHZ) < -2 were followed up to the age of 24 mo and monitored for growth, infections, and EED. Well-nourished local children (n = 51) were controls, based on consistent WHZ > 0 and height-for-age Z score (HAZ) > -1 on 2 consecutive visits at 3 and 6 mo. Serum bile acid (sBA) profiles were measured by tandem MS at the ages of 3-6 and 9 mo and before nutritional intervention. Biopsies and duodenal aspirates were obtained following upper gastrointestinal endoscopy from a subset of children (n = 63) that responded poorly to nutritional intervention. BA composition in paired plasma and duodenal aspirates was compared based on the severity of EED histopathological scores and correlated to clinical and growth outcomes. RESULTS Remarkably, >70% of undernourished Pakistani infants displayed elevated sBA concentrations consistent with subclinical cholestasis. Serum glycocholic acid (GCA) correlated with linear growth faltering (HAZ, r = -0.252 and -0.295 at the age of 3-6 and 9 mo, respectively, P <0.001) and biomarkers of inflammation. The proportion of GCA positively correlated with EED severity for both plasma (rs = 0.324 P = 0.02) and duodenal aspirates (rs = 0.307 P = 0.06) in children with refractory wasting that underwent endoscopy, and the proportion of secondary BA was low in both undernourished and EED children. CONCLUSIONS Dysregulated bile acid metabolism is associated with growth faltering and EED severity in undernourished children. Restoration of intestinal BA homeostasis may offer a novel therapeutic target for undernutrition in children with EED. This trial was registered at clinicaltrials.gov as NCT03588013.
Collapse
Affiliation(s)
- Xueheng Zhao
- Division of Pathology & Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Rong Huang
- Division of Pathology & Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Lubaina Ehsan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Edward Dobrzykowski III
- Division of Pathology & Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA,Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Junfang Zhao
- Division of Pathology & Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sana Syed
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Virginia, Charlottesville, VA, USA,Departments of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Jennie Z Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Najeeha T Iqbal
- Departments of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan,Departments of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Junaid Iqbal
- Departments of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan,Departments of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Kamran Sadiq
- Departments of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sheraz Ahmed
- Departments of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Yael Haberman
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA,Department of Pediatrics, Sheba Medical Center, Tel-HaShomer, affiliated with the Tel-Aviv University, Israel,Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lee A Denson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA,Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Syed Asad Ali
- Departments of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | |
Collapse
|
11
|
Ariff S, Sadiq K, Jiwani U, Ahmed K, Nuzhat K, Ahmed S, Nizami Q, Khan IA, Ali N, Soofi SB, Bhutta ZA. Evaluation the Effectiveness of Abridged IMNCI (7-Day) Course v Standard (11-Day) Course in Pakistan. Matern Child Health J 2021; 26:530-536. [PMID: 34669101 PMCID: PMC8917018 DOI: 10.1007/s10995-021-03276-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2021] [Indexed: 12/02/2022]
Abstract
Background The conventional IMCI training for healthcare providers is delivered in 11 days, which can be expensive and disruptive to the normal clinical routines of the providers. An equally effective, shorter training course may address these challenges. Methods We conducted a quasi-experimental study in two provinces (Sindh and Punjab) of Pakistan. 104 healthcare providers were conveniently selected to receive either the abridged (7-day) or the standard (11-day) training. Knowledge and clinical skills of the participants were assessed before, immediately on conclusion of, and six months after the training. Results The improvement in mean knowledge scores of the 7-day and 11-day training groups was 31.6 (95% CI 24.3, 38.8) and 29.4 (95% CI 23.9, 34.9) respectively, p = 0.630 while the improvement in mean clinical skills scores of the 7-day and 11-day training groups was 23.8 (95% CI: 19.3, 28.2) and 23.0 (95% CI 18.9, 27.0) respectively, p = 0.784. The decline in mean knowledge scores six months after the training was − 12.4 (95% CI − 18.5, − 6.4) and − 6.4 (95% CI − 10.5, − 2.3) in the 7-day and 11-day groups respectively, p = 0.094. The decline in mean clinical skills scores six months after the training was − 6.3 (95% CI − 11.3, − 1.3) in the 7-day training group and − 9.1 (95% CI − 11.5, − 6.6) in the 11-day group, p = 0.308. Conclusion An abridged IMNCI training is equally effective as the standard training. However, training for certain illnesses may be better delivered by the standard course. Supplementary Information The online version contains supplementary material available at 10.1007/s10995-021-03276-3.
Collapse
Affiliation(s)
- Shabina Ariff
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Kamran Sadiq
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Uswa Jiwani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Khalil Ahmed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Khadija Nuzhat
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shakeel Ahmed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Qamruddin Nizami
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Iqtidar A Khan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Sajid Bashir Soofi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan. .,Center of Excellence in Women and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan.
| | - Zulfiqar A Bhutta
- Center of Excellence in Women and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan.
| |
Collapse
|
12
|
Qureshi S, Yousafzai MT, Rozi S, Qureshi S, Hotwani A, Sadiq K, Parkash O, Kazi AM, Kabir F, Usmani H, Qamar FN. Detection of typhoid carriers by duodenal fluid culture in a tertiary care hospital, Karachi: A cross-sectional study. J PAK MED ASSOC 2021; 71:2069-2072. [PMID: 34418032 DOI: 10.47391/jpma.580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We aimed to detect typhoid carriers by performing duodenal fluid culture in patients in a tertiary care hospital in Pakistan. A cross-sectional study was conducted during 2017 at the Aga Khan University Hospital, Karachi. Patients who underwent upper gastrointestinal endoscopy were included. Participants were interviewed, and duodenal fluid samples were taken for culture to detect Salmonella typhi (S. typhi) and paratyphi. A polymerase chain reaction on 100 randomly selected sub-samples was also conducted. A total of 477 participants were enrolled. The mean age was 42.4±15.5 years. History of typhoid fever was present in 73 (15.3%) participants. Out of the 477 duodenal fluid cultures tested for various micro-organisms, 250 (52.4%) were positive. Neither S. typhi nor paratyphi were isolated. S. typhi was also not detected by PCR. To better detect S. typhi carriage in general population, future studies should target people with gall bladder diseases and screen them using culture and PCR based methods.
Collapse
Affiliation(s)
- Sonia Qureshi
- Department of Paediatrics, Aga Khan University Hospital, Karachi
| | | | - Shafquat Rozi
- Department of Community Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Shahida Qureshi
- Department of Paediatric, Aga Khan University Hospital, Karachi, Pakistan
| | - Aneeta Hotwani
- Department of Paediatric, Aga Khan University Hospital, Karachi, Pakistan
| | - Kamran Sadiq
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Om Parkash
- Department of Medicine, The Aga Khan University & Hospital, Karachi
| | - Abdul Momin Kazi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Furqan Kabir
- Department of Paediatric, Aga Khan University Hospital, Karachi, Pakistan
| | - Hadi Usmani
- Department of Paediatric, Aga Khan University Hospital, Karachi, Pakistan
| | - Farah Naz Qamar
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| |
Collapse
|
13
|
Jamil Z, Iqbal NT, Idress R, Ahmed Z, Sadiq K, Mallawaarachchi I, Iqbal J, Syed S, Hotwani A, Kabir F, Ahmed K, Ahmed S, Umrani F, Ma JZ, Aziz F, Kalam A, Moore SR, Ali SA. Gut integrity and duodenal enteropathogen burden in undernourished children with environmental enteric dysfunction. PLoS Negl Trop Dis 2021; 15:e0009584. [PMID: 34264936 PMCID: PMC8352064 DOI: 10.1371/journal.pntd.0009584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 08/09/2021] [Accepted: 06/17/2021] [Indexed: 11/18/2022] Open
Abstract
Environmental enteric dysfunction (EED) is a subclinical condition of intestinal inflammation, barrier dysfunction and malabsorption associated with growth faltering in children living in poverty. This study explores association of altered duodenal permeability (lactulose, rhamnose and their ratio) with higher burden of enteropathogen in the duodenal aspirate, altered histopathological findings and higher morbidity (diarrhea) that is collectively associated with linear growth faltering in children living in EED endemic setting. In a longitudinal birth cohort, 51 controls (WHZ > 0, HAZ > −1.0) and 63 cases (WHZ< -2.0, refractory to nutritional intervention) were recruited. Anthropometry and morbidity were recorded on monthly bases up to 24 months of age. Dual sugar assay of urine collected after oral administration of lactulose and rhamnose was assessed in 96 children from both the groups. Duodenal histopathology (n = 63) and enteropathogen analysis of aspirate via Taqman array card (n = 60) was assessed in only cases. Giardia was the most frequent pathogen and was associated with raised L:R ratio (p = 0.068). Gastric microscopy was more sensitive than duodenal aspirate in H. pylori detection. Microscopically confirmed H. pylori negatively correlated with HAZ at 24 months (r = −0.313, p = 0.013). Regarding histopathological parameters, goblet cell reduction significantly correlated with decline in dual sugar excretion (p< 0.05). Between cases and controls, there were no significant differences in the median (25th, 75th percentile) of urinary concentrations (μg/ml) of lactulose [27.0 (11.50, 59.50) for cases vs. 38.0 (12.0, 61.0) for controls], rhamnose [66.0 (28.0, 178.0) vs. 86.5 (29.5, 190.5)] and L:R ratio [0.47 (0.24, 0.90) vs. 0.51 (0.31, 0.71)] respectively. In multivariable regression model, 31% of variability in HAZ at 24 months of age among cases and controls was explained by final model including dual sugars. In conclusion, enteropathogen burden is associated with altered histopathological features and intestinal permeability. In cases and controls living in settings of endemic enteropathy, intestinal permeability test may predict linear growth. However, for adoption as a screening tool for EED, further validation is required due to its complex intestinal pathophysiology. EED is a subclinical condition of compromised gut integrity secondary to frequent and repeated exposure to enteropathogens in global settings with a high prevalence of undernutrition. In this study, we reported association of gut mucosal architecture with a dual sugar intestinal permeability assay (lactulose-rhamnose) in Pakistani children. In the presence of duodenal enteropathogens, features such as chronic inflammation, intra-epithelial lymphocytosis, enterocyte injury and Paneth cell reduction were consistently observed. When comparing undernourished cases and controls living in the same setting, we found urinary excretion of the sugars was similar among groups; however, variability in HAZ among children at 24 months was partially explained by a model that includes excretion values.
Collapse
Affiliation(s)
- Zehra Jamil
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeha Talat Iqbal
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Romana Idress
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Zubair Ahmed
- Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Kamran Sadiq
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Indika Mallawaarachchi
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, United States of America
| | - Junaid Iqbal
- Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sana Syed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition; Department of Pediatrics, University of Virginia, Charlottesville, Virginia, United States of America
| | - Aneeta Hotwani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Furqan Kabir
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Kumail Ahmed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sheraz Ahmed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Fayaz Umrani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Jennie Z. Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, United States of America
| | - Fatima Aziz
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Adil Kalam
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sean R. Moore
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition; Department of Pediatrics, University of Virginia, Charlottesville, Virginia, United States of America
- * E-mail: (SRM); (SAA)
| | - Syed Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- * E-mail: (SRM); (SAA)
| |
Collapse
|
14
|
Syed S, Ehsan L, Shrivastava A, Sengupta S, Khan M, Kowsari K, Guleria S, Sali R, Kant K, Kang SJ, Sadiq K, Iqbal NT, Cheng L, Moskaluk CA, Kelly P, Amadi BC, Ali SA, Moore SR, Brown DE. Artificial Intelligence-based Analytics for Diagnosis of Small Bowel Enteropathies and Black Box Feature Detection. J Pediatr Gastroenterol Nutr 2021; 72:833-841. [PMID: 33534362 PMCID: PMC8767179 DOI: 10.1097/mpg.0000000000003057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Striking histopathological overlap between distinct but related conditions poses a disease diagnostic challenge. There is a major clinical need to develop computational methods enabling clinicians to translate heterogeneous biomedical images into accurate and quantitative diagnostics. This need is particularly salient with small bowel enteropathies; environmental enteropathy (EE) and celiac disease (CD). We built upon our preliminary analysis by developing an artificial intelligence (AI)-based image analysis platform utilizing deep learning convolutional neural networks (CNNs) for these enteropathies. METHODS Data for the secondary analysis was obtained from three primary studies at different sites. The image analysis platform for EE and CD was developed using CNNs including one with multizoom architecture. Gradient-weighted class activation mappings (Grad-CAMs) were used to visualize the models' decision-making process for classifying each disease. A team of medical experts simultaneously reviewed the stain color normalized images done for bias reduction and Grad-CAMs to confirm structural preservation and biomedical relevance, respectively. RESULTS Four hundred and sixty-one high-resolution biopsy images from 150 children were acquired. Median age (interquartile range) was 37.5 (19.0-121.5) months with a roughly equal sex distribution; 77 males (51.3%). ResNet50 and shallow CNN demonstrated 98% and 96% case-detection accuracy, respectively, which increased to 98.3% with an ensemble. Grad-CAMs demonstrated models' ability to learn different microscopic morphological features for EE, CD, and controls. CONCLUSIONS Our AI-based image analysis platform demonstrated high classification accuracy for small bowel enteropathies which was capable of identifying biologically relevant microscopic features and emulating human pathologist decision-making process. Grad-CAMs illuminated the otherwise "black box" of deep learning in medicine, allowing for increased physician confidence in adopting these new technologies in clinical practice.
Collapse
Affiliation(s)
- Sana Syed
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Lubaina Ehsan
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Aman Shrivastava
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
- Data Science Institute, University of Virginia, Charlottesville, VA
| | - Saurav Sengupta
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
- Data Science Institute, University of Virginia, Charlottesville, VA
| | - Marium Khan
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Kamran Kowsari
- Systems and Information Engineering, University of Virginia, Charlottesville, VA, USA
- University of California Los Angeles, Los Angeles, CA, USA
| | - Shan Guleria
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Rasoul Sali
- Systems and Information Engineering, University of Virginia, Charlottesville, VA, USA
| | - Karan Kant
- Data Science Institute, University of Virginia, Charlottesville, VA
| | - Sung-Jun Kang
- Data Science Institute, University of Virginia, Charlottesville, VA
| | - Kamran Sadiq
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeha T. Iqbal
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Lin Cheng
- Pathology Department, Rush University Medical Center, Chicago, IL, USA
| | | | - Paul Kelly
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
- Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Beatrice C. Amadi
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - S. Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sean R. Moore
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Donald E. Brown
- Systems and Information Engineering, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
15
|
Haberman Y, Iqbal NT, Ghandikota S, Mallawaarachchi I, Tzipi Braun, Dexheimer PJ, Rahman N, Hadar R, Sadiq K, Ahmad Z, Idress R, Iqbal J, Ahmed S, Hotwani A, Umrani F, Ehsan L, Medlock G, Syed S, Moskaluk C, Ma JZ, Jegga AG, Moore SR, Ali SA, Denson LA. Mucosal Genomics Implicate Lymphocyte Activation and Lipid Metabolism in Refractory Environmental Enteric Dysfunction. Gastroenterology 2021; 160:2055-2071.e0. [PMID: 33524399 PMCID: PMC8113748 DOI: 10.1053/j.gastro.2021.01.221] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Environmental enteric dysfunction (EED) limits the Sustainable Development Goals of improved childhood growth and survival. We applied mucosal genomics to advance our understanding of EED. METHODS The Study of Environmental Enteropathy and Malnutrition (SEEM) followed 416 children from birth to 24 months in a rural district in Pakistan. Biomarkers were measured at 9 months and tested for association with growth at 24 months. The duodenal methylome and transcriptome were determined in 52 undernourished SEEM participants and 42 North American controls and patients with celiac disease. RESULTS After accounting for growth at study entry, circulating insulin-like growth factor-1 (IGF-1) and ferritin predicted linear growth, whereas leptin correlated with future weight gain. The EED transcriptome exhibited suppression of antioxidant, detoxification, and lipid metabolism genes, and induction of anti-microbial response, interferon, and lymphocyte activation genes. Relative to celiac disease, suppression of antioxidant and detoxification genes and induction of antimicrobial response genes were EED-specific. At the epigenetic level, EED showed hyper-methylation of epithelial metabolism and barrier function genes, and hypo-methylation of immune response and cell proliferation genes. Duodenal coexpression modules showed association between lymphocyte proliferation and epithelial metabolic genes and histologic severity, fecal energy loss, and wasting (weight-for-length/height Z < -2.0). Leptin was associated with expression of epithelial carbohydrate metabolism and stem cell renewal genes. Immune response genes were attenuated by giardia colonization. CONCLUSIONS Children with reduced circulating IGF-1 are more likely to experience stunting. Leptin and a gene signature for lymphocyte activation and dysregulated lipid metabolism are implicated in wasting, suggesting new approaches for EED refractory to nutritional intervention. ClinicalTrials.gov, Number: NCT03588013. (https://clinicaltrials.gov/ct2/show/NCT03588013).
Collapse
Affiliation(s)
- Yael Haberman
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio,Department of Pediatrics, Sheba Medical Center, Tel-HaShomer, affiliated with the Tel-Aviv University, Israel
| | - Najeeha T. Iqbal
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan,Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Sudhir Ghandikota
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center Cincinnati, Department of Computer Science, University of Cincinnati College of Engineering, Cincinnati, Ohio
| | | | - Tzipi Braun
- Department of Pediatrics, Sheba Medical Center, Tel-HaShomer, affiliated with the Tel-Aviv University, Israel
| | - Phillip J. Dexheimer
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Najeeb Rahman
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Rotem Hadar
- Department of Pediatrics, Sheba Medical Center, Tel-HaShomer, affiliated with the Tel-Aviv University, Israel
| | - Kamran Sadiq
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zubair Ahmad
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Romana Idress
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Junaid Iqbal
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan,Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Sheraz Ahmed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Aneeta Hotwani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Fayyaz Umrani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Lubaina Ehsan
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Greg Medlock
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Sana Syed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan,Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Chris Moskaluk
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Jennie Z. Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Anil G. Jegga
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio,Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center Cincinnati, Department of Computer Science, University of Cincinnati College of Engineering, Cincinnati, Ohio
| | - Sean R. Moore
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia,Sean R. Moore, MD, MS, Division of Pediatric Gastroenterology, Hepatology, & Nutrition, University of Virginia, 409 Lane Rd., Charlottesville, VA 22908.
| | - Syed Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Lee A. Denson
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio,Correspondence Address correspondence to: Lee A Denson, MD, Division of Pediatric Gastroenterology, Hepatology, & Nutrition, Cincinnati Children’s Hospital Medical Center, MLC 2010, 3333 Burnet Avenue, Cincinnati, Ohio 45229. fax: (513) 636-558.
| |
Collapse
|
16
|
Ahmed R, Jurair H, Sadiq K. Upper gastrointestinal bleed in a toddler - an unusual encounter revealing foreign body ingestion. J PAK MED ASSOC 2021; 71:1249-1251. [PMID: 34125781 DOI: 10.47391/jpma.03-301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Foreign body (FB) ingestion is common in children; however, management varies based on the object ingested, its location and clinical presentation. Urgent intervention is needed if any warning signs are present. We describe the case of a four-year-old child who presented with acute onset of life-threatening upper gastro intestinal bleeding. He had no other significant previous or present complaint, and results of lab workup were inconclusive. Endoscopic evaluation revealed a sharp and hard object which was removed. Post-operative period, duration of hospitalization and subsequent follow up were uneventful. Through this report, we wish to draw the attention of healthcare providers to the dangerous effects of FB ingestion and also emphasise that FB ingestion should be considered in differential diagnosis when unexplained upper GI haemorrhage symptoms occur acutely.
Collapse
Affiliation(s)
- Rahim Ahmed
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Humaira Jurair
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Kamran Sadiq
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| |
Collapse
|
17
|
Harrison E, Syed S, Ehsan L, Iqbal NT, Sadiq K, Umrani F, Ahmed S, Rahman N, Jakhro S, Ma JZ, Hughes M, Ali SA. Machine learning model demonstrates stunting at birth and systemic inflammatory biomarkers as predictors of subsequent infant growth - a four-year prospective study. BMC Pediatr 2020; 20:498. [PMID: 33126871 PMCID: PMC7597024 DOI: 10.1186/s12887-020-02392-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/15/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Stunting affects up to one-third of the children in low-to-middle income countries (LMICs) and has been correlated with decline in cognitive capacity and vaccine immunogenicity. Early identification of infants at risk is critical for early intervention and prevention of morbidity. The aim of this study was to investigate patterns of growth in infants up through 48 months of age to assess whether the growth of infants with stunting eventually improved as well as the potential predictors of growth. METHODS Height-for-age z-scores (HAZ) of children from Matiari (rural site, Pakistan) at birth, 18 months, and 48 months were obtained. Results of serum-based biomarkers collected at 6 and 9 months were recorded. A descriptive analysis of the population was followed by assessment of growth predictors via traditional machine learning random forest models. RESULTS Of the 107 children who were followed up till 48 months of age, 51% were stunted (HAZ < - 2) at birth which increased to 54% by 48 months of age. Stunting status for the majority of children at 48 months was found to be the same as at 18 months. Most children with large gains started off stunted or severely stunted, while all of those with notably large losses were not stunted at birth. Random forest models identified HAZ at birth as the most important feature in predicting HAZ at 18 months. Of the biomarkers, AGP (Alpha- 1-acid Glycoprotein), CRP (C-Reactive Protein), and IL1 (interleukin-1) were identified as strong subsequent growth predictors across both the classification and regressor models. CONCLUSION We demonstrated that children most children with stunting at birth remained stunted at 48 months of age. Value was added for predicting growth outcomes with the use of traditional machine learning random forest models. HAZ at birth was found to be a strong predictor of subsequent growth in infants up through 48 months of age. Biomarkers of systemic inflammation, AGP, CRP, IL1, were also strong predictors of growth outcomes. These findings provide support for continued focus on interventions prenatally, at birth, and early infancy in children at risk for stunting who live in resource-constrained regions of the world.
Collapse
Affiliation(s)
- Elizabeth Harrison
- School of Medicine, University of Virginia, Charlottesville, VA, USA.,Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sana Syed
- School of Medicine, University of Virginia, Charlottesville, VA, USA. .,Department of Paediatrics and Child Health, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan.
| | - Lubaina Ehsan
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Najeeha T Iqbal
- Department of Paediatrics and Child Health, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan
| | - Kamran Sadiq
- Department of Paediatrics and Child Health, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan
| | - Fayyaz Umrani
- Department of Paediatrics and Child Health, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan
| | - Sheraz Ahmed
- Department of Paediatrics and Child Health, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan
| | - Najeeb Rahman
- Department of Paediatrics and Child Health, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan
| | - Sadaf Jakhro
- Department of Paediatrics and Child Health, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan
| | - Jennie Z Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Molly Hughes
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - S Asad Ali
- Department of Paediatrics and Child Health, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi, 74800, Pakistan.
| |
Collapse
|
18
|
Shokry E, Sadiq K, Soofi S, Habib A, Bhutto N, Rizvi A, Ahmad I, Demmelmair H, Uhl O, Bhutta ZA, Koletzko B. Impact of Treatment with RUTF on Plasma Lipid Profiles of Severely Malnourished Pakistani Children. Nutrients 2020; 12:nu12072163. [PMID: 32708260 PMCID: PMC7401247 DOI: 10.3390/nu12072163] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/10/2020] [Accepted: 07/16/2020] [Indexed: 12/22/2022] Open
Abstract
(1) Background: Little is known on impacts of ready-to-use therapeutic food (RUTF) treatment on lipid metabolism in children with severe acute malnutrition (SAM). (2) Methods: We analyzed glycerophospholipid fatty acids (FA) and polar lipids in plasma of 41 Pakistani children with SAM before and after 3 months of RUTF treatment using gas chromatography and flow-injection analysis tandem mass spectrometry, respectively. Statistical analysis was performed using univariate, multivariate tests and evaluated for the impact of age, sex, breastfeeding status, hemoglobin, and anthropometry. (3) Results: Essential fatty acid (EFA) depletion at baseline was corrected by RUTF treatment which increased EFA. In addition, long-chain polyunsaturated fatty acids (LC-PUFA) and the ratio of arachidonic acid (AA)/linoleic acid increased reflecting greater EFA conversion to LC-PUFA, whereas Mead acid/AA decreased. Among phospholipids, lysophosphatidylcholines (lyso.PC) were most impacted by treatment; in particular, saturated lyso.PC decreased. Higher child age and breastfeeding were associated with great decrease in total saturated FA (ΣSFA) and lesser decrease in monounsaturated FA and total phosphatidylcholines (ΣPC). Conclusions: RUTF treatment improves EFA deficiency in SAM, appears to enhance EFA conversion to biologically active LC-PUFA, and reduces lipolysis reflected in decreased ΣSFA and saturated lyso.PC. Child age and breastfeeding modify treatment-induced changes in ΣSFA and ΣPC.
Collapse
Affiliation(s)
- Engy Shokry
- Department of Pediatrics, Ludwig-Maximilians-University Paediatrics, Division of Metabolic and Nutritional Medicine, Dr. von Hauner Children’s Hospital, 80337 Munich, Germany; (E.S.); (H.D.); (O.U.)
| | - Kamran Sadiq
- Department of Pediatrics & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (K.S.); (S.S.)
| | - Sajid Soofi
- Department of Pediatrics & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (K.S.); (S.S.)
- Center of Excellence in Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (A.H.); (N.B.); (A.R.); (I.A.)
| | - Atif Habib
- Center of Excellence in Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (A.H.); (N.B.); (A.R.); (I.A.)
| | - Naveed Bhutto
- Center of Excellence in Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (A.H.); (N.B.); (A.R.); (I.A.)
| | - Arjumand Rizvi
- Center of Excellence in Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (A.H.); (N.B.); (A.R.); (I.A.)
| | - Imran Ahmad
- Center of Excellence in Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (A.H.); (N.B.); (A.R.); (I.A.)
| | - Hans Demmelmair
- Department of Pediatrics, Ludwig-Maximilians-University Paediatrics, Division of Metabolic and Nutritional Medicine, Dr. von Hauner Children’s Hospital, 80337 Munich, Germany; (E.S.); (H.D.); (O.U.)
| | - Olaf Uhl
- Department of Pediatrics, Ludwig-Maximilians-University Paediatrics, Division of Metabolic and Nutritional Medicine, Dr. von Hauner Children’s Hospital, 80337 Munich, Germany; (E.S.); (H.D.); (O.U.)
| | - Zulfiqar A. Bhutta
- Center of Excellence in Women & Child Health, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; (A.H.); (N.B.); (A.R.); (I.A.)
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
- Correspondence: (Z.A.B.); (B.K.); Tel.: +17-573248424 (Z.A.B.); +49-89-44005-2826 (B.K.); Fax: +49-89-44005-7742 (B.K.)
| | - Berthold Koletzko
- Department of Pediatrics, Ludwig-Maximilians-University Paediatrics, Division of Metabolic and Nutritional Medicine, Dr. von Hauner Children’s Hospital, 80337 Munich, Germany; (E.S.); (H.D.); (O.U.)
- Correspondence: (Z.A.B.); (B.K.); Tel.: +17-573248424 (Z.A.B.); +49-89-44005-2826 (B.K.); Fax: +49-89-44005-7742 (B.K.)
| |
Collapse
|
19
|
Liu TC, VanBuskirk K, Ali SA, Kelly MP, Holtz LR, Yilmaz OH, Sadiq K, Iqbal N, Amadi B, Syed S, Ahmed T, Moore S, Ndao IM, Isaacs MH, Pfeifer JD, Atlas H, Tarr PI, Denno DM, Moskaluk CA. A novel histological index for evaluation of environmental enteric dysfunction identifies geographic-specific features of enteropathy among children with suboptimal growth. PLoS Negl Trop Dis 2020; 14:e0007975. [PMID: 31929525 PMCID: PMC6980693 DOI: 10.1371/journal.pntd.0007975] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 01/24/2020] [Accepted: 12/06/2019] [Indexed: 02/06/2023] Open
Abstract
Background A major limitation to understanding the etiopathogenesis of environmental enteric dysfunction (EED) is the lack of a comprehensive, reproducible histologic framework for characterizing the small bowel lesions. We hypothesized that the development of such a system will identify unique histology features for EED, and that some features might correlate with clinical severity. Methods Duodenal endoscopic biopsies from two cohorts where EED is prevalent (Pakistan, Zambia) and North American children with and without gluten sensitive enteropathy (GSE) were processed for routine hematoxylin & eosin (H&E) staining, and scanned to produce whole slide images (WSIs) which we shared among study pathologists via a secure web browser-based platform. A semi-quantitative scoring index composed of 11 parameters encompassing tissue injury and response patterns commonly observed in routine clinical practice was constructed by three gastrointestinal pathologists, with input from EED experts. The pathologists then read the WSIs using the EED histology index, and inter-observer reliability was assessed. The histology index was further used to identify within- and between-child variations as well as features common across and unique to each cohort, and those that correlated with host phenotype. Results Eight of the 11 histologic scoring parameters showed useful degrees of variation. The overall concordance across all parameters was 96% weighted agreement, kappa 0.70, and Gwet’s AC 0.93. Zambian and Pakistani tissues shared some histologic features with GSE, but most features were distinct, particularly abundance of intraepithelial lymphocytes in the Pakistani cohort, and marked villous destruction and loss of secretory cell lineages in the Zambian cohort. Conclusions We propose the first EED histology index for interpreting duodenal biopsies. This index should be useful in future clinical and translational studies of this widespread, poorly understood, and highly consequential disorder, which might be caused by multiple contributing processes, in different regions of the world. The study of EED has been limited by the lack of a rigorously tested, reproducible histology index that can provide insight to the pathogenesis of this entity. In this study we report the first duodenal histology index that was developed using an unbiased approach, with excellent inter-observer reproducibility, for the study of EED. The EED histology index readily identified histologic features that are common or unique to cohorts of distinct geographic locations. Incorporating the histology index into future clinical studies will provide useful insight into the pathogenesis and for intervention strategy development.
Collapse
Affiliation(s)
- Ta-Chiang Liu
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Kelley VanBuskirk
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Syed A. Ali
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - M. Paul Kelly
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Lori R. Holtz
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Omer H. Yilmaz
- The David H. Koch Institute for Integrative Cancer Research at MIT, Cambridge, MA, Department of Pathology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Kamran Sadiq
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeha Iqbal
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Sana Syed
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Sean Moore
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - I. Malick Ndao
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Michael H. Isaacs
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - John D. Pfeifer
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Hannah Atlas
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States of America
| | - Phillip I. Tarr
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Donna M. Denno
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States of America
| | - Christopher A. Moskaluk
- Department of Pathology, University of Virginia, Charlottesville, VA, United States of America
- * E-mail:
| |
Collapse
|
20
|
Iqbal NT, Syed S, Kabir F, Jamil Z, Akhund T, Qureshi S, Liu J, Ma JZ, Guleria S, Gewirtz A, Duggan CP, Hughes MA, Sadiq K, Ali A. Pathobiome driven gut inflammation in Pakistani children with Environmental Enteric Dysfunction. PLoS One 2019; 14:e0221095. [PMID: 31442248 PMCID: PMC6707605 DOI: 10.1371/journal.pone.0221095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 07/30/2019] [Indexed: 01/05/2023] Open
Abstract
Environmental Enteric Dysfunction (EED) is an acquired small intestinal inflammatory condition underlying high rates of stunting in children <5 years of age in low- and middle-income countries. Children with EED are known to have repeated exposures to enteropathogens and environmental toxins that leads to malabsorptive syndrome. We aimed to characterize association of linear growth faltering with enteropathogen burden and subsequent changes in EED biomarkers. In a longitudinal birth cohort (n = 272), monthly anthropometric measurements (Length for Age Z score- LAZ) of asymptomatic children were obtained up to 18 months. Biological samples were collected at 6 and 9 months for the assessment of biomarkers. A customized TaqMan array card was used to target 40 enteropathogens in fecal samples. Linear regression was applied to study the effect of specific enteropathogen infection on change in linear growth (ΔLAZ). Presence of any pathogen in fecal sample correlated with serum flagellin IgA (6 mo, r = 0.19, p = 0.002), fecal Reg 1b (6 mo, r = 0.16, p = 0.01; 9mo, r = 0.16, p = 0.008) and serum Reg 1b (6 mo, r = 0.26, p<0.0001; 9 mo, r = 0.15, p = 0.008). At 6 months, presence of Campylobacter [β (SE) 7751.2 (2608.5), p = 0.003] and ETEC LT [β (SE) 7089.2 (3015.04), p = 0.019] was associated with increase in MPO. Giardia was associated with increase in Reg1b [β (SE) 72.189 (26.394), p = 0.006] and anti-flic IgA[β (SE) 0.054 (0.021), p = 0.0091]. Multiple enteropathogen infections in early life negatively correlated with ΔLAZ, and simultaneous changes in gut inflammatory and permeability markers. A combination vaccine targeting enteropathogens in early life could help in the prevention of future stunting.
Collapse
Affiliation(s)
- Najeeha T. Iqbal
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Department of Biological & Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Sana Syed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - Furqan Kabir
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zehra Jamil
- Department of Biological & Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Tauseef Akhund
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shahida Qureshi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Jie Liu
- Department of Medicine, University of Virginia, Charlottesville, VA, United States of America
| | - Jennie Z. Ma
- Department of Medicine, University of Virginia, Charlottesville, VA, United States of America
| | - Shan Guleria
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - Andrew Gewirtz
- Center for Inflammation Immunity & Infection, Georgia State University, Atlanta, Georgia, United States of America
| | - Christopher P. Duggan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Departments of Global Health and Population, and Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Molly A. Hughes
- Department of Medicine, University of Virginia, Charlottesville, VA, United States of America
| | - Kamran Sadiq
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- * E-mail:
| |
Collapse
|
21
|
Iqbal NT, Syed S, Sadiq K, Khan MN, Iqbal J, Ma JZ, Umrani F, Ahmed S, Maier EA, Denson LA, Haberman Y, McNeal MM, Setchell KDR, Zhao X, Qureshi S, Shen L, Moskaluk CA, Liu TC, Yilmaz O, Brown DE, Barratt MJ, Kung VL, Gordon JI, Moore SR, Ali SA. Study of Environmental Enteropathy and Malnutrition (SEEM) in Pakistan: protocols for biopsy based biomarker discovery and validation. BMC Pediatr 2019; 19:247. [PMID: 31331393 PMCID: PMC6643315 DOI: 10.1186/s12887-019-1564-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 05/31/2019] [Indexed: 12/26/2022] Open
Abstract
Background Environmental Enteropathy (EE), characterized by alterations in intestinal structure, function, and immune activation, is believed to be an important contributor to childhood undernutrition and its associated morbidities, including stunting. Half of all global deaths in children < 5 years are attributable to under-nutrition, making the study of EE an area of critical priority. Methods Community based intervention study, divided into two sub-studies, 1) Longitudinal analyses and 2) Biopsy studies for identification of EE features via omics analyses. Birth cohorts in Matiari, Pakistan established: moderately or severely malnourished (weight for height Z score (WHZ) < − 2) children, and well-nourished (WHZ > 0) children. Blood, urine, and fecal samples, for evaluation of potential biomarkers, will be collected at various time points from all participants (longitudinal analyses). Participants will receive appropriate educational and nutritional interventions; non-responders will undergo further evaluation to determine eligibility for further workup, including upper gastrointestinal endoscopy. Histopathological changes in duodenal biopsies will be compared with duodenal biopsies obtained from USA controls who have celiac disease, Crohn’s disease, or who were found to have normal histopathology. RNA-Seq will be employed to characterize mucosal gene expression across groups. Duodenal biopsies, luminal aspirates from the duodenum, and fecal samples will be analyzed to define microbial community composition (omic analyses). The relationship between histopathology, mucosal gene expression, and community configuration will be assessed using a variety of bioinformatic tools to gain better understanding of disease pathogenesis and to identify mechanism-based biomarkers. Ethical review committees at all collaborating institutions have approved this study. All results will be made available to the scientific community. Discussion Operational and ethical constraints for safely obtaining intestinal biopsies from children in resource-poor settings have led to a paucity of human tissue-based investigations to understand and reverse EE in vulnerable populations. Furthermore, EE biomarkers have rarely been correlated with gold standard histopathological confirmation. The Study of Environmental Enteropathy and Malnutrition (SEEM) is designed to better understand the pathophysiology, predictors, biomarkers, and potential management strategies of EE to inform strategies to eradicate this debilitating pathology and accelerate progress towards the 2030 Sustainable Development Goals. Trial registration Retrospectively registered; clinicaltrials.gov ID NCT03588013. Electronic supplementary material The online version of this article (10.1186/s12887-019-1564-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Najeeha T Iqbal
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan.,Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Sana Syed
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan.,Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Kamran Sadiq
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Marium N Khan
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Junaid Iqbal
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan.,Department of Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | - Jennie Z Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Fayaz Umrani
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sheraz Ahmed
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Elizabeth A Maier
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lee A Denson
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Yael Haberman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Monica M McNeal
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kenneth D R Setchell
- Clinical Mass Spectrometry, Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Xueheng Zhao
- Clinical Mass Spectrometry, Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shahida Qureshi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Lanlan Shen
- Department of Pediatrics, Baylor College of Medicine, USDA/ARS Children's Nutrition Research Center, Houston, TX, USA
| | | | - Ta-Chiang Liu
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Omer Yilmaz
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Koch Institute for Integrative Cancer Research at MIT and Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Donald E Brown
- Data Science Institute, University of Virginia, Charlottesville, VA, USA
| | - Michael J Barratt
- Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA
| | - Vanderlene L Kung
- Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffrey I Gordon
- Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sean R Moore
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA.
| | - S Asad Ali
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan.
| |
Collapse
|
22
|
Syed S, Al-Boni M, Khan MN, Sadiq K, Iqbal NT, Moskaluk CA, Kelly P, Amadi B, Ali SA, Moore SR, Brown DE. Assessment of Machine Learning Detection of Environmental Enteropathy and Celiac Disease in Children. JAMA Netw Open 2019; 2:e195822. [PMID: 31199451 PMCID: PMC6575155 DOI: 10.1001/jamanetworkopen.2019.5822] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/30/2019] [Indexed: 12/16/2022] Open
Abstract
Importance Duodenal biopsies from children with enteropathies associated with undernutrition, such as environmental enteropathy (EE) and celiac disease (CD), display significant histopathological overlap. Objective To develop a convolutional neural network (CNN) to enhance the detection of pathologic morphological features in diseased vs healthy duodenal tissue. Design, Setting, and Participants In this prospective diagnostic study, a CNN consisting of 4 convolutions, 1 fully connected layer, and 1 softmax layer was trained on duodenal biopsy images. Data were provided by 3 sites: Aga Khan University Hospital, Karachi, Pakistan; University Teaching Hospital, Lusaka, Zambia; and University of Virginia, Charlottesville. Duodenal biopsy slides from 102 children (10 with EE from Aga Khan University Hospital, 16 with EE from University Teaching Hospital, 34 with CD from University of Virginia, and 42 with no disease from University of Virginia) were converted into 3118 images. The CNN was designed and analyzed at the University of Virginia. The data were collected, prepared, and analyzed between November 2017 and February 2018. Main Outcomes and Measures Classification accuracy of the CNN per image and per case and incorrect classification rate identified by aggregated 10-fold cross-validation confusion/error matrices of CNN models. Results Overall, 102 children participated in this study, with a median (interquartile range) age of 31.0 (20.3-75.5) months and a roughly equal sex distribution, with 53 boys (51.9%). The model demonstrated 93.4% case-detection accuracy and had a false-negative rate of 2.4%. Confusion metrics indicated most incorrect classifications were between patients with CD and healthy patients. Feature map activations were visualized and learned distinctive patterns, including microlevel features in duodenal tissues, such as alterations in secretory cell populations. Conclusions and Relevance A machine learning-based histopathological analysis model demonstrating 93.4% classification accuracy was developed for identifying and differentiating between duodenal biopsies from children with EE and CD. The combination of the CNN with a deconvolutional network enabled feature recognition and highlighted secretory cells' role in the model's ability to differentiate between these histologically similar diseases.
Collapse
Affiliation(s)
- Sana Syed
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Virginia, Charlottesville
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Mohammad Al-Boni
- Systems and Information Engineering, University of Virginia, Charlottesville
| | - Marium N. Khan
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Virginia, Charlottesville
| | - Kamran Sadiq
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeha T. Iqbal
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Paul Kelly
- Blizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - S. Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sean R. Moore
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Virginia, Charlottesville
| | - Donald E. Brown
- Data Science Institute, University of Virginia, Charlottesville
| |
Collapse
|
23
|
Abstract
BACKGROUND Persistent diarrhoea (PD), defined as diarrhoeal symptoms for longer than 2 weeks, still forms a substantial disease burden in children under 5 years of age. This article provides an overview of the current knowledge of PD and discusses novel concepts. METHODS A literature search on PD was performed which focused on evidence on epidemiology, pathophysiology and management of the disease. RESULTS The prevalence of PD has potentially decreased over the last decades. Debate remains around the role of specific bacterial, viral and parasitic infections with PD. PD is associated with malnutrition and a compromised immune system, including that caused by HIV infection. Management includes fluid resuscitation and improving nutritional status. There is a lack of evidence on the use of antibiotic therapy for PD. There is increasing interest in nutrient-based interventions, including pre- and/or probiotics that can modify the microbiome and thereby potentially prevent or improve the outcome of PD in children. CONCLUSION As PD remains a significant health burden, multicentre clinical trials are needed to inform future treatment guidelines. ABBREVIATIONS PD, persistent diarrhoea; EED, environmental enteric dysfunction; IBD, inflammatory bowel disease; WHO, World Health Organization.
Collapse
Affiliation(s)
- Robert H J Bandsma
- a Division of Gastroenterology, Hepatology and Nutrition , Hospital for Sick Children , Toronto , Canada.,b Translational Medicine Program, Hospital for Sick Children , Toronto , Canada.,c Centre for Global Child Health, Hospital for Sick Children , Toronto , Canada.,d Department of Nutrition Sciences , University of Toronto , Toronto , Canada
| | - Kamran Sadiq
- e Department of Paediatrics and Child Health , Aga Khan University , Karachi , Pakistan
| | - Zulfiqar A Bhutta
- c Centre for Global Child Health, Hospital for Sick Children , Toronto , Canada.,d Department of Nutrition Sciences , University of Toronto , Toronto , Canada.,e Department of Paediatrics and Child Health , Aga Khan University , Karachi , Pakistan
| |
Collapse
|
24
|
Syed S, Yeruva S, Herrmann J, Sailer A, Sadiq K, Iqbal N, Kabir F, Ahmed K, Qureshi S, Moore SR, Turner J, Ali SA. Environmental Enteropathy in Undernourished Pakistani Children: Clinical and Histomorphometric Analyses. Am J Trop Med Hyg 2018; 98:1577-1584. [PMID: 29611507 PMCID: PMC6086170 DOI: 10.4269/ajtmh.17-0306] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Despite nutrition interventions, stunting thought to be secondary to underlying environmental enteropathy (EE) remains pervasive among infants residing in resource-poor countries and remains poorly characterized. From a birth cohort of 380 children, 65 malnourished infants received 12 weeks of nutritional supplementation with ready-to-use therapeutic food (RUTF). Eleven children with insufficient response to RUTF underwent upper endoscopy with duodenal biopsies, which were compared with U.S., age-matched specimens for healthy, celiac disease, non-celiac villous atrophy, non-celiac intraepithelial lymphocytosis, and graft-versus-host disease patients. Of the 11 children biopsied, EE was found in 10 (91%) with one subject with celiac disease. Morphometry demonstrated decreased villus-to-crypt (V:C) ratios in EE relative to healthy and non-celiac lymphocytosis patients. Environmental enteropathy villus volumes were significantly decreased relative to healthy controls. In EE, average CD3+ cells per 100 epithelial cells and per 1,000 µm2 of lamina propria and the number of lamina propria CD20+ B-cell aggregates were increased relative to all other groups. Our results indicate that V:C ratios are reduced in EE but are less severe than in celiac disease. Environmental enteropathy intraepithelial and lamina propria T lymphocytosis is of greater magnitude than that in celiac disease. The increases in lamina propria B and T lymphocytes suggest that non-cytolytic lymphocytic activation may be a more prominent feature of EE relative to celiac disease. These results provide new insights into shared yet distinct histological and immunological features of EE and celiac disease in children.
Collapse
Affiliation(s)
- Sana Syed
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Pediatrics, University of Virginia, Charlottesville, Virginia.,Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan.,Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sunil Yeruva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeremy Herrmann
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anne Sailer
- Department of Pathology, University of Chicago, Chicago, Illinois
| | - Kamran Sadiq
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeha Iqbal
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Furqan Kabir
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Kumail Ahmed
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shahida Qureshi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sean R Moore
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Jerrold Turner
- Department of Pathology, University of Chicago, Chicago, Illinois.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - S Asad Ali
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| |
Collapse
|
25
|
Syed S, Iqbal NT, Sadiq K, Ma JZ, Akhund T, Xin W, Moore SR, Liu E, Qureshi S, Gosselin K, Gewirtz A, Duggan CP, Ali SA. Serum anti-flagellin and anti-lipopolysaccharide immunoglobulins as predictors of linear growth faltering in Pakistani infants at risk for environmental enteric dysfunction. PLoS One 2018; 13:e0193768. [PMID: 29509790 PMCID: PMC5839587 DOI: 10.1371/journal.pone.0193768] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 02/17/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Environmental Enteric Dysfunction (EED) in children from low-income countries has been linked to linear growth declines. There is a critical need to identify sensitive and early EED biomarkers. OBJECTIVE Determine whether levels of antibodies against bacterial components flagellin (flic) and lipopolysaccharide (LPS) predict poor growth. DESIGN/METHODS In a prospective birth cohort of 380 children in rural Pakistan blood and stool samples were obtained at ages 6 and 9 months. Linear mixed effects models were used to examine longitudinal associations between quartiles of anti-flic and anti-LPS antibodies and changes in LAZ, WAZ and WLZ scores. Spearman's correlations were measured between anti-flic and anti-LPS immunoglobulins with measures of systemic/enteric inflammation and intestinal regeneration. RESULTS Anti-LPS IgA correlated significantly with CRP, AGP and Reg1 serum at 6mo and with MPO at 9mo. In multivariate analysis at 6mo of age, higher anti-LPS IgA levels predicted greater declines in LAZ scores over subsequent 18mo (comparing highest to lowest quartile, β (SE) change in LAZ score/year = -0.313 (0.125), p-value = 0.013). Anti-flic Ig A in the two highest quartiles measured at 9mo of age had declines in LAZ of -0.269 (0.126), p = 0.033; and -0.306 (0.129), p = 0.018 respectively, during the subsequent 18mo of life, compared to those in the lowest quartile of anti-flic IgA. CONCLUSIONS AND RELEVANCE Elevated anti-flic IgA and anti-LPS IgA antibodies at 6 and 9mo, predict declines in linear growth. Systemic and enteric inflammation correlated with anti-LPS IgA provides mechanistic considerations for potential future interventions.
Collapse
Affiliation(s)
- Sana Syed
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
- Department of Pediatrics, the Aga Khan University, Karachi, Pakistan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA, United States of America
| | - Najeeha T. Iqbal
- Department of Pediatrics, the Aga Khan University, Karachi, Pakistan
| | - Kamran Sadiq
- Department of Pediatrics, the Aga Khan University, Karachi, Pakistan
| | - Jennie Z. Ma
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States of America
| | - Tauseef Akhund
- Department of Pediatrics, the Aga Khan University, Karachi, Pakistan
| | - Wenjun Xin
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States of America
| | - Sean R. Moore
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - Enju Liu
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA, United States of America
| | - Shahida Qureshi
- Department of Pediatrics, the Aga Khan University, Karachi, Pakistan
| | - Kerri Gosselin
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA, United States of America
| | - Andrew Gewirtz
- Center for Inflammation Immunity & Infection, Georgia State University, Atlanta, GA, United States of America
| | - Christopher P. Duggan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA, United States of America
- Departments of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - S. Asad Ali
- Department of Pediatrics, the Aga Khan University, Karachi, Pakistan
| |
Collapse
|
26
|
Avinashi V, Sadiq K, Nicol S. A280 SPECIALIZED FORMULA USE FOR THE TREATMENT OF COW MILK PROTEIN ALLERGY. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy008.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- V Avinashi
- BC Children’s Hospital, Vancouver, BC, Canada
| | - K Sadiq
- BC Children’s Hospital, Vancouver, BC, Canada
| | - S Nicol
- BC Children’s Hospital, Vancouver, BC, Canada
| |
Collapse
|
27
|
Ahmed QS, Fadoo Z, Sadiq K, Altaf S. Hepatitis C at presentation in a newly diagnosed infant with B Acute Lymphoblastic Leukemia. Pediatric Hematology Oncology Journal 2018. [DOI: 10.1016/j.phoj.2017.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
28
|
Syed S, Dinallo V, Iqbal NT, Di Iorio L, Di Fusco D, Guleria S, Amadi BC, Sadiq K, Moskaluk C, Ali SA, Kelly P, Monteleone G. High SMAD7 and p-SMAD2,3 expression is associated with environmental enteropathy in children. PLoS Negl Trop Dis 2018; 12:e0006224. [PMID: 29415065 PMCID: PMC5819826 DOI: 10.1371/journal.pntd.0006224] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 02/20/2018] [Accepted: 01/09/2018] [Indexed: 01/10/2023] Open
Abstract
Enteropathies such as Crohn's disease are associated with enteric inflammation characterized by impaired TGF-β signaling, decreased expression of phosphorylated (p)-SMAD2,3 and increased expression of SMAD7 (an inhibitor of SMAD3 phosphorylation). Environmental enteropathy (EE) is an acquired inflammatory disease of the small intestine (SI), which is associated with linear growth disruption, cognitive deficits, and reduced oral vaccine responsiveness in children <5 y in resource-poor countries. We aimed to characterize EE inflammatory pathways by determining SMAD7 and p-SMAD2,3 levels (using Western blotting) in EE duodenal biopsies (N = 19 children, 7 from Pakistan, 12 from Zambia) and comparing these with healthy controls (Ctl) and celiac disease (CD) patients from Italy. Densitometric analysis of immunoblots showed that EE SI biopsies expressed higher levels of both SMAD7 (mean±SD in arbitrary units [a.u.], Ctl = 0.47±0.20 a.u., EE = 1.13±0.25 a.u., p-value = 0.03) and p-SMAD2,3 (mean±SD, Ctl = 0.38±0.14 a.u., EE = 0.60±0.10 a.u., p-value = 0.03). Immunohistochemistry showed that, in EE, SMAD7 is expressed in both the epithelium and in mononuclear cells of the lamina propria (LP). In contrast, p-SMAD3 in EE is expressed much more prominently in epithelial cells than in the LP. The high SMAD7 immunoreactivity and lack of p-SMAD3 expression in the LP suggests defective TGF-β signaling in the LP in EE similar to a previously reported SMAD7-mediated inflammatory pathway in refractory CD and Crohn's disease. However, Western blot densitometry showed elevated p-SMAD2,3 levels in EE, possibly suggesting a different inflammatory pathway than Crohn's disease but more likely reflecting cumulative protein expression from across all compartments of the mucosa as opposed to the LP alone. Further studies are needed to substantiate these preliminary results and to illustrate the relationship between SMAD proteins, TGF-β signaling, and inflammatory cytokine production, all of which may be potential therapeutic targets.
Collapse
Affiliation(s)
- Sana Syed
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Department of Pediatrics, Division of Gastroenterology, Hepatology, & Nutrition, University of Virginia, Charlottesville, United States of America
| | - Vincenzo Dinallo
- Department of Systems Medicine, University of Rome 'Tor Vergata', Rome, Italy
| | - Najeeha T. Iqbal
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Laura Di Iorio
- Department of Systems Medicine, University of Rome 'Tor Vergata', Rome, Italy
| | - Davide Di Fusco
- Department of Systems Medicine, University of Rome 'Tor Vergata', Rome, Italy
| | - Shan Guleria
- Department of Pediatrics, Division of Gastroenterology, Hepatology, & Nutrition, University of Virginia, Charlottesville, United States of America
| | - Beatrice C. Amadi
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Kamran Sadiq
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Christopher Moskaluk
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - S. Asad Ali
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
- Blizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome 'Tor Vergata', Rome, Italy
- * E-mail:
| |
Collapse
|
29
|
Soofi S, Khan GN, Sadiq K, Ariff S, Habib A, Kureishy S, Hussain I, Umer M, Suhag Z, Rizvi A, Bhutta Z. Prevalence and possible factors associated with anaemia, and vitamin B 12 and folate deficiencies in women of reproductive age in Pakistan: analysis of national-level secondary survey data. BMJ Open 2017; 7:e018007. [PMID: 29275342 PMCID: PMC5770950 DOI: 10.1136/bmjopen-2017-018007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To determine the prevalence and possible factors associated with anaemia, and vitamin B12 and folate deficiencies in women of reproductive age (WRA) in Pakistan. METHODS A secondary analysis was conducted on data collected through the large-scale National Nutrition Survey in Pakistan in 2011. Anaemia was defined as haemoglobin levels <12 g/dL, vitamin B12 deficiency as serum vitamin B12 levels of <203 pg/mL (150 pmol/L) and folate deficiency as serum folate levels <4 ng/mL (10 nmol/L). RESULTS A total of 11 751 blood samples were collected and analysed. The prevalence of anaemia, vitamin B12 deficiency and folate deficiency was 50.4%, 52.4% and 50.8%, respectively. After adjustment, the following factors were positively associated with anaemia: living in Sindh province (RR 1.07; 95% CI 1.04 to 1.09) P<0.00, food insecure with moderate hunger (RR 1.03; 95% CI 1.00 to 1.06) P=0.02, four or more pregnancies (RR 1.03; 95% CI 1.01 to 1.05) P<0.00, being underweight (RR 1.03; 95% CI 1.00 to 1.05) P=0.02, being overweight or obese (RR 0.95; 95% CI 0.93 to 0.97) P<0.00 and weekly intake of leafy green vegetables (RR 0.98; 95% CI 0.95 to 1.00) P=0.04. For vitamin B12 deficiency, a positive association was observed with rural population (RR 0.81; 95% CI 0.66 to 1.00) P=0.04, living in Khyber Pakhtunkhwa province (RR 1.25; 95% CI 1.11 to 1.43) P<0.00 and living in Azad Jammu and Kashmir (RR 1.50; 95% CI 1.08 to 2.08) P=0.01. Folate deficiency was negatively associated with daily and weekly intake of eggs (RR 0.89; 95% CI 0.81 to 0.98) P=0.02 and (RR 0.88; 95% CI 0.78 to 0.99) P=0.03. CONCLUSIONS In Pakistan, anaemia, and vitamin B12 and folate deficiencies are a severe public health concern among WRA. Our findings suggest that further research is needed on culturally appropriate short-term and long-term interventions within communities and health facilities to decrease anaemia, and vitamin B12 and folate deficiencies among Pakistani women.
Collapse
Affiliation(s)
- Sajid Soofi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Gul Nawaz Khan
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Kamran Sadiq
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shabina Ariff
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Atif Habib
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sumra Kureishy
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Imtiaz Hussain
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Muhammad Umer
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zamir Suhag
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Arjumand Rizvi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zulfiqar Bhutta
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Global Child Health at the Hospital for Sick Children, Toronto, Canada
| |
Collapse
|
30
|
Abstract
Objective: To determine clinical features and relevant laboratory investigations of patient with celiac disease (CD) and comparing classical celiac disease (CCD) with Non-diarrheal celiac disease (NDCD). Methods: This is a five years retrospective study conducted at The Aga Khan University Hospital Karachi, Pakistan from January 2010 to December 2015, enrolling children from one year to 15 years of either gender diagnosed as celiac disease in accordance with revised ESPGHAN criteria. Biopsy samples with grade 2 or more on Modified Marsh Classification were considered as consistent with celiac disease. Celiac patients were categorized into Classical celiac disease (with Chronic Diarrhea) and non-diarrheal celiac disease (Atypical celiac) and their clinical features and relevant laboratory investigations were documented. Results: Total 66 patients were selected with celiac disease according to inclusion criteria, 39 (59.09%) patients were labeled as CCD and 27 (40.91%) patients were labeled as NDCD. Marsh grading 3a and above were more marked in CCD as compared to NDCD. Mean titer for Tissue transglutaminase antibodies (TTG) were higher in CCD group in comparison to NDCD group. In CCD, the most common clinical presentations were abdominal distension whereas in NDCD, the most remarkable features were recurrent abdominal pain (62.9%). Frequency of failure to thrive is significantly high in CCD (82.05%) but patients merely with short stature were more common in NDCD (33.3%). Refractory anemia was present in 66.6% patients in NDCD group and 41.1% patients in CCD group. 74.3% patients in CCD group were vitamin D deficient whereas 85% patient had vitamin D deficiency in NDCD group (p= 0.03). Conclusion: NDCD is not uncommon in our population. Recurrent abdominal pain, failure to thrive or patients only with short stature and refractory anemia are prominent features in NCDC group whereas abdominal distension, failure to thrive and recurrent abdominal pain were noticeable features in CCD. High grade histopathology and raised antibodies titer is hallmark of CCD. Vitamin D deficiency is almost equally present in both groups.
Collapse
Affiliation(s)
- Danish Abdul Aziz
- Dr. Danish Abdul Aziz, MBBS, MRCPCH, FCPS. Senior Instructor, Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
| | - Misha Kahlid
- Misha Khalid, Final Year of MBBS Medical Student, Aga Khan University Hospital, Karachi, Pakistan
| | - Fozia Memon
- Dr. Fozia Memon, MBBS, FCPS, Chief Resident, Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
| | - Kamran Sadiq
- Dr. Kamran Sadiq, MBBS, FCPS. Assistant Professor and Paediatric Gastroenterologist, Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
| |
Collapse
|
31
|
Abstract
Objective: To determine different clinical presentationsand disease location demarcatedby upper and lower gastrointestinal endoscopyand relevant histopathologyin children diagnosed with inflammatory bowel disease (IBD). Methods: This is 5 years (2010 to 2015) retrospective studyconducted at the Aga Khan University Hospitalenrolling65admitted children between 6 months to 15years from either gender, diagnosed with IBD on clinical presentation, endoscopy and biopsy. Different clinical presentations at the time of diagnosis were noted in different categories of the disease. All patients underwent upper and lower (up to the terminal ileum) endoscopy with multiple punch biopsies and histologic assessment of mucosal specimens. All endoscopies were done by paediatric gastroenterologists at endoscopy suite of the hospital and all specimens were reported by the pathology department. ESPGHAN revised criteria for the diagnosis of inflammatory bowel disease in children and an adolescent was used to standardize our diagnosis. Extent of disease on endoscopy and relevant histopathology of the biopsy samples were noted at the time of diagnosis. Data was summarized using mean, standard deviation, numbers and percentages for different variables. Results: Total 56 children were enrolled according to inclusion criteria. There were 34children (61.53%) diagnosed with ulcerative colitis (UC), 10 patients (16.92%) had Crohn’sDisease (CD) and 11 (21.53%) patients were labeled as Indeterminate colitis (IC). Mean age at onset of symptoms was10.03±2.44 and mean age at diagnosis was11.10±2.36. Abdominal pain (80%) and chronic diarrhea (70%) were common symptoms in CD whereas bloody diarrhea (79.41%) and rectal bleeding(64.70%)were common presentation in UC. Patients diagnosed with indeterminate colitis(IC) had similar clinical features as in UC patients. Only 7% patients had some extra-intestinal features in the form of joint pain and/or uveitis. Aspartate aminotransferase level (95.18 ±12.89) was relatively high in patients withCD in comparison with other categories of IBD. Endoscopic findings and relevant histopathology of biopsy samples in UC showed 65% patient had pan-colitis and 13 % with disease restricted to rectum only whereas in CD 70% patient had disease in ileo-colon and only 10 % had involvement of ileum at the time diagnosis. Conclusion: Patients with UC dominated in our cohort. The most common clinical presentation in UC was bloody diarrhea and rectal bleeding and patients with CDhad abdominal pain and chronic diarrhea as predominant clinical features. Extraintestinal features were uncommon in our cohort. In endoscopic findings, pan-colitis was the mostfrequentfinding in UC and ileo-colonwas common location in CD. IC and UC shared common clinical features and disease location on endoscopy.
Collapse
Affiliation(s)
- Danish Abdul Aziz
- Dr. Danish Abdul Aziz, MBBS, MRCPCH, FCPS. Senior Instructor, Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
| | - Maryum Moin
- MaryumMoin, Final Year MBBS Medical StudentAga Khan University Hospital, Karachi, Pakistan
| | - Atif Majeed
- Dr. AtifMajeed, MBBS. Instructor, Department of Gastroenterology, Aga Khan University Hospital, Karachi, Pakistan
| | - Kamran Sadiq
- Dr. Kamran Sadiq, MBBS, FCPS. AssistantProfessor and PaediatricGastroenterologist, Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
| | - Abdul Gaffar Biloo
- Prof. Dr. Abdul GaffarBilloo, MBBS, MRCP, FRCP, Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
| |
Collapse
|
32
|
Soofi S, Ariff S, Sadiq K, Habib A, Bhatti Z, Ahmad I, Hussain M, Ali N, Cousens S, Bhutta ZA. Evaluation of the uptake and impact of neonatal vitamin A supplementation delivered through the Lady Health Worker programme on neonatal and infant morbidity and mortality in rural Pakistan: an effectiveness trial. Arch Dis Child 2017; 102:216-223. [PMID: 27471856 DOI: 10.1136/archdischild-2016-310542] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 05/31/2016] [Accepted: 06/04/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Despite evidence for the benefits of vitamin A supplementation (VAS) among children 6 to 59 months of age, the feasibility of introduction and potential benefit of VAS in the neonatal period in public health programmes is uncertain. OBJECTIVE The primary objective was to evaluate the feasibility and effectiveness of early neonatal VAS (single dose of 50 000 international units within 48-72 hours after birth) delivered through the public sector Lady Health Worker (LHW) programme in rural Pakistan and to document its association with a reduction in mortality at 6 months of age. METHODS A community-based, cluster randomised, placebo-controlled trial was undertaken in two districts of rural Pakistan. LHWs dispensed vitamin A/placebo in identical capsules to newborn infants within 48-72 hours of birth. Follow-up visits were undertaken at 1 week of age and every 4 weeks thereafter until 6 months of age. RESULTS Of a total of 15 433 consecutive pregnancies among eligible women of reproductive age, 13 225 pregnancies were registered, 12 218 live births identified and 11 028 newborn infants reached by LHWs. Of these, 5380 (49%) received neonatal VAS and 5648 (51%) placebo. The LHWs successfully delivered the capsules to 79% of newborns within 72 hours of birth with no significant adverse effects. Although the proportion of days observed with symptoms of fever, diarrhoea or rapid breathing were lower with neonatal VAS, these differences were not statistically significant. Mortality rates in the two groups were comparable at 6 months of age. CONCLUSIONS While our study demonstrated that neonatal VAS was safe and could be feasibly delivered by LHWs in Pakistan as part of their early postnatal visits, the overall lack of benefit on neonatal and 6-month morbidity and mortality in our population suggests the need for further evaluation of this intervention in populations at risk. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT00674089.
Collapse
Affiliation(s)
- Sajid Soofi
- Women & Child Health Division, The Aga Khan University, Karachi, Pakistan
| | - Shabina Ariff
- Women & Child Health Division, The Aga Khan University, Karachi, Pakistan
| | - Kamran Sadiq
- Women & Child Health Division, The Aga Khan University, Karachi, Pakistan
| | - Atif Habib
- Women & Child Health Division, The Aga Khan University, Karachi, Pakistan
| | - Zaid Bhatti
- Women & Child Health Division, The Aga Khan University, Karachi, Pakistan
| | - Imran Ahmad
- Women & Child Health Division, The Aga Khan University, Karachi, Pakistan
| | - Masawar Hussain
- Women & Child Health Division, The Aga Khan University, Karachi, Pakistan
| | - Nabeela Ali
- John Snow International Research Institute, Islamabad, Pakistan
| | - Simon Cousens
- London School of Hygiene and Tropical Medicine, London, UK
| | - Zulfiqar A Bhutta
- Women & Child Health Division, The Aga Khan University, Karachi, Pakistan.,London School of Hygiene and Tropical Medicine, London, UK.,Centre for Global Child Health, The Hospital for Sick Children, Toronto, UK
| |
Collapse
|
33
|
Soofi SB, Ariff S, Khan U, Turab A, Khan GN, Habib A, Sadiq K, Suhag Z, Bhatti Z, Ahmed I, Bhal R, Bhutta ZA. Diagnostic accuracy of WHO verbal autopsy tool for ascertaining causes of neonatal deaths in the urban setting of Pakistan: a hospital-based prospective study. BMC Pediatr 2015; 15:144. [PMID: 26438252 PMCID: PMC4595242 DOI: 10.1186/s12887-015-0450-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 09/14/2015] [Indexed: 11/13/2022] Open
Abstract
Background Globally, clinical certification of the cause of neonatal death is not commonly available in developing countries. Under such circumstances it is imperative to use available WHO verbal autopsy tool to ascertain causes of death for strategic health planning in countries where resources are limited and the burden of neonatal death is high. The study explores the diagnostic accuracy of WHO revised verbal autopsy tool for ascertaining the causes of neonatal deaths against reference standard diagnosis obtained from standardized clinical and supportive hospital data. Methods All neonatal deaths were recruited between August 2006 –February 2008 from two tertiary teaching hospitals in Province Sindh, Pakistan. The reference standard cause of death was established by two senior pediatricians within 2 days of occurrence of death using the International Cause of Death coding system. For verbal autopsy, trained female community health worker interviewed mother or care taker of the deceased within 2–6 weeks of death using a modified WHO verbal autopsy tool. Cause of death was assigned by 2 trained pediatricians. The performance was assessed in terms of sensitivity and specificity. Results Out of 626 neonatal deaths, cause-specific mortality fractions for neonatal deaths were almost similar in both verbal autopsy and reference standard diagnosis. Sensitivity of verbal autopsy was more than 93 % for diagnosing prematurity and 83.5 % for birth asphyxia. However the verbal autopsy didn’t have acceptable accuracy for diagnosing the congenital malformation 57 %. The specificity for all five major causes of neonatal deaths was greater than 90 %. Conclusion The WHO revised verbal autopsy tool had reasonable validity in determining causes of neonatal deaths. The tool can be used in resource limited community-based settings where neonatal mortality rate is high and death certificates from hospitals are not available.
Collapse
Affiliation(s)
- Sajid Bashir Soofi
- Department of Pediatrics & Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Shabina Ariff
- Department of Pediatrics & Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Ubaidullah Khan
- Department of Pediatrics, King Edward Medical University, Lahore, Pakistan.
| | - Ali Turab
- Department of Pediatrics & Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Gul Nawaz Khan
- Department of Pediatrics & Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Atif Habib
- Department of Pediatrics & Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Kamran Sadiq
- Department of Pediatrics & Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Zamir Suhag
- Department of Pediatrics & Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Zaid Bhatti
- Department of Pediatrics & Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Imran Ahmed
- Department of Pediatrics & Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Rajiv Bhal
- Department of Child and Adolescent Health and Development, World Health Organization, Geneva, Switzerland.
| | - Zulfiqar Ahmed Bhutta
- Department of Pediatrics & Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan. .,Center for Global Child Health, Hospital for Sick Children, Toronto, Canada.
| |
Collapse
|
34
|
Sadiq K, Stack M, Black R. Wear mapping of CoCrMo alloy in simulated bio-tribocorrosion conditions of a hip prosthesis bearing in calf serum solution. Materials Science and Engineering: C 2015; 49:452-462. [DOI: 10.1016/j.msec.2015.01.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 12/01/2014] [Accepted: 01/04/2015] [Indexed: 11/17/2022]
|
35
|
Nausheen S, Soofi SB, Sadiq K, Habib A, Turab A, Memon Z, Khan MI, Suhag Z, Bhatti Z, Ahmed I, Bahl R, Bhutta S, Bhutta ZA. Validation of verbal autopsy tool for ascertaining the causes of stillbirth. PLoS One 2013; 8:e76933. [PMID: 24130814 PMCID: PMC3793932 DOI: 10.1371/journal.pone.0076933] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 09/04/2013] [Indexed: 10/30/2022] Open
Abstract
OBJECTIVE To assess performance of the WHO revised verbal autopsy tool for ascertaining the causes of still birth in comparison with reference standard cause of death ascertained by standardized clinical and supportive data. METHODS All stillbirths at a tertiary hospital in Karachi, Pakistan were prospectively recruited into study from August 2006- February 2008. The reference standard cause of death was established by two senior obstetricians within 48 hours using the ICD coding system. Verbal autopsy interviews using modified WHO tool were conducted by trained health workers within 2- 6 weeks of still birth and the cause of death was assigned by second panel of obstetricians. The performance was assessed in terms of sensitivity, specificity and Kappa. RESULTS There were 204 still births. Of these, 80.8% of antepartum and 50.5% of intrapartum deaths were correctly diagnosed by verbal autopsy. Sensitivity of verbal autopsy was highest 68.4%, (95%CI: 46-84.6) for congenital malformation followed by obstetric complication 57.6%, (95%CI: 25-84.2). The specificity for all major causes was greater than 90%. The level of agreement was high (kappa=0.72) for anomalies and moderate (k=0.4) for all major causes of still birth, except asphyxia. CONCLUSION Our results suggest that verbal autopsy has reasonable validity in identifying and discriminating between causes of stillbirth in Pakistan. On the basis of these findings, we feel it has a place in resource constrained areas to inform strategic planning and mobilization of resources to attain Millennium Development Goals.
Collapse
Affiliation(s)
- Sidrah Nausheen
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Sajid B. Soofi
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Kamran Sadiq
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Atif Habib
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Ali Turab
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Zahid Memon
- Maternal and Newborn Health Program, Research & Advocacy Fund, Islamabad, Pakistan
| | | | - Zamir Suhag
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Zaid Bhatti
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Imran Ahmed
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Rajiv Bahl
- Department of Child and Adolescent Health and Development, World Health Organization, Geneva, Switzerland
| | - Shireen Bhutta
- Department of Obstetrics & Gynecology, Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Zulfiqar A. Bhutta
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
- Centre of Excellence in Women & Child Health, Aga Khan University, Karachi, Pakistan
- Center for Global Child Health, Hospital for Sick Children, Toronto, Canada
| |
Collapse
|
36
|
Habib MA, Soofi S, Sadiq K, Samejo T, Hussain M, Mirani M, Rehmatullah A, Ahmed I, Bhutta ZA. A study to evaluate the acceptability, feasibility and impact of packaged interventions ("Diarrhea Pack") for prevention and treatment of childhood diarrhea in rural Pakistan. BMC Public Health 2013; 13:922. [PMID: 24090125 PMCID: PMC3851134 DOI: 10.1186/1471-2458-13-922] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 09/25/2013] [Indexed: 12/03/2022] Open
Abstract
Background Diarrhea remains one of the leading public health issues in developing countries and is a major contributor in morbidity and mortality in children under five years of age. Interventions such as ORS, Zinc, water purification and improved hygiene and sanitation can significantly reduce the diarrhea burden but their coverage remains low and has not been tested as packaged intervention before. This study attempts to evaluate the package of evidence based interventions in a “Diarrhea Pack” through first level health care providers at domiciliary level in community based settings. This study sought to evaluate the acceptability, feasibility and impact of diarrhea Pack on diarrhea burden. Methods A cluster randomized design was used to evaluate the objectives of the project a union council was considered as a cluster for analysis, a total of eight clusters, four in intervention and four in control were included in the study. We conducted a baseline survey in all clusters followed by the delivery of diarrhea Pack in intervention clusters through community health workers at domiciliary level and through sales promoters to health care providers and pharmacies. Four quarterly surveillance rounds were conducted to evaluate the impact of diarrhea pack in all clusters by an independent team of Field workers. Results Both the intervention and control clusters were similar at the baseline but as the study progress we found a significant increase in uptake of ORS and Zinc along with the reduction in antibiotic use, diarrhea burden and hospitalization in intervention clusters when compared with the control clusters. We found that the Diarrhea Pack was well accepted with all of its components in the community. Conclusion The intervention was well accepted and had a productive impact on the uptake of ORS and zinc and reduction in the use of antibiotics. It is feasible to deliver interventions such as diarrhea pack through community health workers in community settings. The intervention has the potential to be scaled up at national level.
Collapse
Affiliation(s)
- Muhammad Atif Habib
- Department of Paediatrics and Child Health, Women and Child Health Division, Aga Khan University, Karachi, Pakistan.
| | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Abstract
PURPOSE OF REVIEW Childhood malnutrition is prevalent in developing countries and contributes to one-third of all deaths in these countries. There have been advances in prevention of childhood malnutrition and the purpose of this article was to review the current evidence in the field. RECENT FINDINGS Multiple micronutrient (MMN) supplements during pregnancy reduce the incidence of maternal anemia and small for gestational-age babies. Recent evidence suggest that combined supplementation of MMNs with protein energy supplement is more effective than MMN supplementation alone. It is now recommended that HIV-infected mothers can exclusively breast-feed their infants for 6 months when the mother or infant is on effective antiretroviral therapy. Home fortification of complementary foods reduces the prevalence of anemia in infancy and combined supplementation of MMNs with lipid-based supplements improves growth in young children. Ready-to-use therapeutic foods have been successfully used to manage severe acute malnutrition in the community. Zinc supplementation is associated with a reduction in diarrhea and respiratory disease morbidity and improves linear growth. Vitamin A supplementation decreases the incidence of diarrhea and measles. Water supply, sanitation, and hygiene are important for the prevention of malnutrition because of their direct impact on infectious disease. SUMMARY There is clear evidence on the causes and consequences of malnutrition as well as effective interventions to prevent undernutrition. The next step is to implement these packages of interventions at large scale. A global effort is required that should entail unified and compelling advocacy among governments, lead organizations, and institutions.
Collapse
Affiliation(s)
- Aamer Imdad
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | | | | |
Collapse
|
38
|
Ariff S, Soofi SB, Sadiq K, Feroze AB, Khan S, Jafarey SN, Ali N, Bhutta ZA. Evaluation of health workforce competence in maternal and neonatal issues in public health sector of Pakistan: an Assessment of their training needs. BMC Health Serv Res 2010; 10:319. [PMID: 21110888 PMCID: PMC3012669 DOI: 10.1186/1472-6963-10-319] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 11/27/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND More than 450 newborns die every hour worldwide, before they reach the age of four weeks (neonatal period) and over 500,000 women die from complications related to childbirth. The major direct causes of neonatal death are infections (36%), Prematurity (28%) and Asphyxia (23%). Pakistan has one of the highest perinatal and neonatal mortality rates in the region and contributes significantly to global neonatal mortality. The high mortality rates are partially attributable to scarcity of trained skilled birth attendants and paucity of resources. Empowerment of health care providers with adequate knowledge and skills can serve as instrument of change. METHODS We carried out training needs assessment analysis in the public health sector of Pakistan to recognize gaps in the processes and quality of MNCH care provided. An assessment of Knowledge, Attitude, and Practices of Health Care Providers on key aspects was evaluated through a standardized pragmatic approach. Meticulously designed tools were tested on three tiers of health care personnel providing MNCH in the community and across the public health care system. The Lady Health Workers (LHWs) form the first tier of trained cadre that provides MNCH at primary care level (BHU) and in the community. The Lady Health Visitor (LHVs), Nurses, midwives) cadre follow next and provide facility based MNCH care at secondary and tertiary level (RHCs, Taluka/Tehsil, and DHQ Hospitals). The physician/doctor is the specialized cadre that forms the third tier of health care providers positioned in secondary and tertiary care hospitals (Taluka/Tehsil and DHQ Hospitals). The evaluation tools were designed to provide quantitative estimates across various domains of knowledge and skills. A priori thresholds were established for performance rating. RESULTS The performance of LHWs in knowledge of MNCH was good with 30% scoring more than 70%. The Medical officers (MOs), in comparison, performed poorly in their knowledge of MNCH with only 6% scoring more than 70%. All three cadres of health care providers performed poorly in the resuscitation skill and only 50% were able to demonstrate steps of immediate newborn care. The MOs performed far better in counselling skills compare to the LHWs. Only 50 per cent of LHWs could secure competency scale in this critical component of skills assessment. CONCLUSIONS All three cadres of health care providers performed well below competency levels for MNCH knowledge and skills. Standardized training and counselling modules, tailored to the needs and resources at district level need to be developed and implemented. This evaluation highlighted the need for periodic assessment of health worker training and skills to address gaps and develop targeted continuing education modules. To achieve MDG4 and 5 goals, it is imperative that such deficiencies are identified and addressed.
Collapse
Affiliation(s)
- Shabina Ariff
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Pakistan
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Syed M, Saleem T, Iqbal MA, Javed F, Khan MBS, Sadiq K. Effects of leather industry on health and recommendations for improving the situation in Pakistan. Arch Environ Occup Health 2010; 65:163-172. [PMID: 20705577 DOI: 10.1080/19338241003730895] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The leather industry and its associated sectors contribute significantly to the Pakistani economy. There are around 600 tanneries in Pakistan that are concentrated in 3 major cities (Kasur, Karachi, Sialkot). Waste discharge from tanneries pollutes the air, soil, and water, causing serious health problems. Exposure to such contaminated environmental milieu has been seen to culminate in a multiple array of disease processes such as asthma, dermatitis, hepatic and neurological disorders, and various malignancies. An overall dearth of research on the occupational hazards of employment in the leather industry as well as its effects on pediatric population was observed during literature review with particular reference to Pakistan. It is recommended that research should be conducted about the health hazards in the leather industry in Pakistan as well as globally to gather data that can be translated into effective prevention programs for both adults as well as pediatric populations.
Collapse
Affiliation(s)
- Madiha Syed
- Medical College, Aga Khan University, Karachi, Pakistan
| | | | | | | | | | | |
Collapse
|