Climate shocks and nutrition: The role of food security policies and programs in enhancing maternal and neonatal survival in Niger

Niger is afflicted with high rates of poverty, high fertility rates, frequent environmental crises, and climate change. Recurrent droughts and floods have led to chronic food insecurity linked to poor maternal and neonatal nutrition outcomes in vulnerable regions. We analyzed maternal and neonatal nutrition trends and subnational variability between 2000 and 2021 with a focus on the implementation of policies and programs surrounding two acute climate shocks in 2005 and 2010. We used four sources of data: (a) national household surveys for maternal and newborn nutritional indicators allowing computation of trends and differences at national and regional levels; (b) document review of food security reports; (c) 30 key informant interviews and; (d) one focus group discussion. Many food security policies and nutrition programs were enacted from 2000 to 2020. Gains in maternal and neonatal nutrition indicators were more significant in targeted vulnerable regions of Maradi, Zinder, Tahoua and Tillabéri, from 2006 to 2021. However, poor access to financial resources for policy execution and suboptimal implementation of plans have hindered progress. In response to the chronic climate crisis over the last 20 years, the Nigerien government and program implementers have demonstrated their commitment to reducing food insecurity and enhancing resilience to climate shocks by adopting a deliberate multisectoral effort. However, there is more that can be achieved with a continued focus on vulnerable regions to build resilience, targeting high risk populations, and investing in infrastructure to improve health systems, food systems, agriculture systems, education systems, and social protection.

Moderate Accuracy of Survey Responses about Infant and Young Child Feeding Counseling Reported by Mothers with Children Less than 1 Year of Age in India

BACKGROUND

Counseling on infant and young child feeding (IYCF) to support optimal breastfeeding and complementary feeding practices is an essential intervention, and accurate coverage data is needed to identify gaps and monitor progress. However, coverage information captured during household surveys has not yet been validated.

OBJECTIVES

We examined the validity of maternal reports of IYCF counseling received during community-based contacts and factors associated with reporting accuracy.

METHODS

Direct observations of home visits conducted by community workers in 40 villages in Bihar, India served as the "gold standard" to maternal reports of IYCF counseling received during 2-wk follow-up surveys (n = 444 mothers with children less than 1 y of age, interviews matched to direct observations). Individual-level validity was assessed by calculating sensitivity, specificity, and AUC. Population-level bias was measured using the inflation factor (IF). Multivariable regression models were used to examine factors associated with response accuracy.

RESULTS

Prevalence of IYCF counseling during home visits was very high (90.1%). Maternal report of any IYCF counseling received in the past 2 wk was moderate (AUC: 0.60; 95% CI: 0.52, 0.67), and population bias was low (IF = 0.90). However, the recall of specific counseling messages varied. Maternal report of any breastfeeding, exclusive breastfeeding, and dietary diversity messages had moderate validity (AUC > 0.60), but other child feeding messages had low individual validity. Child age, maternal age, maternal education, mental stress, and social desirability were associated with reporting accuracy of multiple indicators.

CONCLUSIONS

Validity of IYCF counseling coverage was moderate for several key indicators. IYCF counseling is an information-based intervention that may be received from various sources, and it may be challenging to achieve higher reporting accuracy over a longer recall period. We consider the modest validity results as positive and suggest that these coverage indicators may be useful for measuring coverage and tracking progress over time.

Transcriptome Analysis of Host Inflammatory Responses to the Ectoparasitic Mite Sarcoptes scabiei var. hominis

Scabies, a human skin infestation caused by the ectoparasitic mite Sarcoptes scabiei var. hominis, affects more than 200 million people globally. The prevailing knowledge of the disease process and host immune response mechanisms is limited. A better understanding of the host-parasite relationship is essential for the identification of novel vaccine and drug targets. Here we aimed to interrogate the transcriptomic profiles of mite-infested human skin biopsies with clinical manifestations of ordinary scabies subjects ("OS"; n = 05) and subjects naive to scabies ("control"; n = 03) using RNASeq data analysis. A combined clustering, network, and pathway mapping approach enabled us to identify key signaling events in the host immune and pro-inflammatory responses to S. scabiei infestation. The clustering patterns showed various differentially expressed genes including inflammatory responses and innate immunity genes (DEFB4A, IL-19, CXCL8, CSF3, SERPINB4, S100A7A, HRNR) and notably upregulation of the JAK-STAT pathway in scabies-infested samples. Mite-infested human skin biopsies (GSE178563) were compared with an ex-vivo porcine infested model (E-MTAB-6433) and human skin equivalents (GSE48459). Marked enrichment of immune response pathways (JAK-STAT signaling, IL-4 and IL-13 pathway, and Toll receptor cascade), chemokine ligands and receptors (CCL17, CCL18, CCL3L1, CCL3L3, CCR7), and cytokines (IL-13 and IL-20) were observed. Additionally, genes known for their role in psoriasis and atopic dermatitis were upregulated, e.g., IL-19. The detailed transcriptomic profile has provided an insight into molecular functions, biological processes, and immunological responses and increased our understanding about transcriptomic regulation of scabies in human.

Trends and inequalities in the nutritional status of adolescent girls and adult women in sub-Saharan Africa since 2000: a cross-sectional series study

Introduction

Evidence on the rate at which the double burden of malnutrition unfolds is limited. We quantified trends and inequalities in the nutritional status of adolescent girls and adult women in sub-Saharan Africa.

Methods

We analysed 102 Demographic and Health Surveys between 1993 and 2017 from 35 countries. We assessed regional trends through cross-sectional series analyses and ran multilevel linear regression models to estimate the average annual rate of change (AARC) in the prevalence of underweight, anaemia, anaemia during pregnancy, overweight and obesity among women by their age, residence, wealth and education levels. We quantified current absolute inequalities in these indicators and wealth-inequality trends.

Results

There was a modest decline in underweight prevalence (AARC=−0.14 percentage points (pp), 95% CI −0.17 to -0.11). Anaemia declined fastest among adult women and the richest pregnant women with an AARC of −0.67 pp (95% CI −1.06 to -0.28) and −0.97 pp (95% CI −1.60 to -0.34), respectively, although it affects all women with no marked disparities. Overweight is increasing rapidly among adult women and women with no education. Capital city residents had a threefold more rapid rise in obesity (AARC=0.47 pp, 95% CI 0.39, 0.55), compared with their rural counterparts. Absolute inequalities suggest that Ethiopia and South Africa have the largest gap in underweight (15.4 pp) and obesity (28.5 pp) respectively, between adult and adolescent women. Regional wealth inequalities in obesity are widening by 0.34 pp annually.

Conclusion

Underweight persists, while overweight and obesity are rising among adult women, the rich and capital city residents. Adolescent girls do not present adverse nutritional outcomes except anaemia, remaining high among all women. Multifaceted responses with an equity lens are needed to ensure no woman is left behind.

Effectiveness and cost-effectiveness of 4 supplementary foods for treating moderate acute malnutrition: results from a cluster-randomized intervention trial in Sierra Leone

BACKGROUND

Moderate acute malnutrition (MAM) affects 33 million children annually. Investments in formulations of corn-soy blended flours and lipid-based nutrient supplements have effectively improved MAM recovery rates. Information costs and cost-effectiveness differences are still needed.

OBJECTIVES

We assessed recovery and sustained recovery rates of MAM children receiving a supplementary food: ready-to-use supplementary food (RUSF), corn soy whey blend with fortified vegetable oil (CSWB w/oil), or Super Cereal Plus with amylase (SC + A) compared to Corn Soy Blend Plus with fortified vegetable oil (CSB+ w/oil). We also estimated differences in costs and cost effectiveness of each supplement.

METHODS

In Sierra Leone, we randomly assigned 29 health centers to provide a supplement containing 550 kcal/d for ∼12 wk to 2691 children with MAM aged 6-59 mo. We calculated cost per enrollee, cost per child who recovered, and cost per child who sustained recovery each from 2 perspectives: program perspective and caregiver perspective, combined.

RESULTS

Of 2653 MAM children (98.6%) with complete data, 1676 children (63%) recovered. There were no significant differences in the odds of recovery compared to CSB+ w/oil [0.83 (95% CI: 0.64-1.08) for CSWB w/oil, 1.01 (95% CI: 0.78-1.3) for SC + A, 1.05 (95% CI: 0.82-1.34) for RUSF]. The odds of sustaining recovery were significantly lower for RUSF (0.7; 95% CI 0.49-0.99) but not CSWB w/oil or SC + A [1.08 (95% CI: 0.73-1.6) and 0.96 (95% CI: 0.67-1.4), respectively] when compared to CSB+ w/oil. Costs per enrollee [US dollars (USD)/child] ranged from $105/child in RUSF to $112/child in SC + A and costs per recovered child (USD/child) ranged from $163/child in RUSF to $179/child in CSWB w/oil, with overlapping uncertainty ranges. Costs were highest per sustained recovery (USD/child), ranging from $214/child with the CSB+ w/oil to $226/child with the SC + A, with overlapping uncertainty ranges.

CONCLUSIONS

The 4 supplements performed similarly across recovery (but not sustained recovery) and costed measures. Analyses of posttreatment outcomes are necessary to estimate the full cost of MAM treatment. This trial was registered at clinicaltrials.gov as NCT03146897.

Importance of human papillomavirus infection in squamous cell carcinomas of the tongue in Guangdong Province, China

Objective

Methods

Results

Conclusion

The 2020 International Alliance for the Control of Scabies Consensus Criteria for the Diagnosis of Scabies

BACKGROUND

Scabies is a common parasitic skin condition that causes considerable morbidity globally. Clinical and epidemiological research for scabies has been limited by a lack of standardization of diagnostic methods.

OBJECTIVES

To develop consensus criteria for the diagnosis of common scabies that could be implemented in a variety of settings.

METHODS

Consensus diagnostic criteria were developed through a Delphi study with international experts. Detailed recommendations were collected from the expert panel to define the criteria features and guide their implementation. These comments were then combined with a comprehensive review of the available literature and the opinion of an expanded group of international experts to develop detailed, evidence-based definitions and diagnostic methods.

RESULTS

The 2020 International Alliance for the Control of Scabies (IACS) Consensus Criteria for the Diagnosis of Scabies include three levels of diagnostic certainty and eight subcategories. Confirmed scabies (level A) requires direct visualization of the mite or its products. Clinical scabies (level B) and suspected scabies (level C) rely on clinical assessment of signs and symptoms. Evidence-based, consensus methods for microscopy, visualization and clinical symptoms and signs were developed, along with a media library.

CONCLUSIONS

The 2020 IACS Criteria represent a pragmatic yet robust set of diagnostic features and methods. The criteria may be implemented in a range of research, public health and clinical settings by selecting the appropriate diagnostic levels and subcategories. These criteria may provide greater consistency and standardization for scabies diagnosis. Validation studies, development of training materials and development of survey methods are now required. What is already known about this topic? The diagnosis of scabies is limited by the lack of accurate, objective tests. Microscopy of skin scrapings can confirm the diagnosis, but it is insensitive, invasive and often impractical. Diagnosis usually relies on clinical assessment, although visualization using dermoscopy is becoming increasingly common. These diagnostic methods have not been standardized, hampering the interpretation of findings from clinical research and epidemiological surveys, and the development of scabies control strategies. What does this study add? International consensus diagnostic criteria for common scabies were developed through a Delphi study with global experts. The 2020 International Alliance for the Control of Scabies (IACS) Criteria categorize diagnosis at three levels of diagnostic certainty (confirmed, clinical and suspected scabies) and eight subcategories, and can be adapted to a range of research and public health settings. Detailed definitions and figures are included to aid training and implementation. The 2020 IACS Criteria may facilitate the standardization of scabies diagnosis.

Targeting interleukin-10 signalling for cancer immunotherapy, a promising and complicated task

Interleukin 10 (IL-10) belongs to IL-10 family cytokines that are critical for maintaining the integrity of epithelial tissues, protecting pathogenic infection, and preventing excessive immune responses to damage self. Temporal IL-10 signaling blockade enhances vaccine-induced tumor regression by CD8 + T cells. IL-10, especially pegylated IL-10, mediates tumor regression by expanding tumor-infiltrating CD8 + T cells. Moreover, targeting IL-10 enhances immune checkpoint inhibitor mediated tumor regression. In the current paper, we will review recent advances in this area and discuss the complexity of IL-10 manipulation for cancer therapy.

Cost-Effectiveness of 4 Specialized Nutritious Foods in the Prevention of Stunting and Wasting in Children Aged 6-23 Months in Burkina Faso: A Geographically Randomized Trial

BACKGROUND

There is a variety of specialized nutritious foods available for use in programs targeting undernutrition, but evidence supporting the choice of product is limited.

OBJECTIVES

We compared the cost-effectiveness of 4 specialized nutritious foods to prevent stunting and wasting in children aged 6-23 mo in Burkina Faso.

METHODS

Four geographic regions were randomly assigned to 1 of 4 intervention arms: Corn-Soy Blend Plus (CSB+) programmed with separate fortified vegetable oil (the reference food), Corn-Soy-Whey Blend (CSWB; a new formulation) with oil, SuperCereal Plus (SC+), and ready-to-use supplementary food (RUSF). We compared the effects of each intervention arm on growth (length-for-age z score (LAZ), weight-for-length z score (WLZ), end-line stunting (LAZ < -2), and total monthly measurements of wasting (WLZ < -2). Rations were ∼500 kcal/d, distributed monthly. Children were enrolled in the blanket supplementary feeding program at age ∼6 mo and measured monthly for ∼18 mo. Average costs per child reached were linked with effectiveness to compare the cost-effectiveness of each arm with CSB+ with oil.

RESULTS

In our sample of 6112 children (CSB+, n = 1519; CSWB, n = 1503; SC+, n = 1564; RUSF, n = 1526), none of the foods prevented declines in growth. Children in the SC+ and RUSF arms were not significantly different than those in the CSB+ with oil arm. Children in the CSWB with oil arm experienced higher end-line (measurement at age 22.9-23.9 mo) stunting (OR: 2.07; 95% CI: 1.46, 2.94) and more months of wasting (incidence rate ratio: 1.29; 95% CI: 1.09, 1.51). CSB+ with oil was the least-expensive ration in all costing scenarios ($113-131 2018 US dollars/enrolled child) and similar in effectiveness to SC+ and RUSF, and thus the most cost-effective product for the defined purposes.

CONCLUSIONS

CSB+ with oil was the most cost-effective ration in the prevention of wasting and stunting in this trial. This trial was registered at clinicaltrials.gov as NCT02071563.

How can we realise the full potential of health systems for nutrition?

Poor nutrition contributes substantially to global disease, diminishing the wellbeing of women and children in low and middle income countries, and better nutrition must be part of the universal health coverage agenda, say Rebecca Heidkamp and colleagues

Vitrification of in vitro-derived bovine embryos: targeting enhancement of quality by refining technology and standardising procedures

Bovine invitro fertilisation technology has been widely exploited in commercial settings. The majority of invitro-derived cattle embryos are transferred into recipient cows as recently collected (i.e. 'fresh') embryos due to the lack of a reliable cryopreservation method that results in favourable pregnancy rates following transfer of thawed embryos. This is a primary reason for the poor industry uptake of this extreme temperature freezing process. Numerous investigations into vitrification have revealed the importance of rapid cooling and warming rates, enhancing embryo viability after cryopreservation compared with conventional slow freezing. Those studies spawned a considerable assortment of cryovessels and diversity of procedures, delivering variable rates of success, which makes performing vitrification consistently a practical challenge. Hence, further research is required in order to both optimise and standardise vitrification methodology and to design a cryovessel that enables direct transfer of vitrified embryos to recipients after warming. In parallel with improvements in vitrification, it is important to continue to raise the quality of invitro-derived cattle embryos through modifications in laboratory culture techniques. The twin goals of methodology refinement and standardisation, leading to embryo quality enhancement, are each imperative if invitro fertilisation technology is to be adopted in the field.

Adjuvant statin therapy for oesophageal adenocarcinoma: the STAT-ROC feasibility study

Background

Statins inhibit proliferative signalling in oesophageal adenocarcinoma (OAC) and their use is associated with better survival in observational studies. The present study was undertaken to examine the feasibility of assessing adjuvant statin therapy in patients with operable OAC in a phase III RCT.

Methods

For this multicentre, double‐blind, parallel‐group, randomized, placebo‐controlled feasibility trial, adults with OAC (including Siewert I–II lesions) who had undergone oesophagectomy were centrally allocated (1 : 1) to simvastatin 40 mg or matching placebo by block randomization, stratified by centre. Participants, clinicians and investigators were blinded to treatment allocation. Patients received treatment for up to 1 year. Feasibility outcomes were recruitment, retention, drug absorption, adherence, safety, quality of life, generalizability and survival.

Results

A total of 120 patients were assessed for eligibility at four centres, of whom 32 (26·7 per cent) were randomized, 16 in each group. Seven patients withdrew. Participants allocated to simvastatin had lower low‐density lipoprotein cholesterol levels by 3 months (adjusted mean difference −0·83 (95 per cent c.i. −1·4 to −0·22) mmol/l; P = 0·009). Median adherence to medication was greater than 90 per cent between 3 and 12 months' follow‐up. Adverse events were similar between the groups. Quality‐of‐life data were complete for 98·3 per cent of questionnaire items. Cardiovascular disease, diabetes and aspirin use were more prevalent in the non‐randomized group, whereas tumour site, stage and grade were similar between groups. Survival estimates were imprecise.

Conclusion

This RCT supports the conduct and informs the design considerations for a future phase III trial of adjuvant statin therapy in patients with OAC. Registration number: ISRCTN98060456 (http://www.isrctn/com).

Human papillomavirus infection among head and neck squamous cell carcinomas in southern China

Human papillomavirus (HPV) related tumours account for a significant proportion of head and neck squamous cell carcinomas (HNSCCs) in developed countries. They respond better to chemo- and radio-therapy, and have a better stage specific prognosis. To establish their prevalence in China, we assessed a series of histology confirmed HNSCCs collected in Zhejiang and Guangdong provinces by PCR for HPV DNA and by immunohistochemistry for p16 protein status. Among 303 HNSCCs, HPV DNA was detected in 26.4%, with HPV16 DNA in 71% of these. Of HNSCC located in the oropharynx, 38.55% (32/83) were HPV+ve. In this series, p16 status was a relatively poor predictor of HPV status as detected by PCR. The stage specific survival time of HPV+ HNSCCs was significantly longer than for HPV- HNSCC. HPV status should be assessed for oropharyngeal cancers in China to assist with appropriate management, and prophylaxis against HPV infection should be considered to reduce the incidence of this disease.

Comparative Effectiveness of Four Specialized Nutritious Food Products for Treatment of Moderate Acute Malnutrition in Sierra Leone (P10-140-19)

Objectives

This study compared the effectiveness of 4 specialized nutritious foods (SNFs) used for the treatment of moderate acute malnutrition (MAM) in children <5 years of age in Pujehun District, Sierra Leone.

Methods

This was a cluster-randomized trial operating through a supplementary feeding program (SFP) providing SNFs for treatment of MAM. Three study foods were fortified blended foods – Super Cereal Plus w/amylase (SC + A), Corn-soy Blend Plus w/oil (CSB + w/oil), and Corn-soy-whey Blend w/oil (CSWB w/oil) – and one was a lipid-based Ready to Use Supplementary Food (RUSF). From 4/2017 to 11/2018, children with MAM, defined as mid-upper arm circumference (MUAC) ≥11.5 cm and <12.5 cm without bipedal edema, were enrolled at participating health clinics and received rations bi-weekly until they reached an outcome or for up to 12 weeks. A stratified randomization technique was used to select 28 sites and randomize them into 7 per arm based on pre-determined criteria. During the study, an 8th site was added to the CSWB w/oil arm due to low enrollment. The primary outcome was graduation from SFP defined as MUAC ≥12.5 cm within the 12-week treatment period. Mixed-effect regression assessed whether there were differences in graduation rates among children treated with one of the 4 SNFs.

Results

A total of 2683 children were enrolled out of a planned sample size of ∼5000. Overall: 63% graduated from MAM, 19% developed severe acute malnutrition (SAM), 7% defaulted (missed 3 visits in a row), 1% died, and 10% reached no outcome within 12 weeks. Twenty-five % were transferred into the study from SAM treatment. By study arm, graduation rates were: 62% in CSWB w/oil, 65% in SC + A, 64% in CSB + w/oil, 62% in RUSF. In an unadjusted model, statistically significant differences in graduation rates between the arms were not detected. Data analysis is ongoing to determine if this finding is maintained in adjusted models.

Conclusions

The 4 foods performed comparably in treating MAM in unadjusted analysis. Decision-making by donors, governments, and programmers on which food to program should also be based on cost-effectiveness analysis.

Funding Sources

Supported by the Office of Food for Peace, Bureau for Democracy, Conflict, and Humanitarian Assistance, U.S. Agency for International Development.

Lactulose: Mannitol Test as an Indicator of a Potential Modifier of the Effect of Specialized Nutritious Foods in the Treatment of Moderate Acute Malnutrition in Sierra Leone (P10-122-19)

Objectives

The objective of the study was to examine whether EED at enrollment modifies the effect of specialized nutritious foods (SNFs) on graduation from a moderate acute malnutrition (MAM) treatment program.

Methods

This sub-study was nested within a cluster randomized trial of MAM children 6–59 months of age supplemented with one of four SNFs: Super Cereal Plus w/amylase (SC + A), Corn Soy Blend Plus w/oil (CSB + w/oil - referent), Corn Soy Whey Blend w/oil (CSWB w/oil), and Ready to Use Supplementary Food (RUSF). Children with mid-upper arm circumference (MUAC) ≥11.5 cm and <12.5 cm with no clinical complications were enrolled. Children received the study food until they reached MUAC ≥12.5 cm or up to 12 weeks. EED was assessed at enrollment using the lactulose: mannitol (L: M) test. Samples from 387 participants were analyzed. Logistic regression was used to test for effect modification by L: M ratio (LM), L: M excretion ratio (LMER), and % lactulose excreted (%L).

Results

At enrollment, the mean ± SD age of sub-study participants was 14.5 ± 9.12 months, 57% were female, and 24% previously had severe acute malnutrition (SAM). The median LM was 0.49 (interquartile range, IQR = 0.42), LMER was 0.10 (IQR = 0.08), and %L was 0.34 (IQR = 0.42). The overall graduation rate was 66% (range: 60% to 74% by food). LMER, LM, and %L did not modify the effect of the study foods in unadjusted models (P = 0.116, P = 0.116, P = 0.176), and models adjusted for age, gender, and previous SAM (P = 0.057, P = 0.057, P = 0.337). Analysis excluding children with watery stool after L: M dosing (N = 16), but not before as reported by the caregiver, showed statistically significant effect modification by LMER (P = 0.03; SC + A vs. CSB + : β = 12.69, P = 0.013) and L: M ratio (P = 0.03, SC + A vs. CSB + : β = 2.55, P = 0.013).

Conclusions

In this study we did not find EED (L: M test) at enrollment to modify the effect of SNFs on likelihood of graduation from a MAM treatment program. This may be because EED did not affect graduation from the program, or because EED severity changes over the course of treatment. Watery stool post L: M dosing should be systematically recorded and its effect assessed in analysis.

Funding Sources

This work was supported by the Office of Food for Peace, Bureau for Democracy, Conflict, and Humanitarian Assistance, U.S. Agency for International Development.

Self-Reported Adherence to Ration Guidance During Preparation or Feeding of Four Specialized Foods May Not Predict Recovery from Moderate Acute Malnutrition (MAM) (P10-143-19)

Objectives

Fortified blended flours (FBFs) require preparation with boiling water, sometimes with fortified vegetable oil (FVO), using prescribed quantities and ratios. Lipid-based nutrient supplements (LNS) are ready-to-eat, individually packaged, and prescribed for consumption without adding other ingredients/foods. This study assessed compliance with recipe and ration instructions and whether this influenced treatment effectiveness for moderate acute malnutrition (MAM).

Methods

A cluster-randomized clinical-effectiveness trial in Sierra Leone compared four isocaloric foods in treating children 6–59 mos with uncomplicated MAM: Corn-Soy Blend Plus with FVO (CSB +), Corn-Soy Whey Blend with FVO (CSWB), Super Cereal Plus with amylase (SC + A), or ready-to-use-supplementary food (RUSF). Caregivers were advised bi-weekly by trained nurses on ingredients, quantities, and daily rations. A random sub-sample participated in in-depth interviews on ingredients used at the last preparation. Respondents were categorized in two ways: (for FBFs) using too little, the correct amount or too much or (for RUSF) correct if eaten without other food; or using the recommended ratios of ingredients. Unadjusted logistic regression evaluated the relationship between compliance and graduation from treatment.

Results

Graduation rates among 958 respondents: 70% CSB + , 67% CSWB, 66% SC + , and 66% RUSF. Reported use of correct ingredients was: 99% of CSB +, 97% of CSWB, and 99% of SC + A and 86% RUSF reported eating without mixing. Reported use of correct amount of flour: 34% in CSB + , 27% in CSWB, and 43% in SC + A of those, 95% in CSB + and 96% in CSWB also used the correct amount of oil. Among all caregivers, 86% in CSB + and 92% in CSWB used the correct amount of oil. In unadjusted models, the relationships between compliance behaviors and graduation were not statistically significant.

Conclusions

Reported use of correct ingredients was high for all study foods; among FBFs, amount of flour was often different from the recommendation while amount of oil was often correct. Further research may explain apparent low importance of emphasizing ration guidance when designing information, education, and communication for MAM treatment programs.

Funding Sources

Office of Food for Peace, Bureau for Democracy, Conflict, and Humanitarian Assistance, U.S. Agency for International Development.

Changes in Body Composition Using Deuterium Dilution Technique Among Young Children Receiving Specialized Nutritious Foods for Moderate Acute Malnutrition in Sierra Leone (P10-141-19)

Objectives

To determine differential changes in children's body composition—fat-free mass (FFM) and fat mass (FM)—after 4 weeks of treatment for moderate acute malnutrition (MAM) with one of 4 four specialized nutritious foods (SNFs).

Methods

This sub-study was nested within a larger cluster-randomized trial comparing the cost-effectiveness of 4 isocaloric SNFs in treating MAM among children 6–59 months in Pujehun District, Sierra Leone: Corn-Soy Blend Plus w/oil (CSB + w/oil), Super Cereal Plus w/amylase (SC + A), Corn-Soy-Whey Blend w/oil (CSWB w/oil) and Ready-to-use-Supplementary Food (RUSF). Children with mid-upper arm circumference (MUAC) ≥11.5 cm and <12.5 cm with no clinical complications were enrolled and received an SNF ration bi-weekly until they reached MUAC ≥12.5 cm or up to 12 weeks. Body composition was assessed using the deuterium dilution technique at program enrollment and after 4 weeks of treatment. Changes in weight, FM, FFM and %FFM overall and by study arm were calculated; statistical significance was determined using t-tests and ANOVA (unadjusted).

Results

Among 336 subjects at enrollment, mean ± SD age was 11.8 ± 6.5 mos, weight was 6.5 ± 0.9 kg, FM was 1.3 ± 0.5 kg, FFM was 5.2 ± 0.9 kg, and %FFM was 80.4 ± 7.3. After 4 weeks of treatment, mean ± SD change in weight was 0.44 ± 0.39 kg (P < 0.001), FM was 0.09 ± 0.60 kg (P = 0.005), FFM was 0.35 ± 0.56 (P < 0.001), and %FFM was 0.003 ± 8.5 (NS). Overall, weight gain consisted on average of 20.9% FM and 79.8% FFM. By study arm, mean ± SD changes in FM and FFM respectively, were: 0.12 ± 0.53 kg and 0.32 ± 0.49 kg in CSB + w/oil; 0.13 ± 0.67 kg and 0.34 ± 0.64 kg in SC + A; 0.08 ± 0.65 kg and 0.36 ± 0.57 kg in CSWB w/oil; 0.02 ± 0.49 kg and 0.39 ± 0.5 kg in RUSF. These changes were not significantly different across study arms.

Conclusions

Over 4 weeks of treatment for MAM, children gained roughly 80% lean mass relative to 20% fat mass. This body composition is consistent with predicted sustainability of recovery from MAM and healthier long-term disease risk. Differential effects on body composition by type of SNF were not detected after 4 weeks of treatment in this study.

Funding Sources

The Office of Food for Peace, Bureau for Democracy, Conflict, and Humanitarian Assistance, U.S. Agency for International Development.

Infliximab is associated with an increased risk of serious infection in patients with psoriasis in the U.K. and Republic of Ireland: results from the British Association of Dermatologists Biologic Interventions Register (BADBIR)

Background

Patients with psoriasis and clinicians are concerned that infliximab may be associated with a risk of serious infections.

Objectives

To compare the risk of serious infections associated with infliximab in patients with chronic plaque psoriasis against a cohort on nonbiologic systemic therapies.

Methods

A prospective cohort study was performed using data from the British Association of Dermatologists Biologic Interventions Register (BADBIR). Infliximab was compared with nonbiologic systemic therapies, inclusive of any exposure to methotrexate, ciclosporin, acitretin, fumaric acid esters, psoralen‐ultraviolet A or hydroxycarbamide. Serious infections were those associated with hospitalization, the use of intravenous antimicrobial therapy and/or those that led to death. Propensity score inverse probability treatment weights were used to adjust for potential confounding from a priori identified covariates. Cox proportional hazards models were calculated to obtain hazard ratios (HRs).

Results

In total, 3843 participants were included for analysis up to October 2016. The incidence rates were significantly higher in the infliximab cohort (47·8 per 1000 person‐years) [95% confidence interval (CI) 35·7–64·0], compared with 14·2 per 1000 person‐years (95% CI 11·5–17·4) in the nonbiologic systemic cohort. Infliximab was associated with an overall increase in the risk of serious infection compared with nonbiologics [adjusted HR (adjHR) 1·95, 95% CI 1·01–3·75] and methotrexate only (adjHR 2·96, 95% CI 1·58–5·57) and a higher risk of serious infection in the first 6 months of therapy (adjHR 3·49, 95% CI 1·14–10·70).

Conclusions

Infliximab is associated with an increased risk of serious infections compared with nonbiologic systemic therapies in patients with psoriasis in the U.K. and the Republic of Ireland.

What's already known about this topic?

Randomized clinical trials are not sufficiently powered to investigate the risk of serious infection in patients with psoriasis who are undergoing treatment with infliximab.

Published observational studies have used different methods to adjust for confounding and different comparators.

Previous studies also lacked the adequate sample size to obtain a precise estimate of the risk of serious infection for infliximab.

What does this study add?

Using methods that better address bias and confounding, our study suggests that infliximab is associated with a higher risk of serious infections compared with nonbiologic systemic therapies in patients with psoriasis.

Patients should be counselled on the risk of serious infection before infliximab is prescribed.

Linked Comment: Puig. Br J Dermatol 2019; 180: 257–258.

Plain language summary available online

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Prospective study in bullous pemphigoid: association of high serum anti-BP180 IgG levels with increased mortality and reduced Karnofsky score

BACKGROUND

Bullous pemphigoid (BP) is a subepidermal blistering disease characterized by autoantibodies against the two hemidesmosomal proteins, BP180 (type XVII collagen) and BP230. The multicentre prospective BLISTER (Bullous Pemphigoid Steroids and Tetracyclines) trial randomized 253 patients with BP to compare the benefits and harms between initial treatment with doxycycline or prednisolone.

OBJECTIVES

To analyse distinct autoantibody profiles for the prediction of the disease course in a well-characterized cohort of BP sera.

METHODS

One hundred and forty-three patients of the BLISTER trial consented to participate in this serological study. Sera taken at baseline were analysed by (i) indirect immunofluorescence, (ii) anti-BP180 NC16A (16th noncollagenous domain) and anti-BP230 enzyme-linked immunosorbent assay and (iii) immunoblotting with various substrates. Results were then linked with clinical parameters including age, Karnofsky score, number of blisters, related adverse events and mortality.

RESULTS

Disease activity correlated with immunoglobulin (Ig)G anti-BP180 levels but not with levels of anti-BP230 IgG and anti-BP180 IgE. High levels of both anti-BP180 IgG and anti-BP230 IgG were associated with a low Karnofsky score. The presence of anti-BP230 IgG was more frequent in older patients. Those with higher total IgE serum levels suffered from fewer adverse events. Higher IgG anti-BP180 levels were associated with an increased 1-year mortality rate.

CONCLUSIONS

Analysis of the autoantibody profile is not only of diagnostic relevance but may also be helpful in predicting the course of the disease.

Experiences and lessons learned for planning and supply of micronutrient powders interventions

Realistic planning for a nutrition intervention is a critical component of implementation, yet effective approaches have been poorly documented. Under the auspices of "The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance," 3 working groups were formed to summarize experiences and lessons across countries regarding micronutrient powders (MNP) interventions for young children. This paper focuses on programmatic experiences in the planning stages of an MNP intervention, encompassing assessment, enabling environment and adaptation, as well as considerations for supply. Methods included a review of published and grey literature, key informant interviews, and deliberations throughout the consultation process. We found that assessments helped justify adopting an MNP intervention, but these assessments were often limited by their narrow scope and inadequate data. Establishing coordinating bodies and integrating MNP into existing policies and programmes have helped foster an enabling environment and support programme stability. Formative research and pilots have been used to adapt MNP interventions to specific contexts, but they have been insufficient to inform scale-up. In terms of supply, most countries have opted to procure MNP through international suppliers, but this still requires understanding and navigating the local regulatory environment at the earliest stages of an intervention. Overall, these findings indicate that although some key planning and supply activities are generally undertaken, improvements are needed to plan for effective scale-up. Much still needs to be learned on MNP planning, and we propose a set of research questions that require further investigation.

Doxycycline compared with prednisolone therapy for patients with bullous pemphigoid: cost-effectiveness analysis of the BLISTER trial

BACKGROUND

Bullous pemphigoid (BP) is an autoimmune blistering skin disorder associated with significant morbidity and mortality. Doxycycline and prednisolone to treat bullous pemphigoid were compared within a randomized controlled trial (RCT).

OBJECTIVES

To compare the cost-effectiveness of doxycycline-initiated and prednisolone-initiated treatment for patients with BP.

METHODS

Quality-of-life (EuroQoL-5D-3L) and resource data were collected as part of the BLISTER trial: a multicentre, parallel-group, investigator-blinded RCT. Within-trial analysis was performed using bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, informing a probabilistic assessment of incremental treatment cost-effectiveness from a health service perspective.

RESULTS

In the base case, there was no robust difference in costs or QALYs per patient at 1 year comparing doxycycline- with prednisolone-initiated therapy [net cost £959, 95% confidence interval (CI) -£24 to £1941; net QALYs -0·024, 95% CI -0·088 to 0·041]. However, the findings varied by baseline blister severity. For patients with mild or moderate blistering (≤ 30 blisters) net costs and outcomes were similar. For patients with severe blistering (> 30 blisters) net costs were higher (£2558, 95% CI -£82 to £5198) and quality of life poorer (-0·090 QALYs, 95% CI -0·22 to 0·042) for patients starting on doxycycline. The probability that doxycycline would be cost-effective for those with severe pemphigoid was 1·5% at a willingness to pay of £20 000 per QALY.

CONCLUSIONS

Consistently with the clinical findings of the BLISTER trial, patients with mild or moderate blistering should receive treatment guided by the safety and effectiveness of the drugs and patient preference - neither strategy is clearly a preferred use of National Health Service resources. However, prednisolone-initiated treatment may be more cost-effective for patients with severe blistering.

Does the Addition of Salubrinal to in vitro Maturation Medium Enhance Bovine Blastocyst Yields and Embryo Cryotolerance?

BACKGROUND

Modifications to in vitro maturation (IVM) media are made to improve rates of blastocyst formation and quality of mammalian embryos. Embryo quality is an important factor in the viability of embryos following cryopreservation. Salubrinal is a specific inhibitor of endoplasmic reticulum stress-induced apoptosis in eukaryotic cells. Here, it was added to IVM medium in an attempt to increase blastocyst formation and to enhance embryo quality in cattle.

OBJECTIVE

To assess the effect on blastocyst formation and cryotolerance of the supplementation of salubrinal to bovine IVM medium.

MATERIALS AND METHODS

Cumulus-oocyte complexes (COCs) collected from slaughterhouse ovaries were assigned randomly to two groups, either cultured in IVM medium that was supplemented with 400 mM salubrinal (treated, 262 COCs) or that was not supplemented (control, 263 COCs). All oocytes of the matured COCs were fertilized in vitro with sperm from the same proven bull and cultured for 6-7 d. At the time of blastocyst collection, expanded blastocysts were chosen for cryopreservation, while early, hatching and hatched blastocysts and those of poor quality were not used. There were 83 expanded blastocysts classified to be of good quality in both the control and salubrinal-treated groups that were subjected to vitrification. After 5 to 10 months of cold storage, the embryos were warmed and cultured in vitro for 24 h to assess the survival rate and for 48 h to assess the hatching rate.

RESULTS

The blastocyst developmental rate in the salubrinal-treated group was similar to that in the control group, 61.5% compared with 62.7% (P > 0.05). The survival rate of blastocysts after vitrification was also similar, at or very close to 100%. In addition, there was no statistically significant difference in the hatching rate of expanded blastocysts derived from the COCs cultured with (treated) and without (control) addition of salubrinal to the IVM medium (91.6% compared with 85.5%; P > 0.05).

CONCLUSION

Supplementation of salubrinal to the IVM medium neither improved nor reduced rates of bovine blastocyst formation and of embryo cryotolerance as determined by post-warming viability.

Generating new evidence, improving clinical practice and developing research capacity: the benefits of recruiting to the U.K. Dermatology Clinical Trials Network's STOP GAP and BLISTER trials

Clinical trials may benefit clinical practice in three ways: firstly, clinicians may change their practice according to the new trial evidence; secondly, clinical processes can improve when working on a trial; and thirdly, research capacity is increased. We held a meeting to present and discuss the results of two large multicentre randomized controlled trials delivered through the U.K. Dermatology Clinical Trials Network. Investigators gave reflections on how the trials had changed their clinical practice. The STOP GAP trial showed that prednisolone and ciclosporin are equally effective as first-line systemic treatment for pyoderma gangrenosum. The final decision of which treatment to use should be based on the different adverse event profiles of the two drugs in relation to comorbidities, along with age, disease severity and patient preference. The BLISTER trial showed that starting people with pemphigoid on doxycycline produces acceptable short-term effectiveness and a superior safety profile to oral corticosteroids. Recruiting to these trials has led to the development of new specialist clinics with improved documentation. It has increased the profile of participating departments and embedded research in the department's activities. Helping to design and run these trials has also allowed trial staff to develop new skills in research design, which has been beneficial for career development. These and other benefits of recruiting to the trials are summarized here. We hope that these reflections will inspire wider involvement in clinical research.

Making Food Aid Fit-for-Purpose in the 21st Century: A Review of Recent Initiatives Improving the Nutritional Quality of Foods Used in Emergency and Development Programming

Important strides have been made recently in upgrading the global food aid agenda in line with evolving medical and nutrition sciences, operational experience, and innovations in food technology. A 2011 report endorsed by the United States Agency for International Development (USAID) recommended numerous improvements to products intended to support improved survival and nutrition in humanitarian programming, as well as greater rigor and transparency in the research agenda that supports innovations in this critical field. This article reviews progress since 2011 made by USAID, and other global food aid providers, in developing food aid products that are fit-for-purpose and are appropriately formulated to save lives in emergencies and to promote healthy mothers and children in nonemergency contexts. It highlights important modifications and addition made to products and identifies persisting knowledge gaps that should be prioritized in future research.

Immunization of looked-after children and young people: a review of the literature

BACKGROUND

Numbers of looked-after children and young people (LACYP) in the UK have risen over the last seven years. Looked-after children and young people should receive regular health assessments, including establishing immunization status and, if needed, developing a health plan to achieve full immunization. The Department for Education publish data on immunizations among LACYP to monitor both how well they are immunized and service performance.

METHODS

A literature review was conducted using four databases (PubMed, Embase, Scopus and Web of Science) on immunization status of LACYP, factors affecting uptake and challenges to immunization, and interventions to improve immunization rates.

RESULTS

Thirty-two papers were identified, 16 of which were UK based. Looked-after children and young people are less likely to be 'up-to-date' with their immunizations than children in the general population. Looked-after children and young people are less likely to receive timely immunizations, and older LACYP are less likely to be 'up-to-date' than younger LACYP. Barriers to immunization include failure to attend health checks, absence from school and frequent placement moves. Unknown and discrepant immunization histories, name changes, sharing of information between organizations and obtaining consent for immunizations are also challenges.

CONCLUSIONS

In recent years, immunization of LACYP has been given a higher priority. However, the immunization figures produced by the Department for Education are problematic because of challenges in determining whether the child is 'up-to-date', and data are not comparable with the general population; ideally, this should be changed to correspond to routine immunization data. In the interim, for reporting purposes, the use of a tool to assist with determining a child's immunization status would be beneficial. When a child's immunization status is incomplete or unknown, Public Health England's algorithm for vaccination of individuals with uncertain or incomplete status should be used. Practice to improve immunization uptake amongst LACYP needs to be evaluated to develop evidence-based recommendations.

Categorical Colormap Optimization with Visualization Case Studies

Mapping a set of categorical values to different colors is an elementary technique in data visualization. Users of visualization software routinely rely on the default colormaps provided by a system, or colormaps suggested by software such as ColorBrewer. In practice, users often have to select a set of colors in a semantically meaningful way (e.g., based on conventions, color metaphors, and logological associations), and consequently would like to ensure their perceptual differentiation is optimized. In this paper, we present an algorithmic approach for maximizing the perceptual distances among a set of given colors. We address two technical problems in optimization, i.e., (i) the phenomena of local maxima that halt the optimization too soon, and (ii) the arbitrary reassignment of colors that leads to the loss of the original semantic association. We paid particular attention to different types of constraints that users may wish to impose during the optimization process. To demonstrate the effectiveness of this work, we tested this technique in two case studies. To reach out to a wider range of users, we also developed a web application called Colourmap Hospital.

Crusted scabies (sarcoptic mange) in four cats due to Sarcoptes scabiei infestation

Four new cases of sarcoptic mange in cats are described. Two cats resided in areas known to be frequented by foxes, another cohabited with a dog recently diagnosed with sarcoptic mange, while the final cat lived with a mixed breed dog that had been treated for sarcoptic mange 7 months previously. Three cases were diagnosed on the basis of characteristic mite size and morphology in skin scraping from representative lesions, situated on the head (two cases) or head and distal hind limbs (one case). Mites were highly mobile and abundant in all instances, and easily detected also in skin biopsy specimens procured from two cases. Eosinophilic inflammation, hyperkeratosis and parakeratosis were prominent in the tissue sections. In the remaining case, the diagnosis was presumptive, based on characteristic lesions, cohabitation with a canine scabies patient and positive response to scabicide therapy. Pruritus was not a prominent clinical feature in any patient and was considered to be absent in three of the four cases. Lesions in three cats with long-standing disease were reminiscent of crusted scabies (synonym: Norwegian scabies, parakeratotic scabies) as seen in human patients. In three cases, in-contact human carriers developed itchy cutaneous papular lesions. Two cases responded promptly to therapy with systemic avermectin drugs, while one responded to topical treatment with lime sulphur and the remaining cat received both a lime sulphur rinse and ivermectin. Sarcoptic mange should be considered in the differential diagnosis of cats with non-pruritic crusting skin diseases, especially when there is contact with foxes or dogs, and when owners have itchy papular lesions.

Inhibitory mechanism of peptides with a repeating hydrophobic and hydrophilic residue pattern on interleukin-10

Interleukin 10 (IL-10) is a cytokine that is able to downregulate inflammation. Its overexpression is directly associated with the difficulty in the clearance of chronic viral infections, such as chronic hepatitis B, hepatitis C and HIV infection, and infection-related cancer. IL-10 signaling blockade has been proposed as a promising way of clearing chronic viral infection and preventing tumor growth in animal models. Recently, we have reported that peptides with a helical repeating pattern of hydrophobic and hydrophilic residues are able to inhibit IL-10 significantly both in vitro and in vivo. ¹ In this work, we seek to further study the inhibiting mechanism of these peptides using sequence-modified peptides. As evidenced by both experimental and molecular dynamics simulation in concert the N-terminal hydrophobic peptide constructed with repeating hydrophobic and hydrophilic pattern of residues is more likely to inhibit IL10. In addition, the sequence length and the ability of protonation are also important for inhibition activity.

Certifications for sight impairment due to age related macular degeneration in England

OBJECTIVES

To examine variability across England in certification rates for age related macular degeneration (AMD) between 1st April 2011 and 31st March 2012.

STUDY DESIGN

Cross-sectional survey.

METHODS

An electronic version of the CVI, the ECVI, was used at the Certifications Office, London, to transfer information from paper based certificates into a database. The electronic certifications data set was queried for all certificates completed in England between April 1st 2011 and March 31st 2012 with the main cause of certifiable visual loss being AMD or with the main cause of certifiable visual loss being multiple pathology but a contributory cause being AMD. Data were explored by type of AMD, visual status, age and sex and then directly standardized rates were computed by English region.

RESULTS

The Certifications Office received 23,616 CVIs for England between April 2011 and March 2012, of which 10,481 (44%) were people certified severely sight-impaired (blind) (SSI) and 12,689 (54%) were certified as sight-impaired (partial sight) (SI). The remainder did not have visual status classified. AMD contributed to 11546 causes of certification on the CVI forms during this period, 53% of forms being for geographic atrophy (GA)/dry AMD which is currently mostly untreatable. The median (interquartile) age at certification for AMD was 86 (81, 90) years and women were more commonly certified than men (66%). Considerable variability was seen across English regions, although there was consistency in that GA was the more common form in all areas.

CONCLUSIONS

There is considerable regional variability in CVI rates in England, which are not attributable to differences in age or sex. Reasons for such variability need examination yet this should not undermine the value of these data in terms of describing those newly registered with sight impairment due to AMD who are predominantly female and over 85 years of age.

Manipulating IL-10 signalling blockade for better immunotherapy

Interleukin 10 is a cytokine with the ability to reduce or terminate inflammation. Chronic viral infection, such as infection of chronic hepatitis B, hepatitis C and HIV, has increased levels of interleukin 10 in peripheral blood. Serum IL-10 levels are also high in certain cancers. Blocking IL-10 signalling at the time of immunisation clears chronic viral infection and prevents tumour growth in animal models. We review recent advances in this area, with the emphasis on potential use of this novel strategy to treat chronic viral infection and cancer in human.

Parasitic mites of medical and veterinary importance--is there a common research agenda?

There are an estimated 0.5-1 million mite species on earth. Among the many mites that are known to affect humans and animals, only a subset are parasitic but these can cause significant disease. We aim here to provide an overview of the most recent work in this field in order to identify common biological features of these parasites and to inform common strategies for future research. There is a critical need for diagnostic tools to allow for better surveillance and for drugs tailored specifically to the respective parasites. Multi-'omics' approaches represent a logical and timely strategy to identify the appropriate mite molecules. Recent advances in sequencing technology enable us to generate de novo genome sequence data, even from limited DNA resources. Consequently, the field of mite genomics has recently emerged and will now rapidly expand, which is a particular advantage for parasitic mites that cannot be cultured in vitro. Investigations of the microbiota associated with mites will elucidate the link between parasites and pathogens, and define the role of the mite in transmission and pathogenesis. The databases generated will provide the crucial knowledge essential to design novel diagnostic tools, control measures, prophylaxes, drugs and immunotherapies against the mites and associated secondary infections.

Lack of anti-factor Xa assay standardization results in significant low molecular weight heparin (enoxaparin) dose variation in neonates and children

INTRODUCTION

Enoxaparin is a frequently used anticoagulant in children. Unlike in adults, consensus guidelines recommend therapeutic monitoring to a target anti-factor Xa level of 0.5-1 U mL(-1) . Therapeutic ranges are not well correlated with clinical outcomes (e.g. thrombosis or hemorrhage), and assays are not standardized. Owing to limited reagent supplies, our clinical laboratory conducted a validation process and switched anti-FXa assays. Although the assays correlated well with each other, anti-FXa values were, on average, 33% higher with the new assay. The target anti-FXa range was not altered. We evaluated how this change in anti-FXa assays influenced enoxaparin dosing (mg kg(-1) ).

METHODS

Enoxaparin dosing and anti-FXa values for all patients started on enoxaparin for the 6 months before and after assay change were retrospectively compiled and analyzed with a Student's t-test.

RESULTS

One hundred and nine children were started on enoxaparin before assay change, and 104 after assay change. The mean therapeutic enoxaparin dose (mg kg(-1) ) was significantly lower in subjects aged < 3 months (P = 0.01) and 3 months to 2 years (P < 0.0001), but not in subjects aged > 2 years (P = 0.18), after assay change. The median number of enoxaparin dose changes required to achieve the target range was significantly reduced after assay change, from 1 to 0 (P = 0.004).

CONCLUSIONS

The current pediatric practice of dose adjustment to achieve and maintain a target anti-FXa range is vulnerable to assay determination, which may provide false reassurance of efficacy and safety and represent misappropriation of time and resources. These data support a pediatric randomized controlled clinical trial comparing the safety and efficacy of enoxaparin weight-based dosing with or without dose titration based on anti-FXa.

Accurate automated quantitative imaging of tortoise erythrocytes using the NIS image analysis system

The standard method for assessing blood cell characteristics using an ocular micrometer is time-consuming and limited. We used the Nikon NIS Elements imaging software and May- Grünwald-Giemsa staining to determine whether automated image analysis is suitable for rapid and accurate quantitative morphometry of erythrocytes. Blood was collected during four seasons from 126 geometric tortoises and the blood smears were evaluated for cell (C) and nuclear (N) characteristics of the erythrocytes. We measured area, length (L), width (W), perimeter, elongation and pixelation intensity, and calculated L/W and N/C areas. Erythrocyte size differed among cohorts; females, the larger sex, had smaller erythrocytes than either males or juveniles. Males had more elongated erythrocytes than females and erythrocytes of adults were more elongated than those of juveniles. Erythrocyte size and shape influence the efficiency of gas exchange owing to surface area to volume ratios, which are greater for small, elongated cells than for large, round cells. The high N/C ratio and low pixelation intensities of males and juveniles indicate that they may have had more immature erythrocytes in their circulation than females. The use of pixelation intensity to indicate the presence of immature erythrocytes was validated by seasonal differences that corresponded to the biology of the tortoises. Pixelation intensity was lowest in winter. We found that automated image analysis is a rapid and reliable method for determining cell size and shape, and it offers the potential for distinguishing among developmental stages that differ in staining intensity. The method should be useful for rapid health assessments, particularly of threatened species, and for comparative studies among different vertebrates.

Anomalous high bifurcation of the common femoral artery at the groin: management of GSV incompetence with endovenous laser ablation

OBJECTIVES

To discuss safety of EVLA in anomalies of the GSV anatomy. To review and discuss complications of surgery involving anomalous anatomy.

METHOD

We report a case of high bifurcation of the common femoral artery wrapping around the saphenofemoral junction.

RESULTS

Successful ablation was achieved with no adverse consequences.

CONCLUSION

EVLA is a safe treatment for SFJ/GSV incompetence in the presence of vascular anomalies that have historically resulted in serious vascular complications from surgery.

Scabies in the developing world--its prevalence, complications, and management

Scabies remains one of the commonest of skin diseases seen in developing countries. Although its distribution is subject to a cycle of infection, with peaks and troughs of disease prevalence, this periodicity is often less obvious in poor communities. Scabies is a condition that affects families, particularly the most vulnerable; it also has the greatest impact on young children. Largely through the association with secondary bacterial infection caused by group A streptococci and Staphylococcus aureus, the burden of disease is compounded by nephritis, rheumatic fever and sepsis in developing countries. However, with a few notable exceptions, it remains largely neglected as an important public health problem. The purpose of this review is to provide an update on the current position of scabies with regard to its complications and control in resource-poor countries.