Treatment Heterogeneity of Water, Sanitation, Hygiene, and Nutrition Interventions on Child Growth by Environmental Enteric Dysfunction and Pathogen Status for Young Children in Bangladesh

Background

Water, sanitation, hygiene (WSH), nutrition (N), and combined (N+WSH) interventions are often implemented by global health organizations, but WSH interventions may insufficiently reduce pathogen exposure, and nutrition interventions may be modified by environmental enteric dysfunction (EED), a condition of increased intestinal permeability and inflammation. This study investigated the heterogeneity of these treatments' effects based on individual pathogen and EED biomarker status with respect to child linear growth.

Methods

We applied cross-validated targeted maximum likelihood estimation and super learner ensemble machine learning to assess the conditional treatment effects in subgroups defined by biomarker and pathogen status. We analyzed treatment (N+WSH, WSH, N, or control) randomly assigned in-utero, child pathogen and EED data at 14 months of age, and child LAZ at 28 months of age. We estimated the difference in mean child length for age Z-score (LAZ) under the treatment rule and the difference in stratified treatment effect (treatment effect difference) comparing children with high versus low pathogen/biomarker status while controlling for baseline covariates.

Results

We analyzed data from 1,522 children, who had median LAZ of -1.56. We found that myeloperoxidase (N+WSH treatment effect difference 0.0007 LAZ, WSH treatment effect difference 0.1032 LAZ, N treatment effect difference 0.0037 LAZ) and Campylobacter infection (N+WSH treatment effect difference 0.0011 LAZ, WSH difference 0.0119 LAZ, N difference 0.0255 LAZ) were associated with greater effect of all interventions on growth. In other words, children with high myeloperoxidase or Campylobacter infection experienced a greater impact of the interventions on growth. We found that a treatment rule that assigned the N+WSH (LAZ difference 0.23, 95% CI (0.05, 0.41)) and WSH (LAZ difference 0.17, 95% CI (0.04, 0.30)) interventions based on EED biomarkers and pathogens increased predicted child growth compared to the randomly allocated intervention.

Conclusions

These findings indicate that EED biomarker and pathogen status, particularly Campylobacter and myeloperoxidase (a measure of gut inflammation), may be related to impact of N+WSH, WSH, and N interventions on child linear growth.

Determinants of livelihood diversification in rural rain-fed region of Pakistan: evidence from fractional multinomial logit (FMLOGIT) estimation

Sustainable livelihoods in less developed countries are threatened by human, natural, physical, social and financial factors. Pakistan is also facing severe negative impacts of these factors in the form of climate shocks, market imperfections and insufficient formal credit availability on rural livelihoods. This study explores rural Pakistani's adaptation to these threats by diversifying income sources and explores the determining factors for adopting specific livelihood diversification strategies. The study is based on a quantitative survey of 295 households in three districts of rain-fed rural regions of Pakistan's Punjab with differing annual rainfall. Results showed that households mitigated against threats to their livelihood by having a diversity of income sources (Simpson Diversity Index = 0.61). Moreover, fractional multinomial regression modelling revealed that greater education was associated with a more diversified livelihood strategy, where income was predominantly derived from off-farm and non-farm livelihood activities. On the other hand, households with older members, more livestock and larger farm size focused their livelihoods on their own farms, or primarily diversified into an off-farm strategy by working on other farms. These findings underscore the importance of improved access to education and infrastructure for livelihood diversification. A policy that focuses on reducing low literacy rates in rural Pakistan may also provide new avenues of livelihood diversifications with enhancement of rural literacy rate to mitigate the risks associated with livelihood strategies of smallholders.

Electrochemical Detection of Dihydroxybenzene Isomers at a Pencil Graphite Based Electrode

In this work, an HB pencil electrode (HBPE) was electrochemically modified by amino acids (AAs) glycine (GLY) and aspartic acid (ASA) and designated as GLY-HB and ASA-HB electrodes. They were used in the detection of dihydroxybenzene isomers (DHBIs) such as hydroquinone (HQ), catechol (CC), and resorcinol (RS), by cyclic voltammetry (CV), and by differential pulse voltammetry. HBPE was characterized by scanning electron microscopy and energy-dispersive X-ray spectroscopy. These three electrodes showed a linear relationship of current with concentration of DHBIs, and the electrochemical processes were diffusion controlled in all cases. In simultaneous detection, the limit of detection, based on signal-to-noise ratio (S/N = 3), for HQ, CC, and RS was 12.473, 16.132, and 25.25 μM, respectively, at bare HBPE; 5.498, 7.119, and 14.794 μM, respectively, at GLY-HB; and 22.459, 25.478, and 38.303 μM, respectively, at ASA-HB. The sensitivity for HQ, CC, and RS was 470.481, 363.781, and 232.416 μA/mM/cm², respectively, at bare HBPE; 364.785, 282.712, and 135.560 μA/mM/cm², respectively, at GLY-HB; and 374.483, 330.108, and 219.574, respectively, at ASA-HB. The interference studies clarified the suitability and reliability of the electrodes for the detection of HQ, CC, and RS in an environmental system. Real sample analysis was done using tap water, and the proposed electrodes expressed recovery with high reproducibility. Meanwhile, these three electrodes have excellent sensitivity and selectivity, which can be used as a promising technique for the detection of DHBIs simultaneously.

Management of Neglected Rupture of Tendoachilles with Long Gap by Flexor Hallucis Longus Tendon Transfer

The tendo achilles is one of most important tendon in human body which often injured through direct trauma or indirect stress on a weakened tendon. Longer the duration after injury the injured parts likely to move apart, fibrosis and degeneration leading to difficulty in repair or reconstruction. Usually a phase of 4 weeks or more without specific treatment is regarded as chronic or neglected rupture. Different authors described many management protocols about the tendo achilles rupture but there is no procedure of choice for neglected rupture with long gap. Prospective case series of 21 patients of neglected tendo achilles rupture with long gap treated with flexor hallucis longus tendon (FHLT) transfer was taken for study from January 2019 to December 2020 in Mymensingh Medical College Hospital, Bangladesh. Average age of patients was 39.47 years with range 22-65 years. Fifteen (15) cases of traumatic rupture in this study with average age 32.66 years and pathologic 6 cases with average age 56.5 years were recorded. We grafted FHLT from channel by incising Henry's knot. Krackow et al.'s technique was followed for tendon mobilization and bone fixation. We made procedure simpler and cheaper; instead of using interference screw the sutured tendon pulled through the heel and anchored over rubber tube or button by Cole method. Post-operative complications were less with one patient with superficial infection which eventually recovered 3 cases of mild pain and 2 cases of numbness. Questionnaire for surgical outcome measure are satisfactory in 19 patients (90.47%). Final follow up AOFAS score at 6 month (91.61±5.41) was highly significant (p<0.001) in comparison to preoperative score (38.71±9.78). These are comparable to other study. Above mentioned scores indicate the reliability of the surgical system. But our study is a prospective case series with minimum cases. To establish the best procedure for neglected tendo achilles rupture with long gap we recommend further study with larger group and Randomized Controlled Trial (RCT) study among different procedure.

Clinical Outcome on Comminuted Femoral Shaft Fractures in Adults Treated by Minimally Invasive Plate Osteosynthesis (MIPO) with Locking Plate

Intramedullary nailing is a pillar in the treatment of femoral shaft fractures. But it is not possible in all cases especially in comminuted fractures. This study has been designed to explain the importance of Minimally Invasive Plate Osteosynthesis (MIPO) with the locking plate in the treatment of comminuted Femoral Shaft Fracture. Twenty (20) such patients were treated by MIPO and analysis has been done in this study to get fruitful result and to find out the effectiveness of this procedure who were admitted at Mymensingh Medical College Hospital, Mymensingh, a tertiary level hospital of Bangladesh from February 2018 to January 2019. Mean age of the patients were 49.20±14.41 years. Based on AO classification, there were 4, 8 and 8 patients belong to type A, B and C respectively. The union period for all the patients was in between 12 to 14 weeks. The mean union period was 12.90±1.997 weeks. Mean follow up period was 19.70±2.77 weeks. Mean full weight bearing period was 16.50±1.10 weeks. In Thoresen scoring system excellent result was 9(45%), good result was 10(20%) and fair result was 01(5%). Mal-alignment happened in two cases. However, delayed union and broken screws were found in two cases each of which was treated accordingly. Comminuted Femoral shaft fracture with MIPO procedure is more effective treatment than intramedullary nailing. Furthermore, mal-alignment is the basic complexity that must be taken away intraoperatively.

Bioaccessibility and speciation of arsenic in children's diets and health risk assessment of an endemic area in Bangladesh

This study determines the bioaccessibility of toxic and carcinogenic arsenic (As) in composite food samples and evaluates potential exposure from food intake in Bangladesh children. Total As (tAs), inorganic As (iAs) and bioaccessible As (BAs) in food composite samples consumed by children were compared between an exposed and a control group (based on As in drinking water). Total As concentrations in composite food samples of children exposed to mean As level of 331 µg/l in drinking and cooking water ranged from 586 to 1975 µg/kg, dry weight over 76-90 µg/kg in the unexposed group. Average iAs in food composites was 73.9% (range: 49.3-90.8%). The fraction of BAs using gastric and gastrointestinal phases was 91 ± 13% and 98 ± 11%, respectively. Daily intake of iAs in the exposed group ranged from 0.41 to 6.38 µg per kg body weight (BW), which was much higher than the unexposed group (0.08-0.15 µg per kg BW). High iAs content and BAs in composite food samples indicated the elevated risk to exposed children. Further research should include both adults and children using larger sample size to determine overall As exposure from food intake in Bangladesh, attention must be given to lowering of As in food.

Effects of Water, Sanitation, Handwashing, and Nutritional Interventions on Environmental Enteric Dysfunction in Young Children: A Cluster-randomized, Controlled Trial in Rural Bangladesh

BACKGROUND

We hypothesized that drinking water, sanitation, handwashing (WSH), and nutritional interventions would improve environmental enteric dysfunction (EED), a potential contributor to stunting.

METHODS

Within a subsample of a cluster-randomized, controlled trial in rural Bangladesh, we enrolled pregnant women in 4 arms: control, WSH, child nutrition counseling plus lipid-based nutrient supplements (N), and nutrition plus WSH (N+WSH). Among the birth cohort, we measured biomarkers of gut inflammation (myeloperoxidase, neopterin), permeability (alpha-1-antitrypsin, lactulose, mannitol), and repair (regenerating gene 1β) at median ages 3, 14, and 28 months. Analysis was intention-to-treat.

RESULTS

We assessed 1512 children. At age 3 months, compared to controls, neopterin was reduced by nutrition (-0.21 log nmol/L; 95% confidence interval [CI], -.37, -.05) and N+WSH (-0.20 log nmol/L; 95% CI, -.34, -.06) interventions; similar reductions were observed at 14 months. At 3 months, all interventions reduced lactulose and mannitol (-0.60 to -0.69 log mmol/L). At 28 months, myeloperoxidase was elevated in the WSH and nutrition arms (0.23-0.27 log ng/mL) and lactulose was higher in the WSH arm (0.30 log mmol/L; 95% CI, .07, .53).

CONCLUSIONS

Reductions in permeability and inflammation at ages 3 and 14 months suggest that the interventions promoted healthy intestinal maturation; however, by 28 months, the WSH and nutrition arms showed elevated EED biomarkers. These results underscore the importance of developing a better understanding of EED pathophysiology and targeting interventions early in childhood, when they are likely to have the largest benefit to intestinal health.

CLINICAL TRIALS REGISTRATION

NCT01590095.

Clinical Outcome in Intra Articular Distal Humerus Fractures in Adults Treated with Different Hardware in a Tertiary Level Hospital of Bangladesh

In adults, distal humerus fractures are infrequent and frequently intra-articular. Customarily encompass both medial and lateral columns. Operative management gives constructive outcomes. The aim of this study was to evaluate clinical outcome in intra articular distal humerus fractures in adults treated by different hardware. This prospective study consists of 20 purposively selected patients with intra articular distal humerus fractures treated by surgical intervention with different hardware who were admitted to Mymensingh Medical College and Hospital, Bangladesh in between November 2016 to October 2018. Surgical approaches were standard dorsal with or without olecranon osteotomy. The mean age of the patients was 32.3 years, range between 18-55 years. The maximum patients i.e. 85% were between 18-45 years. Seventy percent (70%) of the cases admitted were due to Road traffic accident (RTA). Most of the patients were males 14(70%) with right upper limb was involved in 13(65%) cases. Mean Mayo Elbow Performance Score was 81.5 post-operatively. According to Mayo Elbow Performance (MEP) score clinical outcome was excellent in 20%, good in 50%, fair in 25% and poor in 10% of patients. Distal humerus fractures are censorious in nature. Proper anatomical articular reconstruction and stable fixation by surgical intervention helps in fruitful results.

Structures of aniline(pyrrole)+, aniline(ethanol)+, and aniline-(benzene). SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2018;204:665-669. [PMID: 29982157 DOI: 10.1016/j.saa.2018.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Molecular structures of aniline(pyrrole)⁺, aniline(ethanol)⁺, and aniline(benzene)⁺ produced via resonance two-photon ionization at 266 nm were analyzed by infrared predissociation spectroscopy coupled with tandem mass spectrometry. Structural optimization and frequency calculation using density functional theory were carried out to suggest the most probable isomers which are in good agreement with the observed infrared absorption spectra. Intermolecular bonds in the cluster ions were formed such that the electronegative oxygen atom of the solvent molecule or the pi electron of the aromatic ring forms a hydrogen bonding to NH of aniline.

Assessment of Nutritional Status of Infants Living in Arsenic-Contaminated Areas in Bangladesh and Its Association with Arsenic Exposure

Data is scarce on early life exposure to arsenic and its association with malnutrition during infancy. This study followed the nutritional status of a cohort of 120 infants from birth to 9 months of age in an arsenic contaminated area in Bangladesh. Anthropometric data was collected at 3, 6 and 9 months of the infant's age for nutritional assessment whereas arsenic exposure level was assessed via tube well drinking water arsenic concentration at the initiation of the study. Weight and height measurements were converted to Z-scores of weight for age (WAZ-underweight), height for age (HAZ-stunting), weight for height (WHZ-wasting) for children by comparing with WHO growth standard. Arsenic exposure levels were categorized as <50 μg/L and ≥50 μg/L. Stunting rates (<-2 SD) were 10% at 3 months and 44% at both 6 and 9 months. Wasting rates (<-2 SD) were 23.3% at 3 months and underweight rates (<-2 SD) were 25% and 10% at 3 and 6 months of age, respectively. There was a significant association of stunting with household drinking water arsenic exposure ≥50 μg/L at age of 9 months (p = 0.009). Except for stunting at 9 months of age, we did not find any significant changes in other nutritional indices over time or with levels of household arsenic exposure in this study. Our study suggests no association between household arsenic exposure and under-nutrition during infancy; with limiting factors being small sample size and short follow-up. Difference in stunting at 9 months by arsenic exposure at ≥50 μg/L might be a statistical incongruity. Further longitudinal studies are warranted to establish any association.

Selenium-mediated arsenic excretion in mammals: a synchrotron-based study of whole-body distribution and tissue-specific chemistry

Arsenicosis, a syndrome caused by ingestion of arsenic contaminated drinking water, currently affects millions of people in South-East Asia and elsewhere. Previous animal studies revealed that the toxicity of arsenite essentially can be abolished if selenium is co-administered as selenite. Although subsequent studies have provided some insight into the biomolecular basis of this striking antagonism, many details of the biochemical pathways that ultimately result in the detoxification and excretion of arsenic using selenium supplements have yet to be thoroughly studied. To this end and in conjunction with the recent Phase III clinical trial "Selenium in the Treatment of Arsenic Toxicity and Cancers", we have applied synchrotron X-ray techniques to elucidate the mechanisms of this arsenic-selenium antagonism at the tissue and organ levels using an animal model. X-ray fluorescence imaging (XFI) of cryo-dried whole-body sections of laboratory hamsters that had been injected with arsenite, selenite, or both chemical species, provided insight into the distribution of both metalloids 30 minutes after treatment. Co-treated animals showed strong co-localization of arsenic and selenium in the liver, gall bladder and small intestine. X-ray absorption spectroscopy (XAS) of freshly frozen organs of co-treated animals revealed the presence in liver tissues of the seleno bis-(S-glutathionyl) arsinium ion, which was rapidly excreted via bile into the intestinal tract. These results firmly support the previously postulated hepatobiliary excretion of the seleno bis-(S-glutathionyl) arsinium ion by providing the first data pertaining to organs of whole animals.

Meeting Needs of Newly-Married Youth: The Bangladesh Case

In Bangladesh more than 1.15 million couples get married every year and approximately 90 percent of female spouses are below nineteen years of age. It is widely reported that newly married couples (those who are married within the last 12 months) were less likely to have been visited by field workers and have had limited access to family planning including reproductive health services. Findings from 1996–97 Demographic and Health Survey (BDHS) suggest that little change has occurred in the age specific fertility rates among the females belonging to age groups fifteen to nineteen and twenty to twenty-four in the last five years [1]. It is also observed that the current contraceptive use rate in age group fifteen to nineteen was 32.9 percent and approximately 10 percent of women in age group fifteen to nineteen do not want any children. The male methods use rate among the newlywed couples was double the national rate. It suggests that males from the younger generation are more likely to practice male contraceptive methods compared to the older generation. Married youths and those soon-to-be-married are critical demographic segments of the population. Achieving early population stabilization depends on how adequately and effectively the national reproductive health program serves them and how other development programs simultaneously compliments to health efforts. Using 1996–97 BDHS data, this article examines fertility and contraceptive behavior of the married youths in Bangladesh.

Groundwater arsenic contamination in Bangladesh-21 Years of research

Department of Public Health Engineering (DPHE), Bangladesh first identified their groundwater arsenic contamination in 1993. But before the international arsenic conference in Dhaka in February 1998, the problem was not widely accepted. Even in the international arsenic conference in West-Bengal, India in February, 1995, representatives of international agencies in Bangladesh and Bangladesh government attended the conference but they denied the groundwater arsenic contamination in Bangladesh. School of Environmental Studies (SOES), Jadavpur University, Kolkata, India first identified arsenic patient in Bangladesh in 1992 and informed WHO, UNICEF of Bangladesh and Govt. of Bangladesh from April 1994 to August 1995. British Geological Survey (BGS) dug hand tube-wells in Bangladesh in 1980s and early 1990s but they did not test the water for arsenic. Again BGS came back to Bangladesh in 1992 to assess the quality of the water of the tube-wells they installed but they still did not test for arsenic when groundwater arsenic contamination and its health effects in West Bengal in Bengal delta was already published in WHO Bulletin in 1988. From December 1996, SOES in collaboration with Dhaka Community Hospital (DCH), Bangladesh started analyzing hand tube-wells for arsenic from all 64 districts in four geomorphologic regions of Bangladesh. So far over 54,000 tube-well water samples had been analyzed by flow injection hydride generation atomic absorption spectrometry (FI-HG-AAS). From SOES water analysis data at present we could assess status of arsenic groundwater contamination in four geo-morphological regions of Bangladesh and location of possible arsenic safe groundwater. SOES and DCH also made some preliminary work with their medical team to identify patients suffering from arsenic related diseases. SOES further analyzed few thousands biological samples (hair, nail, urine and skin scales) and foodstuffs for arsenic to know arsenic body burden and people sub-clinically affected. SOES and DCH made a few follow-up studies in some districts to know their overall situations after 9 to 18 years of their first exposure. The overall conclusion from these follow-up studies is (a) villagers are now more aware about the danger of drinking arsenic contaminated water (b) villagers are currently drinking less arsenic contaminated water (c) many villagers in affected village died of cancer (d) arsenic contaminated water is in use for agricultural irrigation and arsenic exposure from food chain could be future danger. Since at present more information is coming about health effects from low arsenic exposure, Bangladesh Government should immediately focus on their huge surface water management and reduce their permissible limit of arsenic in drinking water.

Intra-residue interactions in proteins: interplay between serine or cysteine side chains and backbone conformations, revealed by laser spectroscopy of isolated model peptides

Intra-residue interactions play an important role in proteins by influencing local folding of the backbone. Taking advantage of the capability of gas phase experiments to provide relevant information on the intrinsic H-bonding pattern of isolated peptide chains, the intra-residue interactions of serine and cysteine residues, i.e., OH/SH···OC(i) C6 and NH(i···)O/S C5 interactions in Ser/Cys residues, are probed by laser spectroscopy of isolated peptides. The strength of these local side chain-main chain interactions, elegantly documented from their IR spectral features for well-defined conformations of the main chain, demonstrates that a subtle competition exists between the two types of intra-residue bond: the C6 H-bond is the major interaction with Ser, in contrast to Cys where C5 interaction takes over. The restricted number of conformers observed in the gas phase experiment with Ser compared to Cys (where both extended and folded forms are observed) also suggests a significant mediation role of these intra-residue interactions on the competition between the several main chain folding patterns.

Availability of arsenic in human milk in women and its correlation with arsenic in urine of breastfed children living in arsenic contaminated areas in Bangladesh

BACKGROUND

Early life exposure to inorganic arsenic may be related to adverse health effects in later life. However, there are few data on postnatal arsenic exposure via human milk. In this study, we aimed to determine arsenic levels in human milk and the correlation between arsenic in human milk and arsenic in mothers and infants urine.

METHODS

Between March 2011 and March 2012, this prospective study identified a total of 120 new mother-baby pairs from Kashiani (subdistrict), Bangladesh. Of these, 30 mothers were randomly selected for human milk samples at 1, 6 and 9 months post-natally; the same mother baby pairs were selected for urine sampling at 1 and 6 months. Twelve urine samples from these 30 mother baby pairs were randomly selected for arsenic speciation.

RESULTS

Arsenic concentration in human milk was low and non-normally distributed. The median arsenic concentration in human milk at all three time points remained at 0.5 μg/L. In the mixed model estimates, arsenic concentration in human milk was non-significantly reduced by -0.035 μg/L (95% CI: -0.09 to 0.02) between 1 and 6 months and between 6 and 9 months. With the progression of time, arsenic concentration in infant's urine increased non-significantly by 0.13 μg/L (95% CI: -1.27 to 1.53). Arsenic in human milk at 1 and 6 months was not correlated with arsenic in the infant's urine at the same time points (r = -0.13 at 1 month and r = -0.09 at 6 month). Arsenite (AsIII), arsenate (AsV), monomethyl arsonic acid (MMA), dimethyl arsinic acid (DMA) and arsenobetaine (AsB) were the constituents of total urinary arsenic; DMA was the predominant arsenic metabolite in infant urine.

CONCLUSIONS

We observed a low arsenic concentration in human milk. The concentration was lower than the World Health Organization's maximum permissible limit (WHO Permissible Limit 15 μg/kg-bw/week). Our findings support the safety of breastfeeding even in arsenic contaminated areas.