Estimating the serum folate concentration that corresponds to the red blood cell folate concentration threshold associated with optimal neural tube defects prevention: A population-based biomarker survey in Southern India

BACKGROUND

RBC folate concentrations are monitored at the population level, with a recommended threshold for optimal neural tube defect (NTD) prevention. A corresponding threshold for serum folate has not been established.

OBJECTIVES

This study aimed to estimate the serum folate insufficiency threshold corresponding to the RBC folate threshold for NTD prevention and examine how this threshold is modified by vitamin B12 status.

METHODS

Participants were women (15-40 y; not pregnant or lactating; n = 977) from a population-based biomarker survey in Southern India. RBC folate and serum folate were measured via microbiologic assay. RBC folate deficiency (<305 nmol/L) and insufficiency (<748 nmol/L), serum vitamin B12 deficiency (<148 pmol/L) and vitamin B12 insufficiency (<221 pmol/L), elevated plasma MMA (>0.26 μmol/L), elevated plasma homocysteine (>10.0 μmol/L), and elevated HbA1c (≥6.5%) were evaluated. Bayesian linear models were used to estimate unadjusted and adjusted thresholds.

RESULTS

Compared with adequate vitamin B12 status, the estimated serum folate threshold was higher in participants with serum vitamin B12 deficiency (72.5 vs. 28.1 nmol/L) or vitamin B12 insufficiency (48.7 vs. 24.3 nmol/L) and elevated MMA (55.6 vs. 25.9 nmol/L). The threshold was lower in participants with elevated HbA1c (HbA1c ≥6.5% vs. <6.5%; 21.0 vs. 40.5 nmol/L).

CONCLUSIONS

The estimated serum folate threshold for optimal NTD prevention was similar to previous reports (24.3 vs. 25.6 nmol/L) among participants with sufficient vitamin B12 status. However, this threshold was more than 2-fold higher in participants with vitamin B12 deficiency and substantially higher across all indicators of insufficient vitamin B12 status (<221 pmol/L, elevated MMA, combined B12, impaired vitamin B12 status), and lower in participants with elevated HbA1c. Findings suggest a serum folate threshold for NTD prevention may be possible in some settings; however, it may not be appropriate in populations with high prevalence of vitamin B12 insufficiency. Am J Clin Nutr 2023;xx:xx-xx. This trial was registered at https://clinicaltrials.gov as NCT04048330.

Maternal nutritional status and milk volume and composition in India: an observational study

BACKGROUND

Human milk provides essential nutrition for infants, and its benefits are well established. We lack data on the influence of maternal nutritional status on milk volume and composition in low-middle income countries.

OBJECTIVE

We aimed to 1) assess lactation performance (human milk volume, macronutrient composition, and infant energy intake) in Indian females and 2) examine the associations between maternal anthropometry (BMI, percentage body fat) and lactation performance.

METHODS

We conducted an observational study among 232 mother-infant dyads, 2 to 4 mo postpartum in Haryana, India. We used deuterium oxide dose-to-mother technique to measure milk volume and maternal percentage body fat and collected human milk samples to determine macronutrient and energy concentrations. Adjusted multiple linear regression models were used to examine the associations between maternal anthropometry and lactation performance.

RESULTS

The mean BMI and percentage body fat of mothers were 21.7 ± 3.6 kg/m² and 29.5 ± 7.7, respectively. Milk volume and macronutrient composition were similar to the reference values (means ± standard deviations: milk volume, 724 ± 184 mL/d; median (25th, 75th percentile); protein, 9.9 (8.3, 11.7) g/L; fat, 41.0 ± 15.2 g/L; energy density, 0.71 ± 0.14 kcal/g; lactose, 65.5 (55.3, 71.3) g/L). Maternal BMI and percentage body fat were not significantly associated with macronutrient composition. Both maternal BMI and percentage body fat were negatively associated with milk volume (-7.0, 95% CI: -12.4, -1.6 mL/d; -3.5, 95% CI: -6.0, -1.1mL/d, respectively) but there were no effects on the total energy intake of infants after adjusting for covariates.

CONCLUSION

Most mothers had a normal BMI and milk of similar composition and volume to reference values. Future work in populations with a greater burden of underweight and/or obesity are needed to examine the underlying mechanisms between maternal body composition and milk volume. This trial was registered at The Clinical Trials Registry- India as CTRI/2017/01/007636.

Comparison of Anemia Screening Methods Using Paired Venous Samples in Women of Reproductive Age in Southern India

BACKGROUND

Anemia is an important public health problem, and accurate estimates may inform policy and programs. Although hemoglobin (Hb) assessment of venous blood via automated hematology analyzers (AHAs) is recommended, most population-based surveys estimate anemia prevalence based on analysis of capillary blood via portable hemoglobinometers.

OBJECTIVES

We aimed to evaluate screening methods for hemoglobin and anemia assessment using paired venous samples.

METHODS

Participants were women 15-40 y who were not pregnant or lactating. Paired venous whole blood samples (n = 896) were analyzed for hemoglobin (Hb) via portable hemoglobinometer (HemoCue 301) and Coulter Counter AHA. Anemia and severe anemia were defined as Hb <12.0g/dL and <8.0 g/dL, respectively. Bland-Altman methods were used to assess the level of agreement for Hb results (mean difference, SD of differences, limits of agreement). Diagnostic accuracy parameters (sensitivity, specificity, positive predictive value, negative predictive value, accuracy) were calculated to evaluate HemoCue performance compared to the AHA reference, overall and by sociodemographic, nutritional, and metabolic characteristics.

RESULTS

The estimated anemia prevalence was significantly lower via HemoCue vs. AHA (36.3% compared with 41.6%; P value < 0.0001). The HemoCue had 84.4% accuracy for anemia screening and 98.8% for severe anemia, compared to the AHA reference. The HemoCue had 74.8% sensitivity and 91.2% specificity, compared to AHA. HemoCue sensitivity was higher in women with iron deficiency [serum ferritin (SF) <15.0 μg/L: 81.6% compared with SF ≥15.0 μg/L: 41.3%], and lower in women with metabolic risk factors, including overweight [BMI ≥25.0 kg/m2: 63.9% vs. BMI <25.0 kg/m2: 78.8%], or elevated CRP (>1.0 mg/L: 67.2% vs. ≤1.0 mg/L: 82.9%), trunk fat (>35%: 62.7% vs. ≤35%: 80.1%), or whole-body fat (>35%: 63.9% vs. ≤35%: 80.3%).

CONCLUSIONS

Findings suggest that women with anemia may be incorrectly identified as not anemic via portable hemoglobinometer, and anemia prevalence may be underestimated at the population level.This study was registered at clinicaltrials.gov as NCT04048330.

Circulating C-Terminal Agrin Fragment: A Potential Marker for Sarcopenia Among Type 2 Diabetes

BACKGROUND

Undetected onset of sarcopenia among individuals with chronic diseases especially Type 2 Diabetes Mellitus (T2D) makes it important to be evaluated. The feasibility of diagnosing sarcopenia in a clinical setup might be a difficult task. Circulating markers including C-terminal agrin fragment (CAF) are emerging as an alternative. Hence, the objectives of the study were to compare circulating CAF levels between T2D, prediabetes (PD) and healthy controls and to study its association with sarcopenic index, muscle mass, strength and quality.

METHODS

Ninety-nine participants (n = 42, T2D; n = 33, PD; n = 24, healthy controls) aged 18 to 60 yrs were recruited. HOMA (homeostatic model assessment) indices were derived using plasma glucose and insulin. All participants underwent lipid profiling, muscle strength including quality (isokinetic dynamometer), body composition (Dual energy X-ray Absorptiometry (DXA)) and sarcopenic index (appendicular skeletal muscle mass/body weight) assessment. Serum samples were used to estimate CAF levelsusing enzyme-linked immunosorbent assay (ELISA).

RESULTS

Median CAF level was significantly higher among T2D group compared to PD and control groups (P < 0.0001). Circulating CAF levels correlated positively with age and glycated haemoglobin (HbA1c) (both, P < 0.001) and negatively with HOMA-B and muscle quality (both, P < 0.001), and sarcopenic index (P = 0.07). Multivariable analysis demonstrated that the odds of being in the highest tertile category was 7.67, 95% C.I. (2.10, 29.3) among T2D.

CONCLUSION

Circulating CAF levels were significantly higher among T2D compared to PD and control study groups along with reduced skeletal muscle quality. This suggests that the circulating CAF level has the potential to be considered as a clinical marker to evaluate sarcopenia among T2D.

Biomarkers of Choline Metabolism in Women of Reproductive Age in Southern India

Objectives

Inadequate maternal choline intake during pregnancy has been associated with adverse pregnancy and child health outcomes – and has been identified as a potential risk factor for neural tube defects. However, there is limited data on biomarkers of choline metabolism in women of reproductive age (WRA), and few representative population-level data from India. The objective of this analysis was to examine biomarkers of choline metabolism and their correlates in WRA, as part of a population-based biomarker survey in Southern India.

Methods

Participants were WRA (15–40y; n = 980) who were not pregnant or lactating. Free choline, betaine, dimethylglycine, methionine, and trimethylamine N-oxide concentrations were evaluated via liquid chromatography tandem mass spectrometry. Linear regression models were used to examine sociodemographic (e.g., age, parity), dietary (e.g., frequency of animal source food intake), and anthropometric (e.g., body mass index [BMI], waist circumference, waist-hip ratio) correlates of biomarkers of choline metabolism, including betaine concentrations and betaine to choline ratio (B:C).

Results

Betaine concentrations (GM: 44.2 μmol/L [95% CI: 43.4, 45.0]) were 4-fold higher compared to free choline (11.1μmol/L [10.9, 11.2]) levels, with an average B:C of 4.0 [3.9, 4.1]. Increased age (β: −0.01 [SE: 0.002], P < 0.0001), multiparity (multiparous/primiparous vs. nulliparous, P < 0.0001), and increased frequency of animal source food intake (poultry, p = 0.004; red meat, p = 0.01), were associated with lower B:C. Higher BMI (betaine: β: −0.004 [SE: 0.002], p = 0.02; B:C: β: −0.02 [SE: 0.002], P < 0.0001), waist circumference (betaine: −0.002 [0.001], p = 0.02; B:C: −0.01 [0.001], P < 0.0001), and waist-hip ratio (betaine: −0.31 [0.15], p = 0.04; B:C: −1.02 [0.16], P < 0.0001), were also associated with lower betaine concentrations and B:C.

Conclusions

In this population, higher BMI and central adiposity were associated with lower betaine concentrations and B:C. Findings from this biomarker survey will inform prospective research on the role of choline biomarkers in the health and nutritional requirements of WRA.

Funding Sources

Centers for Disease Control and Prevention (5U01DD001007), University of South Carolina Disability Research and Dissemination Center; Cornell DNS; NIH T32DK007158 (HMG); NIH 5T32HD087137 (AF).

Comparison of Anemia Screening Methods Using Paired Venous Samples in Women of Reproductive Age in Southern India

Objectives

To evaluate anemia screening via portable hemoglobinometer (HemoCue 301) compared to automated hematology analyzer (AHA) reference, using paired venous samples from a population-based biomarker survey in Southern India.

Methods

Participants were women of reproductive age (WRA; 15–40 y) who were not pregnant or lactating. Paired venous whole blood samples (n = 896) were analyzed for hemoglobin (Hb) via HemoCue 301 and Coulter Counter AHA, as the gold standard. Serum ferritin (SF) was measured by electrochemiluminescence. Anemia and severe anemia were defined as Hb &lt; 12.0 and &lt; 8.0 g/dL, respectively. SF was adjusted for inflammation using BRINDA methods; iron deficiency (ID) was defined as SF &lt; 15.0 μg/L. Bland-Altman methods were used to assess level of agreement between Hb results (i.e., mean difference, standard deviation of differences, limits of agreement). Diagnostic accuracy parameters (i.e., sensitivity, specificity, positive predictive value, negative predictive value, accuracy) were calculated to evaluate HemoCue performance compared to the AHA reference, overall and by sociodemographic (e.g., age, parity), nutritional (e.g., iron, vitamin B12, folate status), and metabolic (e.g., HbA1c, body mass index (BMI)) characteristics.

Results

The estimated prevalence of anemia (36.3% vs. 41.6%, p &lt; 0.0001) was significantly lower via HemoCue compared to the AHA reference. A total of 84.4% of anemia and 98.8% of severe anemia screening results were concordant. HemoCue had 74.8% sensitivity and 91.2% specificity, compared to AHA. HemoCue sensitivity was higher in women with iron deficiency (SF &lt; 15.0 μg/L: 81.6% vs. ≥15.0 μg/L: 41.3%; p &lt; 0.0001), and lower in WRA who were overweight (BMI ≥ 25.0 kg/m2: 63.9% vs. &lt; 25.0 kg/m2: 78.8%; p = 0.004) or had elevated C-reactive protein (CRP) (CRP &gt; 1.0 mg/L: 67.2% vs. ≤1.0 mg/L: 82.9%; p = 0.001; CRP &gt; 3.0 mg/L: 62.2% vs. ≤3.0 mg/L: 79.3%; p = 0.001).

Conclusions

Findings suggest the estimated prevalence of anemia evaluated via portable hemoglobinometer (HemoCue) was lower compared to the AHA reference. HemoCue sensitivity varied by iron status and metabolic risk factors in this population.

Funding Sources

Centers for Disease Control and Prevention (5U01DD001007), University of South Carolina Disability Research and Dissemination Center; NIH 5T32HD087137 (AF); NIH T32DK007158 (HMG); Cornell DNS.

Iron status and inflammation in women of reproductive age: A population-based biomarker survey and clinical study

BACKGROUND

Women of reproductive age (WRA) are at increased risk for anemia and iron deficiency. However, there is limited population-level data in India, which could help inform evidence-based recommendations and policy.

AIMS

To conduct a population-based biomarker survey of anemia, iron deficiency, and inflammation in WRA in Southern India.

METHODS

Participants were WRA (15-40 y) who were not pregnant or lactating. Blood samples (n = 979) were collected and analyzed for hemoglobin (Hb), serum ferritin (SF), soluble transferrin receptor (sTfR), C-reactive protein (CRP), and alpha-1 acid glycoprotein (AGP). Anemia and severe anemia were defined as Hb < 12.0 and < 8.0 g/dL. Serum ferritin was adjusted for inflammation using BRINDA methods. Iron deficiency was defined as SF <15.0 μg/L, iron insufficiency was defined as SF < 20.0 and < 25.0 μg/L, and iron deficiency anemia was defined as Hb < 12.0 g/dL and SF < 15.0 μg/L. Inflammation was defined as CRP > 5.0 mg/L or AGP > 1.0 g/L. Restricted cubic spline regression models were also used to determine if alternative SF thresholds should be used t to classify iron deficiency.

RESULTS

A total of 41.5% of WRA had anemia, and 3.0% had severe anemia. Findings from spline analyses suggested a SF cut-off of < 15.0 μg/L, consistent with conventional cut-offs for iron deficiency. 46.3% of WRA had SF < 15.0 μg/L (BRINDA-adjusted: 61.5%), 55.0% had SF < 20.0 μg/L (72.7%), 61.8% had SF < 25.0 μg/L (81.0%), and 30.0% had IDA (34.5%). 17.3% of WRA had CRP > 5.0 mg/L and 22.2% had AGP > 1.0 g/L. The prevalence of ID (rural vs. urban: 49.1% vs. 34.9%; p = 0.0004), iron insufficiency (57.8% vs. 43.8%; p = 0.0005), and IDA (31.8% vs. 22.4%; p = 0.01) were significantly higher in rural areas, although CRP levels were lower and there were no differences in elevated CRP or AGP.

CONCLUSIONS

The burden of anemia and iron deficiency in this population was substantial, and increased after adjusting for inflammation, suggesting potential to benefit from screening and interventions.

REGISTRATION NUMBER

NCT04048330.

A Natural Low Phytic Acid Finger Millet Accession Significantly Improves Iron Bioavailability in Indian Women

Iron deficiency and anemia are common in low- and middle-income countries. This is due to a poor dietary iron density and low iron absorption resulting from the high inhibitory phytic acid content in cereal and millet-based diets. Here, we report that a naturally occurring low phytic acid finger millet accession (571 mg 100 g⁻¹), stable across three growing seasons with normal iron content (3.6 mg 100 g⁻¹), increases iron absorption by 3-folds in normal Indian women. The accessions differing in grain phytic acid content, GE 2358 (low), and GE1004 (high) were selected from a core collection of 623 accessions. Whole genome re-sequencing of the accessions revealed significant single nucleotide variations segregating them into distinct clades. A non-synonymous mutation in the EcABCC phytic acid transporter gene between high and low accessions could affect gene function and result in phytic acid differences. The highly sensitive dual stable-isotope erythrocyte incorporation method was adopted to assess the fractional iron absorption. The low phytic acid accession resulted in a significantly higher iron absorption compared with the high phytic acid accession (3.7 vs. 1.3%, p < 0.05). The low phytic acid accession could be effective in preventing iron deficiency in regions where finger millet is habitually eaten. With its low water requirement, finger millet leaves low environmental footprints and hence would be an excellent sustainable strategy to mitigate iron deficiency.

Clinical phenotypes of cardiac sarcoidosis by latent class analysis

Background

Sarcoidosis is a systemic granulomatous disease with cardiac involvement reported in 20–27% of patients [1]. Cardiac sarcoidosis (CS) can lead to atrial or ventricular arrhythmias, various conduction system disorders, heart failure or sudden cardiac death, depending on the location of myocardial involvement [2]. Previous studies have investigated the possible types of CS based on the distribution of myocardial involvement on imaging as well as the role of genetic factors [3,4]. However, there are no studies describing the clinical heterogeneity of CS patients.

Purpose

In order to determine if clinical clusters exist in CS, we carried out a latent class analysis (LCA) to explore potential phenotypes in a large sample of CS patients from the National Inpatient Sample (NIS).

Methods

We identified 848 patients with a diagnosis of CS from the NIS in 2016–2018. A LCA was performed based on comorbidities. Utilizing the Bayesian information criterion and Akaike's information criterion we divided our study population into 3 cohorts. We subsequently applied the LCA model for our study population to fit each patient into one of the 3 cohorts. Finally, we compared the clinical outcomes among the 3 groups.

Results

Following LCA, patients in cohort 3 were strongly associated with a cardiometabolic syndrome profile with the highest prevalence of congestive heart failure (CHF, 95.1%), chronic kidney disease (CKD, 69.7%), diabetes mellitus (68.9%), hyperlipidemia (52.5%) and obesity (45.1%). Patients in cohort 2 had an intermediate prevalence of cardiometabolic syndrome with a universal diagnosis of hypertension (100%) but with the lowest number of CHF (32.5%) patients and none with CKD. Finally, patients in cohort 1 had the least comorbidities in comparison to the other groups but there was a higher prevalence of CHF (71.7%). There was no significant difference in mortality among the 3 groups, but acute respiratory failure was the highest in cohort 3. However, ventricular arrhythmias were more prevalent in cohort 1 patients (Table).

Conclusion

We identified 3 different types of CS based on their clinical phenotype. The clinical outcomes varied among the cohorts with ventricular arrhythmias being the most prevalent in patients with the least cardiometabolic comorbidities.

Funding Acknowledgement

Type of funding sources: None.

Impact of supplementation with milk-cereal mix during 6-12 months of age on growth at 12 months: a 3-arm randomized controlled trial in Delhi, India

BACKGROUND

A large proportion of infants in low- and middle-income countries are stunted. These infants are often fed complementary foods that are low-quality, primarily in terms of protein and micronutrients.

OBJECTIVES

We aimed to test 2 milk-cereal mixes supplemented with modest and high amounts of protein during 6-12 mo of age, compared with no supplementation, for their effect on length-for-age z score (LAZ) at 12 mo of age.

METHODS

Eligible infants (6 mo plus ≤29 d) were randomly assigned to either of the 2 interventions (modest- and high-protein) or a no supplement group. The milk-cereal mixes provided ∼125 kcal, 30%-45% energy from fats, and 80%-100% RDA of multiple micronutrients (MMN). The modest-protein group received 2.5 g protein [protein energy ratio (PER): 8%; 0.75 g from milk source] and the high-protein group received 5.6 g protein (PER: 18%, 1.68 g from milk source). One packet was given daily for 180 d. Counseling on continued breastfeeding and optimal infant-care practices was provided to all.

RESULTS

We enrolled 1548 infants (high-protein: n = 512; modest-protein: n = 519; and no supplement: n = 517). Compared with the no supplement group, there was an improvement in LAZ [adjusted mean difference (MD): 0.08; 95% CI: 0.01, 0.15], weight-for-age z score (MD: 0.12; 95% CI: 0.06, 0.19), weight-for-length z score (MD: 0.11; 95% CI: 0.02, 0.19), and midupper arm circumference z score (MD: 0.10; 95% CI: 0.02, 0.18) in the high-protein group at 12 mo of age. No significant differences for these anthropometric indicators were noted between the modest-protein and no supplement groups or between the high- and modest-protein groups.

CONCLUSIONS

Cereal mixes with higher amounts of milk-based protein and MMN may lead to improvement in linear growth and other anthropometric indexes in infants, compared with no supplementation.This trial was registered at ctri.nic.in as CTRI/2018/04/012932.

Vitamin B12 Status and Metabolic Health in Women of Reproductive Age in Southern India

Objectives

To examine the burden of metabolic outcomes and associations of vitamin B12 status with metabolic health in women of reproductive age (WRA), as part of a population-based biomarker survey in Chittoor, India.

Methods

Participants (980 WRA; 15–40y nonpregnant or lactating) were assessed for glycated hemoglobin (HbA1c; nephelometry) and serum vitamin B12 concentrations (chemiluminescence). Anthropometric measurements and systolic (SBP) and diastolic (DBP) blood pressures were collected in triplicate. Bioelectrical impedance analysis was used to evaluate whole body (WF%) and trunk (TF%) fat among women ≤ 18y. We defined elevated HbA1c as ≤ 6.5% and ≤ 5.7-&lt; 6.5%, and hypertension as stage 1 (SBP 130–139 or DBP 80–89 mmHg) and stage 2 (SBP ≤ 140 or DBP ≤ 90 mmHg). Vitamin B12 was natural logarithmically transformed prior to analyses; vitamin B12 deficiency

was defined as &lt; 148 pmol/L. Linear and binomial regression models were used to examine associations of vitamin B12 status with metabolic outcomes.

Results

A total of 23.3% of adult WRA were overweight (body mass index (BMI): 25.0 to &lt; 30.0 kg/m2) and 9.7% had obesity (≤30.0 kg/m2). Waist circumference (WC; ≤88.9 cm) and waist-hip ratio (WHR; ≤0.85) were elevated in 13.4% and 20.1% of adult WRA. One-fourth of WRA had elevated HbA1c (≤6.5%: 5.0%; ≤5.7-&lt; 6.5%: 20.0%), and 18.6% had hypertension (stage 1: 16.4%; stage 2: 2.2%); 48.3% of WRA were vitamin B12 deficient. Higher continuous vitamin B12 concentrations were associated with lower BMI (β [standard error (SE)] -0.65 [0.28]) and WF% (-1.01 [0.50]); lower risk of elevated WC (risk ratio (RR) [95% confidence interval] 0.64 [0.49–0.85]); and higher risk of HbA1c ≤ 5.7% (1.19 [1.00–1.41]). Vitamin B12 deficiency was associated with higher BMI (β [SE] 0.98 [0.34], p = 0.004), WC (1.96 [0.76]), WF% (1.75 [0.59]), and TF% (2.03 [0.73]); and higher risk of having overweight (RR: 1.31 [1.09–1.58]), elevated WC (1.85 [1.32–2.60]), and WHR (1.38 [1.07–1.78]).

Conclusions

The burden of adverse metabolic outcomes was substantial in this population, and vitamin B12 deficiency was associated with central adiposity and overweight. Evaluating the role of vitamin B12 in the development of metabolic outcomes in future studies could inform screening and interventions to improve vitamin B12 status and metabolic health in WRA.

Funding Sources

Centers for Disease Control and Prevention.

Estimating the Serum Folate Concentration Associated With the Red Blood Cell Folate Threshold for Optimal Neural Tube Defects Prevention: A Population Based Biomarker Survey

Objectives

To estimate the serum folate insufficiency threshold (sf-IT) corresponding to the red blood cell (RBC) folate insufficiency threshold for optimal neural tube defect (NTD) prevention.

Methods

Participants were 977 women of reproductive age (WRA; 15–40y; not pregnant or lactating) from a population-based biomarker survey in Southern India. Venous blood samples were collected at enrollment. Plasma, serum, and red blood cells were centrifuged, processed, and stored &lt; -80°C until batch analysis. Total vitamin B12 concentrations were measured via chemiluminescence; RBC and serum folate concentrations were measured using the World Health Organization-recommended microbiological assay. Vitamin B12 deficiency was defined as total vitamin B12 &lt; 148 pmol/L. Folate

insufficiency was defined as RBC folate &lt; 748 nmol/L, the recommended calibrator-adjusted equivalent of the threshold for population optimal NTD prevention. A previously developed Bayesian model and the RBC and serum folate distributions in this population were used to estimate the sf-IT corresponding to the RBC folate insufficiency threshold for optimal NTD prevention, overall and by age, body mass index (BMI) category, HbA1c, anemia, and vitamin B12 status.

Results

The overall estimated median sf-IT was 37.8 nmol/L (95% credible interval [33.8–43.3]). This threshold was lower in overweight WRA (BMI: ≥25.0 kg/m2: 32.0 nmol/L [27.3–40.2] vs. BMI &lt; 25.0 kg/m2: 36.2 nmol/L [32.2–43.3]), and varied by age (&lt; 25y: 61.3 nmol/L [44.3–111.8]; 25 to 35y: 35.7 nmol/L [30.8–43.5]; ≥35y: 30.8 nmol/L [26.9–37.2]). The sf-IT was lower in anemic WRA (32.9 nmol/L [28.5–40.1]) compared to non-anemic WRA (42.0 nmol/L [36.1–51.3]), and lower in WRA with elevated HbA1c (≥5.7% to &lt; 6.5: 32.4 nmol/L [27.3–41.6]; ≥6.5%: 20.9 nmol/L [17.8–25.6]) vs. WRA with HbA1c &lt; 5.7% (43.8 nmol/L, [37.5–53.7]). The median sf-IT was higher in WRA with vitamin B12 deficiency (72.1 nmol/L [52.0–126.0]), compared to women who were not vitamin B12 deficient (28.1 nmol/L [25.6–31.5]).

Conclusions

The estimated sf-IT is dependent on anemia, elevated HbA1c, BMI, age, and vitamin B12 status.

Funding Sources

Centers for Disease Control and Prevention; AF was supported by the National Institutes of Health #5 T32 HD087137.

Anemia and Vitamin B-12 and Folate Status in Women of Reproductive Age in Southern India: Estimating Population-Based Risk of Neural Tube Defects

BACKGROUND

Women of reproductive age (WRA) are a high-risk population for anemia and micronutrient deficiencies. However, there are few representative population-level data from India, which could help inform evidence-based recommendations and policy.

OBJECTIVE

To conduct a population-based biomarker survey of anemia and vitamin B-12 and folate status in WRA as part of a periconceptional surveillance program in southern India.

METHODS

Participants were WRA (15-40 y) who were not pregnant or lactating. Whole blood (n = 979) was analyzed for hemoglobin via a Coulter counter (Coulter HMX). Plasma, serum, and RBCs were processed and stored at -80°C or less until batch analysis. Vitamin B-12 concentrations were measured via chemiluminescence; RBC and serum folate concentrations were evaluated via microbiological assay. Anemia and severe anemia were defined as hemoglobin <12.0 g/dL and <8.0 g/dL, respectively. Vitamin B-12 deficiency and insufficiency were defined as total vitamin B-12 <148 pmol/L and <221 pmol/L, respectively. Folate deficiency and insufficiency were defined as RBC folate <305 nmol/L and <748 nmol/L. A previously developed Bayesian model was used to predict neural tube defect (NTD) prevalence per 10,000 births.

RESULTS

A total of 41.5% of WRA had anemia and 3.0% had severe anemia. A total of 48.3% of WRA had vitamin B-12 deficiency and 74.3% had vitamin B-12 insufficiency. The prevalence of RBC folate deficiency was 7.6%, and 79.3% of WRA had RBC folate <748 nmol/L, the threshold for optimal NTD prevention. Predicted NTD prevalence per 10,000 births based on RBC folate concentrations was 20.6 (95% uncertainty interval: 16.5-25.5).

CONCLUSIONS

The substantial burden of anemia, vitamin B-12 deficiency, and RBC folate insufficiency in WRA in this setting suggests an opportunity for anemia and birth defects prevention. Findings will directly inform the development of a randomized trial for anemia and birth defects prevention in southern India.This study was registered at clinicaltrials.gov as NCT04048330.

Impact of nutritional interventions among lactating mothers on the growth of their infants in the first 6 months of life: a randomized controlled trial in Delhi, India

BACKGROUND

In lower-middle-income settings, growth faltering in the first 6 mo of life occurs despite exclusive breastfeeding.

OBJECTIVE

The aim was to test the efficacy of an approach to improve the dietary adequacy of mothers during lactation and thus improve the growth of their infants.

METHODS

Eligible mother-infant dyads (infants ≤7 d of age) were randomly assigned to either intervention or control groups. Mothers in the intervention group received snacks that were to be consumed daily, which provided 600 kcal of energy-with 25-30% of energy derived from fats (150-180 kcal) and 13% of energy from protein (80 kcal). Micronutrients were supplemented as daily tablets. We provided counseling on breastfeeding and infant-care practices to mothers in both groups. The primary outcome was attained infant length-for-age z scores (LAZ) at 6 mo of age. Secondary outcomes included exclusive breastfeeding proportion reported by the mother, maternal BMI and midupper arm circumference (MUAC), hemoglobin concentrations in mothers and infants, and the proportion of anemic infants at 6 mo of age.

RESULTS

We enrolled 816 mother-infant dyads. The intervention did not achieve a significant effect on LAZ at 6 mo (adjusted mean difference: 0.09; 95% CI: -0.03, 0.20). Exclusive breastfeeding at 5 mo was higher (45.1% vs. 34.5%; RR: 1.31; 95% CI: 1.04, 1.64) in the intervention group compared with the controls. There were no significant effects on mean hemoglobin concentration or the proportion of anemic infants at 6 mo of age compared with the control group. We noted significant effects on maternal nutritional status (BMI, MUAC, hemoglobin concentration, and proportion anemic).

CONCLUSIONS

Postnatal supplementation of 600 kcal energy, 20 g protein, and multiple micronutrients daily to lactating mothers did not affect infant LAZ at age 6 mo. Such supplementation may improve maternal nutritional status. This trial was registered at Clinical Trials Registry-India as CTRI/2018/04/013095.

Periconceptional surveillance for prevention of anaemia and birth defects in Southern India: protocol for a biomarker survey in women of reproductive age

INTRODUCTION

Women of reproductive age (WRA) are a high-risk population for anaemia and micronutrient deficiencies. Evidence supports the role of periconceptional nutrition in the development of adverse pregnancy complications. However, in India, there are limited population-based data to guide evidence-based recommendations and priority setting. The objective of this study is to conduct a population-based biomarker survey of anaemia and vitamin B₁₂ and folate status in WRA as part of a periconceptional surveillance programme in Southern India.

METHODS

WRA (15-40 years) who are not pregnant or lactating and reside within 50 km² of our community research site in Southern India will be screened and invited to participate in the biomarker survey at our research facility at Arogyavaram Medical Centre. After informed consent/assent, structured interviews will be conducted by trained nurse enumerators to collect sociodemographic, dietary, anthropometry, health and reproductive history data. Venous blood samples will be collected at enrolment; whole blood will be analysed for haemoglobin. Plasma, serum and red blood cells (RBCs) will be processed and stored <-80°C until batch analysis. Vitamin B₁₂ concentrations will be measured via chemiluminescence, and RBC and serum folate concentrations will be evaluated using the World Health Organisation (WHO)-recommended microbiological assay at our laboratory in Bangalore. A WHO surveillance system will also be established to determine the baseline prevalence of birth defects in this setting.

ETHICS AND DISSEMINATION

This study has obtained clearance from the Health Ministry Screening Committee of the Indian Council of Medical Research. The study protocol was reviewed and approved by the Institutional Review Board at Cornell University and the Institutional Ethics Committees at Arogyavaram Medical Centre and St. John's Research Institute. Findings from this biomarker survey will establish the burden of anaemia and micronutrient deficiencies in WRA and directly inform a randomised trial for anaemia and birth defects prevention in Southern India. The results of this study will be disseminated at international research conferences and as published articles in peer-reviewed journals.

TRIAL REGISTRATION NUMBERS

Clinical trials registration number NCT04048330, NCT03853304 and Clinical Trials Registry of India (CTRI) registration number REF/2019/03/024479.

Postpartum atypical hemolytic uremic syndrome: Evaluating thrombotic microangiopathy in the pregnant woman

Acute kidney injury in women during pregnancy and the puerperium is often ascribed to hypertensive complications of pregnancy, especially pre-eclampsia. However, rarer causes, including atypical hemolytic uremic syndrome (aHUS) can be triggered by pregnancy. We present a case of a woman with post-partum acute kidney injury due to aHUS, which was successfully treated with the C5a inhibitor eculizumab. We also present a summary of the evaluation and management of thrombotic microangiopathy in pregnancy.

Fractional iron absorption from enteric-coated ferrous sulphate tablet

Background & objectives:

Iron supplementation is widely used public health measure to manage iron deficiency anaemia. In India, enteric-coated iron tablets are administered to adolescent boys and girls to avoid adverse effects such as gastritis, which reduces compliance, but this may result in poor iron absorption. Data on the absorption of iron from enteric-coated ferrous sulphate tablets are lacking. The present study using stable isotopic approach was aimed to measure iron absorption in iron deficient women.

Methods:

Iron absorption was measured from stable isotope-labelled enteric-coated ferrous sulphate (⁵⁷Fe, ECFS) and uncoated ferrous sulphate (⁵⁸Fe, UCFS) tablets in iron-deficient (n=9) women, aged 18-40 yr with no infection or inflammation. The two types of tablets (ECFS and UCFS) were administered on consecutive days, 60 min after breakfast, and the sequence being random. Blood samples were collected before dosing, and on day 15, to measure iron absorption from the shift in iron isotopic ratios in haemoglobin.

Results:

Eight women completed the iron absorption study. Iron absorption was found to be significantly lower in ECFS compared to UCFS (3.5 vs. 12%, P<0.05) consumption.

Interpretation & conclusions:

Our study showed poor iron bioavailability from ECFS, and supplementation programmes may consider UCFS tablets for better haematological outcomes.

Effect of ascorbic acid rich, micro-nutrient fortified supplement on the iron bioavailability of ferric pyrophosphate from a milk based beverage in Indian school children

BACKGROUND AND OBJECTIVES

Nutritional anemia is a significant public health issue with 50-80% prevalence in Indian children. Fortification of food, specifically milk, with iron is a potential approach to increase dietary iron intake. Ferric pyrophosphate [Fe4(P2O7)3] is organoleptically neutral and is less soluble in acid medium and, further, has low bioavailability in milk. However, since ascorbic acid is a potent enhancer of iron absorption, the coadministration of ascorbic acid with Fe4(P2O7)3 might enhance the absorption of iron. We evaluated the effect of ascorbic acid on iron absorption from a Fe4(P2O7)3 and an ascorbic acid fortified milk beverage with respect to milk fortified with Fe4(P2O7)3 alone.

METHODS AND STUDY DESIGN

A double-blind, two-way crossover, randomized study was conducted in 25 mildly anemic children. The test group received milk fortified with beverage powder containing 7 mg isotopically labeled iron (57Fe/58Fe) as Fe4(P2O7)3, equimolar proportions of ascorbic acid and 200 mg of calcium whereas control group received milk fortified with energy, calcium and iron equivalent beverage powder. Fractional iron absorption was measured by erythrocyte incorporation of stable isotopes of iron (57Fe/58Fe) in both the groups.

RESULTS

The fractional iron absorption from the control drink was 0.80% (95% CI: 0.57, 1.12). Fortifying the milk with an equimolar amount of ascorbic acid increased the fractional iron absorption almost 2-fold to 1.58% (95% CI: 1.13, 2.22).

CONCLUSIONS

The presence of ascorbic acid in an equimolar ratio with that of iron from Fe4(P2O7)3 salt in milk as a fortificant enhanced iron absorption when compared to milk fortified with only Fe4(P2O7)3.

Point of Care Haemoglobin Estimation

The prevalence of anemia in India is still unacceptably high at 53.1 % in non-pregnant women, 50.3% in pregnant women, 58.4% in children 6 months and 22.7% in adult men(1) and remains a major public health problem. For screening, tracking as well as monitoring the progress of anemia in both in primary and community health care for public health programs, hemoglobin needs to be estimated accurately.

Adsorption Induced Changes of Human Hemoglobin on Ferric Pyrophosphate Nanoparticle Surface Probed by Isotope Exchange Mass Spectrometry: An Implication on Structure-Function Correlation

In general, proteins in the biological system interact with nanoparticles (NPs) via adsorption on the particle surface. Understanding the adsorption at the molecular level is crucial to explore NP-protein interactions. The increasing concerns about the risk to human health on NP exposure have been explored through the discovery of a handful protein biomarkers and biochemical analysis. However, detailed information on structural perturbation and associated functional changes of proteins on interaction with NPs is limited. Erythrocytes (red blood cells) are devoid of defense mechanism of protecting NP penetration through endocytosis. Therefore, it is important to investigate the interaction of erythrocyte proteins with NPs. Hemoglobin, the most abundant protein of human erythrocyte, is a tetrameric molecule consisting of α- and β-globin chains in duplicate. In the present study, we have used hemoglobin as a model system to investigate NP-protein interaction with ferric pyrophosphate NPs [NP-Fe₄(P₂O₇)₃]. We report the formation of a bioconjugate of hemoglobin upon adsorption to NP-Fe₄(P₂O₇)₃ surface. Analysis of the bioconjugate indicated that Fe³⁺ ion of NP-Fe₄(P₂O₇)₃ contributed in the bioconjugate formation. Using hydrogen/deuterium exchange based mass spectrometry, it was observed that the amino termini of α- and β-globin chains of hemoglobin were involved in the adsorption on NP surface whereas the carboxy termini of both chains became more flexible in its conformation compared to the respective regions of the normal hemoglobin. Circular dichroism spectra of desorbed hemoglobin indicated an adsorption induced localized structural change in the protein molecule. The formation of bioconjugate led to functional alteration of hemoglobin, as probed by oxygen binding assay. Thus, we hypothesize that the large amount of energy released upon adsorption of hemoglobin to NP surface might be the fundamental cause of structural perturbation of human hemoglobin and subsequent formation of the bioconjugate with an altered function.

Solid pseudopapillary tumour of pancreas

Solid pseudopapillary tumour of pancreas (SPT) is an extremely rare pancreatic tumour, which has a low malignant potential and occurs mainly in young women. Pathologic and imaging findings include a well defined encapsulated pancreatic mass with cystic and solid components with evidence of haemorrhage. This is a case of a 16 years old girl who presented with upper abdominal pain of long duration and epigastric mass on palpation. Computed Tomography (CT) scan demonstrated a large well defined heterogenous attenuation mass of solid enhancing and cystic non enhancing areas, arising from the head of the pancreas. Radiologically it was diagnosed as a case of pancreatic neoplasm. Fine needle aspiration cytology (FNAC) and histopathology of the biopsy material diagnosed as solid pseudopapillary tumour of pancreas.

Light induced toxicity of merocyanine 540-silica nanoparticle complex

The electrostatic binding between the negatively charged lipophilic dye Merocyanine 540 and silica nanoparticles having 3-amino propyl groups at the surface has been characterized using absorption and fluorescence spectroscopy. The binding of the dye with the nanoparticle resulted in significant changes in its absorption spectra. Further the fluorescence intensity and lifetime gets enhanced by more than an order of magnitude. The results obtained suggest that this is due to the reduced photoisomerization rate of the dye bound to the nanoparticle. Consistent with the expectation that a reduction in the photoisomerization rate should enhance the singlet oxygen yield of the dye via intersystem crossing, the light induced toxicity of the dye-nanoparticle complex (tested with MCF cells) was observed to be higher compared to the free dye.

SilkSatDb: a microsatellite database of the silkworm, Bombyx mori

The SilkSatDb (silkmoth microsatellite database) (http://www.cdfd.org.in/silksatdb) is a relational database of microsatellites extracted from the available expressed sequence tags and whole genome shotgun sequences of the silkmoth, Bombyx mori. The database has been rendered with a simple and robust web-based search facility, developed using PHP. The SilkSatDb also stores information on primers developed and validated in the laboratory. Users can retrieve information on the microsatellite and the protocols used, along with informative figures and polymorphism status of those microsatellites. In addition, the interface is coupled with Autoprimer, a primer-designing program, using which users can design primers for the loci of interest.

Clipping of cerebral aneurysm under hypothermic cardiac arrest and simultaneous coronary artery bypass grafting: case report

This report describes a case where joint neurological and cardiac surgery teams cooperated to perform simultaneous procedures of clipping a complex internal carotid artery under hypothermic cardiac arrest and coronary artery bypass grafting. A 69 year old man was evaluated for complaints of double vision, pain behind his right eye, and progressively worsening headaches. Examination showed bilateral upgoing toes and difficulty performing a tandem gait. The patient had a history of myocardial infarction. Brain MRI showed a 1.6 cm diameter, partially thrombosed aneurysm of the right internal carotid artery and posterior communicating artery. Cardiac catheterisation showed critical coronary artery disease of the distal segment of the right coronary artery with 90% stenosis of the midcircumflex artery and an ejection fraction of 40%. After initial exposure of the aneurysm, the cardiac team instituted hypothermic cardiac arrest (21 degree C). The aneurysmal sac was collapsed and dissected from the surrounding perforators. An encircling fenestrated clip was applied and a small part of the neck of the aneurysm was further clipped with straight clips. The cardiac surgery team performed the coronary artery bypass grafting procedure. The patient recovered fully, returned to his normal activities, and is functioning independently.

Induction of phr gene expression in E. coli strain KY706/pPL-1 by He-Ne laser (632.8 nm) irradiation

We have observed that He-Ne laser irradiation of E. coli strain KY706/pPL-1 leads to induction of photolyase gene, phr. The magnitude of induction was found to depend on the He-Ne laser fluence, fluence rate and post-irradiation incubation period in the nutrient medium. The optimum values for fluence and fluence rate were 7x10(3) J/m(2) and 100 W/m(2), respectively, and the induction of phr gene was observed to saturate beyond an incubation period of approximately 2 h. Experiments carried out with singlet oxygen quenchers and with D(2)O suggest that the effect is mediated via singlet oxygen. Photoreactivation studies carried out after UVC exposure of both the He-Ne laser-exposed as well as unexposed cells showed a larger surviving fraction in the He-Ne laser pre-irradiated cells. This can be attributed to He-Ne laser irradiation-induced induction of phr expression. However, since even without photoreactivating light He-Ne laser pre-irradiated cells show higher survival against UVC radiation it appears that He-Ne laser irradiation induces both light-dependent as well as dark DNA repair processes.

Absorption and accumulation of nitrate in plants: influence of environmental factors

Plants adopt various strategies to fulfill their nitrogen nutrition requirement, the most important being the uptake of nitrate from the soil and its subsequent assimilation in to amino acids. The uptake of nitrate is energy dependent and is an active process involving high affinity and low affinity transport systems. The net uptake of the anion depends upon both influx as well as on its passive efflux. When the uptake far exceeds over its assimilation in the plant, there is considerable accumulation of nitrate in the plant parts making them unfit for human and cattle consumption. Various environmental factors affect the uptake and accumulation of nitrate, which along with the genetic component of the plant affecting the net uptake and accumulation of the nitrate, need to be considered and carefully manipulated for effective nitrogen management in the plant, soil and aquatic environment.

Anterior cervical instrumentation enhances fusion rates in multilevel reconstruction in smokers

This retrospective consecutive case study evaluated the effect of anterior plating on multilevel anterior cervical decompressions and fusions in smokers and non-smokers. Multilevel anterior cervical decompression and fusion surgery in smokers provides an important challenge. Higher nonfusion rates in smokers have been reported. Cigarette smoking has been shown to interfere with bone metabolism and revascularization and to suppress bone formation. One hundred six patients underwent anterior cervical decompression and fusion using autografts or allografts and anterior plating. The minimum follow-up was 12 months. The mean age was 50.12 years (+/- 11.72; range, 27 to 80 years). Autografts were used in 90 patients and allograft in 16. The mean level fused was 2.74 (+/- 0.61). Forty-six (45.5%) patients were smokers. Successful fusion was achieved in all but three patients (97.17%). C5 root weakness was seen in four patients (3.8%); two patients experienced acute airway obstruction, of which one required tracheotomy. Temporary recurrent laryngeal nerve palsy developed in three (2.8%) patients. A fusion rate of 97% was achieved in multilevel anterior cervical decompression and fusions using anterior plating. No difference in fusion rates between smokers and nonsmokers was seen. Anterior cervical plating markedly improved the fusion rate in smokers.

Outcomes after posterolateral lumbar fusion with instrumentation in patients treated with adjunctive pulsed electromagnetic field stimulation

Fusion success and clinical outcome were determined in 48 high-risk patients who underwent posterolateral lumbar fusions with internal fixation and were treated with adjunctive pulsed electromagnetic field (PEMF) stimulation postoperatively. An independent radiographic assessment demonstrated a success rate of 97.9%. Following treatment, 59% of the working patients returned to their employment. Overall clinical assessment was excellent in 4.2% of patients, good in 79.2%, and fair in 16.7%; no patient had a poor clinical assessment.

N2 laser-induced oxidation of hemoproteins in red blood cell lysate

Irradiation of red blood cell lysate with a N(2) laser (337 nm) was observed to induce oxidation of hemoproteins. This process showed a strong dependence on the concentration of red blood cell lysate and the dose of radiation. Studies of mechanisms and experiments with deoxygenated red blood cell lysate rule out involvement of any reactive oxygen species and suggest that the process is not a photodynamic reaction.

Activation of expression of the c-fos oncogene by UVA irradiation in cultured human skin fibroblasts

Both broad-spectrum and near-monochromatic (334 nm, 365 nm and 405 nm) UVA (320-380 nm) and near-visible radiations strongly activate accumulation of mRNA corresponding to the nuclear oncogene and transcription factor, c-fos, in cultured human skin fibroblasts within a dose-range encountered in the environment. The oxidizing component of UVA is clearly of central importance to the activation observed because the absence of reduced glutathione strongly enhances the response. In contrast to observations in rodent cells, we observe negligible activation of the gene in human cells after UVB (290-320 nm) radiation. The results of this study provide evidence that UVA radiation strongly activates c-fos gene expression in human dermal fibroblasts, a phenomena that is likely to be reflected in UVA-mediated modulation of genes containing active AP-1-based enhancer elements in the promoter region.

An overview of cerebral aneurysms. Which factors affect the outcome of microsurgical treatment

There is a higher incidence of subarachnoid hemorrhage (SAH) with advancing age. Considerable controversy exists as to whether aggressive therapy is indicated in the elderly. With increased life expectancy, a greater number of elderly patients with SAH will require treatment in the future. This study was undertaken to evaluate the effect of age, aneurysm characteristics, Hunt-Hess grade on admission, race, and smoking status to the eventual outcome. The results of 76 consecutive aneurysms clipped in 67 patients by a single surgeon (B.B.) were analyzed. Among the variables, Hunt-Hess grade at admission seemed to be the only significant factor influencing the outcome in this series (X2MH = 17.136, p < 0.001). Advancing age did not worsen the prognosis after SAH and therefore age should not be a contraindication for aggressive management.

Catalytic mechanism and specificity for hydrolysis and transglycosylation reactions of cytosolic beta-glucosidase from guinea pig liver

Cytosolic beta-glucosidase (CBG) from mammalian liver is known for its broad substrate specificity and has been implicated in the transformation of xenobiotic glycosides. CBG also catalyzes a variety of transglycosylation reactions, which have been been shown with other glycosylhydrolases to function in synthetic and genetic regulatory pathways. We investigated the catalytic mechanism, substrate specificity, and transglycosylation acceptor specificity of guinea pig liver CBG by several methods. These studies indicate that CBG employs a two-step catalytic mechanism with the formation of a covalent enzyme-sugar intermediate and that CBG will transfer sugar residues to primary hydroxyls and equatorial but not axial C-4 hydroxyls of aldopyranosyl sugars. Kinetic studies revealed that correction for transglycosylation reactions is necessary to derive correct kinetic parameters for CBG. Further analyses revealed that for aldopyranosyl substrates, the activation energy barrier is affected most by the presence of a C-6 carbon and by the configuration of the C-2 hydroxyl, whereas the binding energy is affected modestly by the configuration and substituents at C-2, C-4, and C-5. These data indicate that the transglycosylation activity of CBG derives from the formation of a covalently linked enzyme-sugar intermediate and that the specificity of CBG for transglycosylation reactions is different from its specificity for hydrolysis reactions.

Anterior cervical fusion using Caspar plating: analysis of results and review of the literature

BACKGROUND

Ninety-seven patients underwent anterior cervical fusions after discectomy and/or corpectomy. Fibular allograft was used in 13 cases and iliac crest was used in the remaining 84 patients.

METHODS

Lateral cervical spine X-rays were reviewed for evaluation of fusion and instrumentation failures.

RESULTS

Solid fusion was achieved in all but two patients (97.91%). Nineteen patients developed instrumentation related failures. Seven patients developed fracture of one screw each (one superior and six inferior). Ten patients developed screw back out (inferior screw) and in one patient the superior screws were found to be 2 mm posterior to the posterior cortex but did not cause any neurological deficits. Seven of these patients underwent revision surgery. No complications related to the instrumentation were encountered in the last 34 cases. There were no infections in this series. Five patients developed temporary dysphagia. Two developed temporary deltoid weakness and three patients developed transient recurrent laryngeal nerve palsy. One developed acute airway obstruction but the patient had a pre-existing epiglottic anomaly and sleep apnea disorder.

CONCLUSIONS

In selected cases, the Caspar plating system affords an effective means of improving the fusion rate (97.91%) with acceptable instrumentation-related morbidity that improves with experience, (10.7% in the first 38 cases and 1.69% in the last 59 with an overall rate of 7.2%). Temporary neurological deficits seen in this series were probably not related to the Caspar plating procedure itself. Intraoperative fluoroscopic films can be misleading. Therefore regular lateral cervical spine X-rays postplating in the operating room prior to closure are recommended. Lower screws backed out in all failures and this was circumvented by using the bigger (rescue) screws at the inferior end of long constructs.

Correlation between UVA-induced changes in microviscosity, permeability and malondialdehyde formation in liposomal membrane

The lipid peroxidation, 14C-glucose leakage and microviscosity of liposomal membrane increased linearly with increasing UVA fluence. A positive and highly significant correlation was found between these properties of the UVA-exposed liposomal membrane. The possible involvement of singlet oxygen in the UVA-induced damage of liposomal membrane is discussed.

On the induction of protective responses in Salmonella typhimurium strain TA1535/pSK1002 by UVA (365 nm)

Exposure to UVA (365 nm) led to growth delay, loss of viability and inhibition of 3H-thymidine incorporation into the cells of Salmonella typhimurium strain TA1535 containing multiple copies of a plasmid pSK1002 carrying a umuC'-'lacZ fusion gene. Ultraviolet-A induced umu gene expression, as monitored by the estimation of beta-galactosidase, in a linear fluence-dependent manner. The induction of umu gene expression increased with the increase of postirradiation incubation period of the cells in the LB-ampicillin (LBA) medium at 37 degrees C and leveled off from 2 h onward. The induction of gene expression depended on concomitant protein synthesis and represented the induction of the SOS response in the particular S. typhimurium cells used. The exposure to low fluences (sublethal) of UVA also led to the induction of an adaptive response in the same bacterial cells, which made them resistant to subsequent challenge by a much higher fluence of the same radiation. The adaptive response, as monitored by the assays of viability and beta-galactosidase units, increased with the period of exposure to sublethal fluences of UVA, attained a maximum at the UVA exposure of 4.5 kJ/m2 (15 min) and thereafter gradually decreased with further increase of UVA exposure period. Modulation studies involving D2O, LBA growth medium, different scavengers of free radicals and quenchers of activated oxygen species indicated the involvement of both hydroxyl free radicals and singlet oxygen in the UVA-induced umu gene expression.

UVA-induced peroxidation of lipid in the dried film state

Exposure of a dried lipid thin film to UVA produced a dose-dependent linear increase in the three peroxidation products, conjugated diene, lipid hydroperoxide and malondialdehyde (MDA). All three lipid peroxidation products exhibited an inverse dose rate effect. Identical amounts of malondialdehyde were produced when the lipid film was exposed to UVA either directly or through the thickness of the Corning glass on which the film was cast. Antioxidants, alpha-tocopherol, butylated hydroxytoluene (BHT) and the singlet oxygen quencher beta-carotene significantly inhibited the UVA-induced peroxidation of the lipid film. The biological implications of the UVA-induced peroxidation of the dried lipid film are discussed.

Effect of UV-A on the linolenic acid micelles

UV-A produced a dose-dependent linear increase of peroxidation in linolenic acid micelles as detected by the assay of (i) conjugated dienes, (ii) hydroperoxides, (iii) malondialdehyde (MDA), and (iv) the fluorescent adduct formed by the reaction of MDA with the amino acid, glycine. While sodium formate, dimethyl sulfoxide, superoxide dismutase, and ethylenediamine-tetraacetic acid produced no significant inhibition, some generally used singlet oxygen quenchers, beta-carotene, dimethylfuran, L-histidine, and sodium azide, caused significant inhibition of the UV-A-induced peroxidation of the linolenic acid micelles. alpha-Tocopherol and butylated hydroxytoluene produced more than 90% inhibition of the UV-A-induced peroxidation. ESR spectrometry revealed the formation of 2,2,6,6-tetramethylpiperidine oxide in the UV-A-irradiated aqueous solution of 2,2,6,6-tetramethylpiperidine. The involvement of singlet oxygen (1O2) in the UV-A-induced peroxidation of linolenic acid micelles is discussed.

An audit of preschool vision screening

An audit was carried out to clarify the dispute surrounding the vision screening test at 3.5 years. The uptake was 53.5%, sensitivity 77%, specificity 96%, and positive predictive value 50%. In particular the uptake was poor and the test needed a clear policy for the future.

Membrane lipid peroxidation by UV-A: mechanism and implications

UV-A produced a dose-dependent linear increase of lipid peroxidation in liposomal membrane, as detected by the assay of (i) conjugated dienes, (ii) lipid hydroperoxides, (iii) malondialdehydes (MDA), and (iv) the fluorescent adducts formed by the reaction of MDA with glycine and also a linear dose-dependent increase of [14C]glucose efflux from the liposomes. UV-A-induced MDA production could not be inhibited by any significant degree by sodium formate, dimethyl sulfoxide, EDTA, or superoxide dismutase but was very significantly inhibited by butylated hydroxytoluene, alpha-tocopherol, sodium azide, L-histidine, dimethylfuran, and beta-carotene. MDA formation increased with an increase in the D2O content in water, leading to a maximal amount of nearly 50% enhancement of lipid peroxidation in 100% D2O vis-à-vis water used as dispersion medium. The experimental findings indicate the involvement of singlet oxygen as the initiator of the UV-A-induced lipid peroxidation.

An approach towards understanding the genesis of sunlight-induced skin cancer

The molecular basis of the sunlight-induced skin carcinogenesis has been elucidated. Of the two ultraviolet components of sunlight that reach the earth's surface the UV-B is known to be carcinogenic but the mode of action of UV-A, the predominant component of sunlight, is ill understood. Using the liposomes as a model system, it has been shown here that UV-A causes dose-dependent lipid peroxidation as estimated by measurements of conjugated dienes, lipid hydroperoxides, malondialdehydes and the fluorescent adducts (Schiff bases) produced by the reaction of MDA with glycine. Direct exposure to sunlight has also been shown to cause dose-dependent lipid peroxidation. The UV-A induced lipid peroxidation has also been shown to be dependent on dose rate. While the sodium formate, dimethyl sulphoxide, superoxide dismutase and EDTA do not have any significant effect, sodium azide, histidine, beta-carotene and dimethylfuran were shown to inhibit significantly the UV-A induced lipid peroxidation, thereby providing significant evidence of the involvement of singlet oxygen (1O2) as the initiating agent. The use of D2O in place of H2O as the liposome dispersing medium enhanced to great extent the UV-A induced lipid peroxidation, thereby lending additional support to the finding that singlet oxygen was the initiating agent. The possible mode of formation of 1O2 on exposure to UV-A was discussed. This study also highlighted the role of environmental factors on the sunlight-induced cutaneous damage. Finally, the relation between lipid peroxidation, DNA damage and carcinogenesis has been discussed in a way to suggest the possible link between sunlight exposure and causation of skin cancer.