Standard RUTF vs. locally-made RUSF for acutely malnourished children: A quasi-experimental comparison of the impact on growth and compliance in a rural community of Pakistan

BACKGROUND

The reduction in severe and moderate acute malnutrition (SAM and MAM) rates in Pakistan has been sub-optimal compared to other low-and middle-income countries (LMICs). Specially-formulated products have been designed globally to manage SAM and MAM, such as ready-to-use therapeutic food (RUTF) and ready-to-use supplementary food (RUSF), with variable efficacies. RUTF is primarily produced and patented in industrialized countries, raising supply challenges in resource-constrained regions with a high burden of acute malnutrition. RUSF minimizes costs by using locally-available ingredients while providing similar nutritional value. In this study, we compared the efficacy, side effects, and compliance of two months of supplementation with either RUTF or RUSF.

METHODS

Children aged nine months in the rural district of Matiari, Pakistan, with a weight-for-height z-score (WHZ) <-2 received either RUTF (500 kcal sachet) for two months in 2015 or RUSF (520 kcal sachet) for two months in 2018.

RESULTS

The RUSF group had a higher height gain and mid-upper arm circumferences (MUAC) score. Higher compliance was noted with lower side effects in the RUSF group. A higher compliance rate did correlate with the growth parameters in respective groups.

CONCLUSION

Our study found that both RUTF and RUSF partially improve the anthropometric status of acutely malnourished children, with neither being superior to the other.

Successful Treatment of Chronic Hepatitis C Infection With Direct-Acting Antivirals in a Heart Transplant Recipient: A Case Report

BACKGROUND

Heart transplant (HT) recipients with chronic hepatitis C virus (HCV) infection are noted to have higher rates of HCV related morbidity and mortality. Treatment of HCV in the past was fraught with low cure rates, increased risk of graft rejection, and medication-related side effects.

CASE REPORT

We report a case of successful treatment of HCV infection in a HT recipient. The patient was found to have HCV during his pretransplant workup. He underwent uneventful orthotopic HT in 2000. The HCV infection was monitored with regular liver enzymes and the surveillance liver biopsies at 2 and 5 years after HT showed mild but stable liver disease, and he stayed on chronic immunosuppression. He was not offered interferon-based HCV therapy because of the risk of steroid-resistant graft failure and cardiac decompensation. With the availability of the new direct-acting antivirals (DAA) for HCV infection, and worsening of liver fibrosis on noninvasive testing, we treated him with sofosbuvir and simeprevir for 12 weeks. During treatment, he remained clinically stable from a cardiac standpoint and he showed biochemical improvement in his liver and renal functions. Tacrolimus levels remained stable and did not require any dose adjustment. He showed rapid virologic response and subsequently achieved sustained virologic response at 12 weeks.

CONCLUSION

DAA use was safe and effective in treating HCV infection in a HT recipient.

Prevalence of biopsy-proven non-alcoholic fatty liver disease in severely obese subjects without metabolic syndrome

Obesity is a major risk factor for non-alcoholic fatty liver disease (NAFLD). NAFLD encompasses simple fatty liver (FL) and non-alcoholic steatohepatitis (NASH) in its spectrum. NASH can progress to liver cirrhosis and is associated with liver cancer. Not all obese subjects have insulin resistance (IR) or develop metabolic syndrome (MS). This study evaluates the prevalence of NAFLD in severely obese subjects without MS. We retrospectively reviewed 445 charts from our database of severely obese subjects with clinical suspicion of NAFLD and who were selected for laparoscopic Roux-en-Y gastric bypass surgery. One hundred five subjects who did not have MS, as defined by the International Diabetes Foundation, based on comprehensive pre-operative metabolic evaluation were included. Liver biopsy specimens were evaluated for NAFLD. 24% of morbidly obese (mean body mass index [BMI] 48 kg m(-2) ) adult subjects (mean age 38 years) who underwent bariatric surgery did not have MS. NAFLD was identified in 77 (73%) on liver biopsy, out of which 59 (56%) were labelled as FL and 18 (17%) had histological diagnosis of NASH. Age, gender, race and BMI were the same among all groups. Among NAFLD subjects, 22% did not have any additional metabolic component of MS, while 36% had low high-density lipoprotein, 27% had hypertension, 8% had high triglycerides and 6% had hyperglycaemia. IR calculated by HOMA-IR (Homeostatic Model Assessment for Insulin Resistance) and diagnosis of hyperglycaemia was statistically higher in NASH group compared to those who did not have NASH. NAFLD is highly prevalent in morbidly obese individuals who undergo bariatric surgery despite the absence of MS. Diagnosis of hyperglycaemia in such subjects suggests the presence of IR and may have underlying NASH, which is a progressive form of NAFLD.

Characteristics of the positive ion source at reduced gas feed

The neutral beam injector of steady state superconducting tokamak (SST1-NBI) at IPR is designed for injecting upto 1.7 MW of neutral beam (Hº, 30-55 keV) power to the tokamak plasma for heating and current drive. Operations of the positive ion source (PINI or Plug-In-Neutral-Injector) of SST1-NBI were carried out on the NBI test stand. The PINI was operated at reduced gas feed rate of 2-3 Torr l/s, without using the high speed cryo pumps. Experiments were conducted to achieve a stable beam extraction by optimizing operational parameters namely, the arc current (120-300 A), acceleration voltage (16-40 kV), and a suitable control sequence. The beam divergence, power density profiles, and species fractions (H(+):H2(+):H3(+)) were measured by using the diagnostics such as thermal calorimetry, infrared thermography, and Doppler shift spectroscopy. The maximum extracted beam current was about 18 A. A further increase of beam current was found to be limited by the amount of gas feed rate to the ion source.

Evaluation of an Emerging Research Center: Lessons Learned

PROBLEM STATEMENT: Rigorous evaluation assures that research endeavors meet their purpose and achieve stated goals. This is especially true for federally funded exploratory research centers, which tend to be more complex due to the involvement of multiple, interdisciplinary investigators. This study provides an overview of the approach used to develop an evaluation strategy and reports the lessons learned during the initial development of the Center for Ohana Self-Management of Chronic Illness (COSMCI) at the University of Hawai'i at Mānoa School of Nursing and Dental Hygiene. The COSMCI is composed of an interdisciplinary team of researchers and practitioners and aims to advance knowledge in the field of self management of chronic disease in the community setting. APPROACH: A systematic approach was utilized that included formative and summative strategies for ongoing evaluation. The problem was solved by addressing five key concerns: (1) development of research structure, (2) observing the process of the research pilot projects, (3) scholarly activity of COSMCI faculty, (4) dissemination and translation and (5) sustainability prospects. The method of research included formulating process strategies and determine if the plans for developing the Center were followed and whether these plans were effective. Interviews were also conducted at year one and at mid-point though the project. RESULTS: Themes that emerged from our evaluation included inclusion, timelines, realistic expectations, ongoing evaluation and preparing for changes in the team. This provided timely recognition of successes and challenges and facilitated a rapid response for interventions especially during the early development stage of the center. CONCLUSION/RECOMMENDATIONS: Effective development of a successful Center is highly dependent upon having a strong evaluation process in place that can inform ongoing development. An exploratory research center requires ongoing evaluation that allows for celebration of successes, as well as early identification of problems and rapid response.

Acute renal infarction due to renal fibromuscular dyplasia: a case of mistaken identity

A 53 year old male presented with right sided loin pain in the absence of other distinguishing symptoms, past medical history or examination findings. Investigation, a week later, revealed a right sided renal mass. He underwent laparascopic nephrectomy for presumed renal malignancy. Surprisingly, the mass was an area of infarction and the renal artery had intimal-type fibromuscular dysplasia (FMD). This case demonstrates three important points. Firstly, renal infarction is a cause of acute loin pain. Secondly, delayed investigation can alter the radiological appearance of renal infarction. Lastly, FMD is a rare condition, particularly in men, and can cause renal infarction.

Outbreak of shigellosis in Denmark associated with imported baby corn, August 2007

On 16 August 2007, the Danish regional food authority (Fødevareregion Øst) and the Statens Serum Institut (SSI) became aware of an outbreak of Shigella sonnei infections.

Intraoperative complications of cataract surgery in the very old

AIM

To identify whether the risk of an intraoperative complication of phakoemulsification cataract surgery increases with age.

METHODS

1441 consecutive patients undergoing phakoemulsification cataract surgery were assessed preoperatively, and data on the occurrence of intraoperative complications were collected prospectively. Data were entered into a computerised database, and logistic regression was used to examine evidence of an association between age and the risk of an intraoperative complication. In addition, the rates of intraoperative complications were compared between patients > or =88 years and those <88 years, and between patients > or =96 years and those <96 years.

RESULTS

No significant association was found between age and the risk of an intraoperative complication. The authors found little evidence that patients > or =88 years were at a greater risk of an intraoperative complication than those <88 years, or that those > or =96 years are at increased risk; however, numbers were small.

CONCLUSIONS

These results suggest that age alone is not a major risk factor for any intraoperative complications occurring during phakoemulsification cataract surgery. This has implications not just for tailoring the risk of complications occurring to individual patients but also for meaningful comparisons between national complication rates and those of individual surgeons, and better selection of cases suitable for instruction.

Health care workers' ability and willingness to report to duty during catastrophic disasters

Catastrophic disasters create surge capacity needs for health care systems. This is especially true in the urban setting because the high population density and reliance on complex urban infrastructures (e.g., mass transit systems and high rise buildings) could adversely affect the ability to meet surge capacity needs. To better understand responsiveness in this setting, we conducted a survey of health care workers (HCWs) (N =6,428) from 47 health care facilities in New York City and the surrounding metropolitan region to determine their ability and willingness to report to work during various catastrophic events. A range of facility types and sizes were represented in the sample. Results indicate that HCWs were most able to report to work for a mass casualty incident (MCI) (83%), environmental disaster (81%), and chemical event (71%) and least able to report during a smallpox epidemic (69%), radiological event (64%), sudden acute respiratory distress syndrome (SARS) outbreak (64%), or severe snow storm (49%). In terms of willingness, HCWs were most willing to report during a snow storm (80%), MCI (86%), and environmental disaster (84%) and least willing during a SARS outbreak (48%), radiological event (57%), smallpox epidemic (61%), and chemical event (68%). Barriers to ability included transportation problems, child care, eldercare, and pet care obligations. Barriers to willingness included fear and concern for family and self and personal health problems. The findings were consistent for all types of facilities. Importantly, many of the barriers identified are amenable to interventions.

An evaluation of topical and local anesthesia in phacoemulsification

OBJECTIVE

To assess the comparative efficacy of topical and local anesthesia in phacoemulsification.

MATERIAL AND METHODS

The medical records of 186 men and women between the ages of 45-85 years, who underwent elective cataract surgery by phacoemulsification technique, under the care of one surgeon, over a period of one year, from March 1999-March 2000 were reviewed.

RESULTS

Of 186 patients who underwent small incision, self-healing phacoemulsification cataract surgery, 124 received topical and 62 local anesthesia. The most common cataract types were nuclear sclerosis. The duration of surgery with topical anesthesia was shorter. Sutures and eye padding were more frequently applied for procedures done under local anesthesia. Uncorrected visual acuity in the first post-op week was between 20/20-20/50 for 53.6% of the cases done under topical compared to 30.9% in local anesthesia. A similar trend was noted in the visual acuity one month post operatively.

CONCLUSION

The uncorrected visual acuity improves faster and the duration of surgery is shorter when topical anesthesia is used.

A household study of chickenpox in Guinea-Bissau: intensity of exposure is a determinant of severity

OBJECTIVE

To determinate the relative importance of state of nutrition and intensity of exposure for clinical severity of chickenpox in a developing country.

METHODS

A prospective household study was performed in a semi-urban area in Bissau, the capital of Guinea-Bissau, between December 1994 and June 1995. Antibodies were measured in the acute and the convalescence phase to assess validity of clinical diagnoses. The clinical severity of infection was assessed by number of pox, fever response and skin infections. Severity was compared for index cases, i.e. the first case in the house, and secondary and tertiary cases infected following exposure at home.

RESULT

Chickenpox was diagnosed in 165 persons. The clinician's and the mothers' diagnoses corresponded well with the serological results. Median age was 36 months (range 3 months to 30.3 years). There was no correlation between nutritional status measured by arm-circumference and severity of infection. The number of pox was higher for secondary cases than for index cases (median 106 vs. 89, P<0.01), the difference being more pronounced for girls (P=0.018) than for boys (P=0.575). The risk of skin infection as a complication was correlated with the number of pox (P<0.001).

CONCLUSION

Chickenpox was recognised correctly by Guinean mothers. The age distribution in Guinea-Bissau resembled the pattern in developed countries. The intensity of exposure was a major determinant of severity, especially for girls.

How clean is the home environment?: a tool to assess home hygiene

The role of the home environment in the transmission of infectious diseases has been well described in the developing world but has received less attention in developed countries. An increasing focus on home hygiene has emerged in debates regarding the use of antimicrobial products in the home and the potential for development of resistance and in discussions regarding "when is clean too clean" and "what is clean." Studies are clearly needed to further explicate the role of the home in the spread of infectious agents, but before these can be conducted, adequate measurement tools are essential. This article describes extensive psychometric testing undertaken to develop valid and reliable methods and tools to measure home hygiene and focuses on a neighborhood that was primarily Spanish speaking in New York City. The Home Hygiene Assessment Tool described in this article can be used by clinicians and researchers to further elucidate the role of the home environment in the prevention and control of infections.

Matrix metalloproteinase-1 is induced by epidermal growth factor in human bladder tumour cell lines and is detectable in urine of patients with bladder tumours

The matrix metalloproteinases are a family of enzymes that degrade the extracellular matrix and are considered to be important in tumour invasion and metastasis. The effect of epidermal growth factor (EGF) on matrix metalloproteinase-1 (MMP1) production in two human bladder tumour cell lines, RT112 and RT4, has been investigated. In the RT112 cell line, an increase in MMP1 mRNA levels was found after a 6-h incubation with EGF, and this further increased to 20-fold that of control levels at 24- and 48-h treatment with 50 ng ml(-1) of EGF. MMP2 mRNA levels remained constant over this time period, whereas in the RT4 cells no MMP2 transcripts were detectable, but MMP1 transcripts again increased with 24- and 48-h treatment with 50 ng ml(-1) of EGF. MMP1 protein concentration in the conditioned medium from both cell lines increased with 24- and 48-h treatment of the cells and the total MMP1 was higher in the medium than the cells, demonstrating that the bladder tumour cell lines synthesize and secrete MMP1 protein after continuous stimulation with EGF. MMP1 protein was detected in urine from patients with bladder tumours, with a significant increase in concentration with increased stage and grade of tumour. MMP1 urine concentrations may therefore be a useful prognostic indicator for bladder tumour progression.

Differential inhibition by hyperammonemia of the electron transport chain enzymes in synaptosomes and non-synaptic mitochondria in ornithine transcarbamylase-deficient spf-mice: restoration by acetyl-L-carnitine

Sparse-fur (spf) mouse is the ideal animal model to study the neuropathology of congenital ornithine transcarbamylase (OTC) deficiency. Our current hypothesis implies that an ammonia-induced depletion of energy metabolism in the spf mouse, could be due to a reduction in the activities of the enzymes of the electron transport chain and a treatment with acetyl-L-carnitine could normalize this abnormality. We also hypothesized that there might be a differential degree of inhibition in synaptosomal and non-synaptic mitochondria, for the enzymes of the electron transport chain, caused by congenital hyperammonemia. We have therefore measured the activities of NADH-cytochrome C oxidoreductase, succinate cytochrome C oxidoreductase and cytochrome C oxidase in synaptosomes and non-synaptic mitochondria, isolated from spf mice and CD-1 controls with and without acetyl-L-carnitine treatment. Our results indicate a significant reduction (19-34%) in the activities of these complexes in synaptosomes in untreated spf mice, whereas in non-synaptic mitochondria, there was a tendency for the activities to decrease. Acetyl-L-carnitine treatment enhanced these activities (15-64%) for all the three enzyme complexes and its effect was more prominent on succinate cytochrome C oxidoreductase activity (64%). These studies point out that: (a) ammonia-induced disturbances in the energy metabolism could be more pronounced in neuronal mitochondria, and (b) the effect of acetyl-L-carnitine on the restoration of cerebral ATP in hyperammonemia could be through an enhancement of the activities of various electron transport chain enzymes.