Global Economic Burden of Diabetes in Adults: Projections From 2015 to 2030

OBJECTIVE

Despite the importance of diabetes for global health, the future economic consequences of the disease remain opaque. We forecast the full global costs of diabetes in adults through the year 2030 and predict the economic consequences of diabetes if global targets under the Sustainable Development Goals (SDG) and World Health Organization Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020 are met.

RESEARCH DESIGN AND METHODS

We modeled the absolute and gross domestic product (GDP)-relative economic burden of diabetes in individuals aged 20-79 years using epidemiological and demographic data, as well as recent GDP forecasts for 180 countries. We assumed three scenarios: prevalence and mortality 1) increased only with urbanization and population aging (baseline scenario), 2) increased in line with previous trends (past trends scenario), and 3) achieved global targets (target scenario).

RESULTS

The absolute global economic burden will increase from U.S. $1.3 trillion (95% CI 1.3-1.4) in 2015 to $2.2 trillion (2.2-2.3) in the baseline, $2.5 trillion (2.4-2.6) in the past trends, and $2.1 trillion (2.1-2.2) in the target scenarios by 2030. This translates to an increase in costs as a share of global GDP from 1.8% (1.7-1.9) in 2015 to a maximum of 2.2% (2.1-2.2).

CONCLUSIONS

The global costs of diabetes and its consequences are large and will substantially increase by 2030. Even if countries meet international targets, the global economic burden will not decrease. Policy makers need to take urgent action to prepare health and social security systems to mitigate the effects of diabetes.

The association of parental education with childhood undernutrition in low- and middle-income countries: comparing the role of paternal and maternal education

Background: Most existing research on the association of parental education with childhood undernutrition focuses on maternal education and often ignores paternal education. We systematically investigate differences in maternal and paternal education and their association with childhood undernutrition.

Methods: One hundred and eighty Demographic and Health Surveys from 62 countries performed between 1990 and 2014 were analysed. We used linear-probability models to predict childhood undernutrition prevalences, measured as stunting, underweight and wasting, for all combinations of maternal and paternal attainment in school. Models were adjusted for demographic and socio-economic covariates for the child, mother and household, country-level fixed effects and clustering. Additional specifications adjust for local area characteristics instead of country fixed effects.

Results: Both higher maternal and paternal education levels are associated with lower childhood undernutrition. In regressions adjusted for child age and sex as well as country-level fixed effects, the association is stronger for maternal education than for paternal education when their combined level of education is held constant. In the fully adjusted models, the observed differences in predicted undernutrition prevalences are strongly attenuated, suggesting a similar importance of maternal and paternal education. These findings are confirmed by the analysis of composite schooling indicators.

Conclusions: We find that paternal education is similarly important for reducing childhood undernutrition as maternal education and should therefore receive increased attention in the literature.

Diabetes and Hypertension in India: A Nationally Representative Study of 1.3 Million Adults

IMPORTANCE

Understanding how diabetes and hypertension prevalence varies within a country as large as India is essential for targeting of prevention, screening, and treatment services. However, to our knowledge there has been no prior nationally representative study of these conditions to guide the design of effective policies.

OBJECTIVE

To determine the prevalence of diabetes and hypertension in India, and its variation by state, rural vs urban location, and individual-level sociodemographic characteristics.

DESIGN, SETTING, AND PARTICIPANTS

This was a cross-sectional, nationally representative, population-based study carried out between 2012 and 2014. A total of 1 320 555 adults 18 years or older with plasma glucose (PG) and blood pressure (BP) measurements were included in the analysis.

EXPOSURES

State, rural vs urban location, age, sex, household wealth quintile, education, and marital status.

MAIN OUTCOMES AND MEASURES

Diabetes (PG level ≥126 mg/dL if the participant had fasted or ≥200 mg/dL if the participant had not fasted) and hypertension (systolic BP≥140 mm Hg or diastolic BP≥90 mm Hg).

RESULTS

Of the 1 320 555 adults, 701 408 (53.1%) were women. The crude prevalence of diabetes and hypertension was 7.5% (95% CI, 7.3%-7.7%) and 25.3% (95% CI, 25.0%-25.6%), respectively. Notably, hypertension was common even among younger age groups (eg, 18-25 years: 12.1%; 95% CI, 11.8%-12.5%). Being in the richest household wealth quintile compared with being in the poorest quintile was associated with only a modestly higher probability of diabetes (rural: 2.81 percentage points; 95% CI, 2.53-3.08 and urban: 3.47 percentage points; 95% CI, 3.03-3.91) and hypertension (rural: 4.15 percentage points; 95% CI, 3.68-4.61 and urban: 3.01 percentage points; 95% CI, 2.38-3.65). The differences in the probability of both conditions by educational category were generally small (≤2 percentage points). Among states, the crude prevalence of diabetes and hypertension varied from 3.2% (95% CI, 2.7%-3.7%) to 19.9% (95% CI, 17.6%-22.3%), and 18.0% (95% CI, 16.6%-19.5%) to 41.6% (95% CI, 37.8%-45.5%), respectively.

CONCLUSIONS AND RELEVANCE

Diabetes and hypertension prevalence is high in middle and old age across all geographical areas and sociodemographic groups in India, and hypertension prevalence among young adults is higher than previously thought. Evidence on the variations in prevalence by state, age group, and rural vs urban location is critical to effectively target diabetes and hypertension prevention, screening, and treatment programs to those most in need.

Antenatal care services and its implications for vital and health outcomes of children: evidence from 193 surveys in 69 low-income and middle-income countries

OBJECTIVES

Antenatal care (ANC) is an essential part of primary healthcare and its provision has expanded worldwide. There is limited evidence of large-scale cross-country studies on the impact of ANC offered to pregnant women on child health outcomes. We investigate the association of ANC in low-income and middle-income countries with short- and long-term mortality and nutritional child outcomes.

SETTING

We used nationally representative health and welfare data from 193 Demographic and Health Surveys conducted between 1990 and 2013 from 69 low-income and middle-income countries for women of reproductive age (15-49 years), their children and their respective household.

PARTICIPANTS

The analytical sample consisted of 752 635 observations for neonatal mortality, 574 675 observations for infant mortality, 400 426 observations for low birth weight, 501 484 observations for stunting and 512 424 observations for underweight.

MAIN OUTCOMES AND MEASURES

Outcome variables are neonatal and infant mortality, low birth weight, stunting and underweight.

RESULTS

At least one ANC visit was associated with a 1.04% points reduced probability of neonatal mortality and a 1.07% points lower probability of infant mortality. Having at least four ANC visits and having at least once seen a skilled provider reduced the probability by an additional 0.56% and 0.42% points, respectively. At least one ANC visit is associated with a 3.82% points reduced probability of giving birth to a low birth weight baby and a 4.11 and 3.26% points reduced stunting and underweight probability. Having at least four ANC visits and at least once seen a skilled provider reduced the probability by an additional 2.83%, 1.41% and 1.90% points, respectively.

CONCLUSIONS

The currently existing and accessed ANC services in low-income and middle-income countries are directly associated with improved birth outcomes and longer-term reductions of child mortality and malnourishment.

Levels and trends of childhood undernutrition by wealth and education according to a Composite Index of Anthropometric Failure: evidence from 146 Demographic and Health Surveys from 39 countries

BACKGROUND

Governments have endorsed global targets to reduce childhood undernutrition as part of the Sustainable Development Goals. Understanding the socioeconomic differences in childhood undernutrition has the potential to be helpful for targeting policy to reach these goals.

METHODS

We specify a logistic regression model with the Composite Index of Anthropometric Failure (CIAF) as the outcome and indicator variables for wealth quartiles, maternal education categories and a set of covariates as explanatory variables. Wealth and education variables are interacted with a period indicator for 1990-2000 compared with 2001-2014 to observe differences over time. Based on these regressions we calculate predicted CIAF prevalence by wealth and education categories and over time.

RESULTS

The sample included 146 surveys from 39 low-income and lower-middle-income countries with an overall sample size of 533 217 children. CIAF prevalence was 47.5% in 1990-2000, and it declined to 42.6% in 2001-2014. In 1990-2000 the CIAF prevalence of children with mothers with less than primary education was 31 percentage points higher than for mothers with secondary or higher education. This difference slightly decreased to 27 percentage points in 2001-2014. The difference in predicted CIAF prevalence of children from the highest and lowest wealth quartiles was 21 percentage points and did not change over time.

CONCLUSIONS

We find evidence for persistent and even increasing socioeconomic inequalities in childhood undernutrition, which underlines the importance of previous calls for equity-driven approaches targeting the most vulnerable to reduce childhood malnutrition.

The HIV Epidemic in Sub-Saharan Africa is Aging: Evidence from the Demographic and Health Surveys in Sub-Saharan Africa

We use the individual-level data from all available Demographic and Health Surveys (DHS) from 27 sub-Saharan African countries conducted between 2003 and 2012 (40 population-based and nationally representative surveys in total) to calculate HIV testing consent rates and HIV prevalence for each country separately, as well as for the pooled sample. The pooled sample comprised of 427,130 individuals. In most countries HIV prevalence in adults aged 45 years and above is higher than in the total population. We further show that over the past decade HIV prevalence has increased in older age groups, while it has decreased in younger ones. While the age patterns of HIV consent rates vary across the 27 countries included in our sample, analysis of the pooled sample across all countries reveals a u-shaped relationship with lowest consent rates around age 35 years and higher consent rates among younger and older people. We argue that future DHS and other population-based HIV surveys should offer HIV testing to all adults without age limits.

The global economic burden of diabetes in adults aged 20-79 years: a cost-of-illness study

BACKGROUND

Differences in methods and data used in past studies have limited comparisons of the cost of illness of diabetes across countries. We estimate the full global economic burden of diabetes in adults aged 20-79 years in 2015, using a unified framework across all countries. Our objective was to highlight patterns of diabetes-associated costs as well as to identify the need for further research in low-income regions.

METHODS

Epidemiological and economic data for 184 countries were used to estimate the global economic burden of diabetes, regardless of diabetes type. Direct costs were derived using a top-down approach based on WHO general health expenditure figures and prevalence data from the 2015 International Diabetes Federation Diabetes Atlas. Indirect costs were assessed using a human-capital approach, including diabetes-associated morbidity and premature mortality.

FINDINGS

We estimate the global cost of diabetes for 2015 was US$1·31 trillion (95% CI 1·28-1·36) or 1·8% (95% CI 1·8-1·9) of global gross domestic product (GDP). Notably, indirect costs accounted for 34·7% (95% CI 34·7-35·0) of the total burden, although substantial variations existed both in the share and the composition of indirect costs across countries. North America was the most affected region relative to GDP and also the largest contributor to global absolute costs. However, on average, the economic burden as percentage of GDP was larger in middle-income countries than in high-income countries.

INTERPRETATION

Our results suggest a substantial global economic burden of diabetes. Although limited data were available for low-income and middle-income countries, our findings suggest that large diabetes-associated costs are not only a problem in high-income settings but also affect poorer world regions.

FUNDING

None.

Measuring Socioeconomic Inequalities With Predicted Absolute Incomes Rather Than Wealth Quintiles: A Comparative Assessment Using Child Stunting Data From National Surveys

OBJECTIVES

To compare the predictive power of synthetic absolute income measures with that of asset-based wealth quintiles in low- and middle-income countries (LMICs) using child stunting as an outcome.

METHODS

We pooled data from 239 nationally representative household surveys from LMICs and computed absolute incomes in US dollars based on households' asset rank as well as data on national consumption and inequality levels. We used multivariable regression models to compare the predictive power of the created income measure with the predictive power of existing asset indicator measures.

RESULTS

In cross-country analysis, log absolute income predicted 54.5% of stunting variation observed, compared with 20% of variation explained by wealth quintiles. For within-survey analysis, we also found absolute income gaps to be predictive of the gaps between stunting in the wealthiest and poorest households (P < .001).

CONCLUSIONS

Our results suggest that absolute income levels can greatly improve the prediction of stunting levels across and within countries over time, compared with models that rely solely on relative wealth quintiles.

The effect of economic development on population health: a review of the empirical evidence

BACKGROUND

Economic growth is considered an important determinant of population health.

SOURCES OF DATA

Relevant studies investigating the effect of economic growth on health outcomes were identified from Google Scholar and PubMed searches in economics and medical journals.

AREAS OF AGREEMENT

Additional resources generated through economic growth are potentially useful for improving population health.

AREAS OF CONTROVERSY

The empirical evidence on the aggregate effect of economic growth on population health is rather mixed and inconclusive.

GROWING POINTS

The causal pathways from economic growth to population health are crucial and failure or success in completing the pathways explains differences in empirical findings.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future research should investigate how additional resources can more effectively reach those in need and how additional resources can be used more efficiently. It is particularly relevant to understand why preventive health care in developing countries is very price elastic whereas curative health care is very health inelastic and how this understanding can inform public health policy.

One Size Fits All? The Validity of a Composite Poverty Index Across Urban and Rural Households in South Africa

Composite indices have been prominently used in poverty research. However, validity of these indices remains subject to debate. This paper examines the validity of a common type of composite poverty indices using data from a cross-sectional survey of 2477 households in urban and rural KwaZulu-Natal, South Africa. Multiple-group comparisons in structural equation modelling were employed for testing differences in the measurement model across urban and rural groups. The analysis revealed substantial variations between urban and rural respondents both in the conceptualisation of poverty as well as in the weights and importance assigned to individual poverty indicators. The validity of a 'one size fits all' measurement model can therefore not be confirmed. In consequence, it becomes virtually impossible to determine a household's poverty level relative to the full sample. Findings from our analysis have important practical implications in nuancing how we can sensitively use composite poverty indices to identify poor people.

Diabetes diagnosis and care in sub-Saharan Africa: pooled analysis of individual data from 12 countries

BACKGROUND

Despite widespread recognition that the burden of diabetes is rapidly growing in many countries in sub-Saharan Africa, nationally representative estimates of unmet need for diabetes diagnosis and care are in short supply for the region. We use national population-based survey data to quantify diabetes prevalence and met and unmet need for diabetes diagnosis and care in 12 countries in sub-Saharan Africa. We further estimate demographic and economic gradients of met need for diabetes diagnosis and care.

METHODS

We did a pooled analysis of individual-level data from nationally representative population-based surveys that met the following inclusion criteria: the data were collected during 2005-15; the data were made available at the individual level; a biomarker for diabetes was available in the dataset; and the dataset included information on use of core health services for diabetes diagnosis and care. We first quantified the population in need of diabetes diagnosis and care by estimating the prevalence of diabetes across the surveys; we also quantified the prevalence of overweight and obesity, as a major risk factor for diabetes and an indicator of need for diabetes screening. Second, we determined the level of met need for diabetes diagnosis, preventive counselling, and treatment in both the diabetic and the overweight and obese population. Finally, we did survey fixed-effects regressions to establish the demographic and economic gradients of met need for diabetes diagnosis, counselling, and treatment.

FINDINGS

We pooled data from 12 nationally representative population-based surveys in sub-Saharan Africa, representing 38 311 individuals with a biomarker measurement for diabetes. Across the surveys, the median prevalence of diabetes was 5% (range 2-14) and the median prevalence of overweight or obesity was 27% (range 16-68). We estimated seven measures of met need for diabetes-related care across the 12 surveys: (1) percentage of the overweight or obese population who received a blood glucose measurement (median 22% [IQR 11-37]); and percentage of the diabetic population who reported that they (2) had ever received a blood glucose measurement (median 36% [IQR 27-63]); (3) had ever been told that they had diabetes (median 27% [IQR 22-51]); (4) had ever been counselled to lose weight (median 15% [IQR 13-23]); (5) had ever been counselled to exercise (median 15% [IQR 11-30]); (6) were using oral diabetes drugs (median 25% [IQR 18-42]); and (7) were using insulin (median 11% [IQR 6-13]). Compared with those aged 15-39 years, the adjusted odds of met need for diabetes diagnosis (measures 1-3) were 2·22 to 3·53 (40-54 years) and 3·82 to 5·01 (≥55 years) times higher. The adjusted odds of met need for diabetes diagnosis also increased consistently with educational attainment and were between 3·07 and 4·56 higher for the group with 8 years or more of education than for the group with less than 1 year of education. Finally, need for diabetes care was significantly more likely to be met (measures 4-7) in the oldest age and highest educational groups.

INTERPRETATION

Diabetes has already reached high levels of prevalence in several countries in sub-Saharan Africa. Large proportions of need for diabetes diagnosis and care in the region remain unmet, but the patterns of unmet need vary widely across the countries in our sample. Novel health policies and programmes are urgently needed to increase awareness of diabetes and to expand coverage of preventive counselling, diagnosis, and linkage to diabetes care. Because the probability of met need for diabetes diagnosis and care consistently increases with age and educational attainment, policy makers should pay particular attention to improved access to diabetes services for young adults and people with low educational attainment.

FUNDING

None.

Association between household unavailability of iodized salt and child growth: evidence from 89 demographic and health surveys

BACKGROUND

Although a strong biological basis exists for a role of iodine in somatic growth failure in childhood, this relation has not been previously studied on a large scale to our knowledge.

OBJECTIVE

We investigated if a general association exists between the household unavailability of iodized salt and child growth across countries.

DESIGN

We used 89 nationally representative, repeated, cross-sectional and mutually comparable demographic and health surveys that were conducted between 1994 and 2012 across 46 low- and middle-income countries. We analyzed the data for the outcome variables of stunting (low height-for-age), underweight (low weight-for-age), wasting (low weight-for-height), and low birth weight in children aged between 0 and 59 mo at the time of the interview with the use of logistic regression models. Our samples consisted of 390,328 children for the stunting analysis, 397,080 children for the underweight analysis, 384,163 children for the wasting analysis, and 187,744 children for the low-birth-weight analysis. Models were adjusted for individual, maternal, and household covariates and fixed effects on the level of the primary sampling unit.

RESULTS

In the fully adjusted models, the unavailability of iodized salt was associated with 3% higher odds of being stunted (95% CI of ORs: 1.00, 1.06; P = 0.04), 5% higher odds of being underweight (95% CI: 1.02, 1.09; P < 0.01), and 9% higher odds of low birth weight (95% CI: 1.02, 1.17; P = 0.01). When India was excluded from the sample, the association was only statistically significant (P = 0.05) for low birth weight.

CONCLUSION

Although we did not establish causality in our analysis, the findings might indicate that the causal effect of iodized salt on child growth, if it exists, is most profound in utero and is not universally effective across all countries with respect to longer-run child-growth outcomes such as stunting and underweight.

Prevalence of and factors associated with frailty and disability in older adults from China, Ghana, India, Mexico, Russia and South Africa

BACKGROUND

The severe burden imposed by frailty and disability in old age is a major challenge for healthcare systems in low- and middle-income countries alike. The current study aimed to provide estimates of the prevalence of frailty and disability in older adult populations and to examine their relationship with socioeconomic factors in six countries.

METHODS

Focusing on adults aged 50+ years, a frailty index was constructed as the proportion of deficits in 40 variables, and disability was assessed using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), as part of the Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, Russia and South Africa.

RESULTS

This study included a total of 34,123 respondents. China had the lowest percentages of older adults with frailty (13.1%) and with disability (69.6%), whereas India had the highest percentages (55.5% and 93.3%, respectively). Both frailty and disability increased with age for all countries, and were more frequent in women, although the sex gap varied across countries. Lower levels of both frailty and disability were observed at higher levels of education and wealth. Both education and income were protective factors for frailty and disability in China, India and Russia, whereas only income was protective in Mexico, and only education in South Africa.

CONCLUSIONS

Age-related frailty and disability are increasing concerns for older adult populations in low- and middle-income countries. The results indicate that lower levels of frailty and disability can be achieved for older people, and the study highlights the need for targeted preventive approaches and support programs.

Bilateral Trade Flows and Income Distribution Similarity

Current models of bilateral trade neglect the effects of income distribution. This paper addresses the issue by accounting for non-homothetic consumer preferences and hence investigating the role of income distribution in the context of the gravity model of trade. A theoretically justified gravity model is estimated for disaggregated trade data (Dollar volume is used as dependent variable) using a sample of 104 exporters and 108 importers for 1980–2003 to achieve two main goals. We define and calculate new measures of income distribution similarity and empirically confirm that greater similarity of income distribution between countries implies more trade. Using distribution-based measures as a proxy for demand similarities in gravity models, we find consistent and robust support for the hypothesis that countries with more similar income-distributions trade more with each other. The hypothesis is also confirmed at disaggregated level for differentiated product categories.

Effect of preorganization on the affinity of synthetic DNA binding motifs for nucleotide ligands

Triplexes with a gap in the purine strand have been shown to bind adenosine or guanosine derivatives through a combination of Watson-Crick and Hoogsteen base pairing. Rigidifying the binding site should be advantageous for affinity. Here we report that clamps delimiting the binding site have a modest effect on affinity, while bridging the gap of the purine strand can strongly increase affinity for ATP, cAMP, and FAD. The lowest dissociation constants were measured for two-strand triple helical motifs with a propylene bridge or an abasic nucleoside analog, with Kd values as low as 30 nM for cAMP in the latter case. Taken together, our data suggest that improving preorganization through covalent bridges increases the affinity for nucleotide ligands. But, a bulky bridge may also block one of two alternative binding modes for the adenine base. The results may help to design new receptors, switches, or storage motifs for purine-containing ligands.

Association between economic growth and early childhood undernutrition: evidence from 121 Demographic and Health Surveys from 36 low-income and middle-income countries

BACKGROUND

Economic growth is widely regarded as a necessary, and often sufficient, condition for the improvement of population health. We aimed to assess whether macroeconomic growth was associated with reductions in early childhood undernutrition in low-income and middle-income countries.

METHODS

We analysed data from 121 Demographic and Health Surveys from 36 countries done between Jan 1, 1990, and Dec 31, 2011. The sample consisted of nationally representative cross-sectional surveys of children aged 0-35 months, and the outcome variables were stunting, underweight, and wasting. The main independent variable was per-head gross domestic product (GDP) in constant prices and adjusted for purchasing power parity. We used logistic regression models to estimate the association between changes in per-head GDP and changes in child undernutrition outcomes. Models were adjusted for country fixed effects, survey-year fixed effects, clustering, and demographic and socioeconomic covariates for the child, mother, and household.

FINDINGS

Sample sizes were 462,854 for stunting, 485,152 for underweight, and 459,538 for wasting. Overall, 35·6% (95% CI 35·4-35·9) of young children were stunted (ranging from 8·7% [7·6-9·7] in Jordan to 51·1% [49·1-53·1] in Niger), 22·7% (22·5-22·9) were underweight (ranging from 1·8% [1·3-2·3] in Jordan to 41·7% [41·1-42·3] in India), and 12·8% (12·6-12·9) were wasted (ranging from 1·2% [0·6-1·8] in Peru to 28·8% [27·5-30·0] in Burkina Faso). At the country level, no association was seen between average changes in the prevalence of child undernutrition outcomes and average growth of per-head GDP. In models adjusted only for country and survey-year fixed effects, a 5% increase in per-head GDP was associated with an odds ratio (OR) of 0·993 (95% CI 0·989-0·995) for stunting, 0·986 (0·982-0·990) for underweight, and 0·984 (0·981-0·986) for wasting. ORs after adjustment for the full set of covariates were 0·996 (0·993-1·000) for stunting, 0·989 (0·985-0·992) for underweight, and 0·983 (0·979-0·986) for wasting. These findings were consistent across various subsamples and for alternative variable specifications. Notably, no association was seen between per-head GDP and undernutrition in young children from the poorest household wealth quintile. ORs for the poorest wealth quintile were 0·997 (0·990-1·004) for stunting, 0·999 (0·991-1·008) for underweight, and 0·991 (0·978-1·004) for wasting.

INTERPRETATION

A quantitatively very small to null association was seen between increases in per-head GDP and reductions in early childhood undernutrition, emphasising the need for direct health investments to improve the nutritional status of children in low-income and middle-income countries.

FUNDING

None.

Patterns of frailty in older adults: comparing results from higher and lower income countries using the Survey of Health, Ageing and Retirement in Europe (SHARE) and the Study on Global AGEing and Adult Health (SAGE)

We use the method of deficit accumulation to describe prevalent and incident levels of frailty in community-dwelling older persons and compare prevalence rates in higher income countries in Europe, to prevalence rates in six lower income countries. Two multi-country data collection efforts, SHARE and SAGE, provide nationally representative samples of adults aged 50 years and older. Forty items were used to construct the frailty index in each data set. Our study shows that the level of frailty was distributed along the socioeconomic gradient in both higher and lower income countries such that those individuals with less education and income were more likely to be frail. Frailty increased with age and women were more likely to be frail in most countries. Across samples we find that the level of frailty was higher in the higher income countries than in the lower income countries.

Does access to improved sanitation reduce childhood diarrhea in rural India?

Almost nine million children under 5 years of age die every year. Diarrhea is considered to be the second leading cause of under-five mortality in developing countries. About one out of five deaths is caused by diarrhea. In this paper, we use the newly available data set District Level Household Survey 3 to quantify the impact of access to improved sanitation on diarrheal morbidity for children less than 5 years of age in India. Using propensity score matching, we find that access to improved sanitation reduces the risk of contracting diarrhea by 2.2 percentage points. There is considerable heterogeneity in the impacts of improved sanitation. We find statistically insignificant treatment effects for children in low or middle socioeconomic status households and for girls; however, boys and children in high socioeconomic status households experienced economically significant treatment effects. The magnitude of the treatment effect differs largely by hygiene behavior.

The emergence of three human development clubs

We examine the joint distribution of levels of income per capita, life expectancy, and years of schooling across countries in 1960 and in 2000. In 1960 countries were clustered in two groups; a rich, highly educated, high longevity “developed” group and a poor, less educated, high mortality, “underdeveloped” group. By 2000 however we see the emergence of three groups; one underdeveloped group remaining near 1960 levels, a developed group with higher levels of education, income, and health than in 1960, and an intermediate group lying between these two. This finding is consistent with both the ideas of a new “middle income trap” that countries face even if they escape the “low income trap”, as well as the notion that countries which escaped the poverty trap form a temporary “transition regime” along their path to the “developed” group.

Deletion of the late cornified envelope genes LCE3B and LCE3C may promote chronic hand eczema with allergic contact dermatitis

BACKGROUND

Genetically determined defects in epidermal skin barrier function may contribute to the development of irritant and/or allergic contact dermatitis in chronic hand eczema (CHE).

OBJECTIVES

To assess whether a deletion in the late cornified envelope genes LCE3B and LCE3C may constitute a genetic predisposition for the development of CHE or any of its subtypes.

PATIENTS AND METHODS

A total of 153 German patients with clearly defined CHE subtypes and 268 healthy individuals were screened for the deletion LCE3C_LCE3B-del by allele-specific polymerase chain reaction.

RESULTS

Classification of the patients by etiologic subtypes revealed an association between the LCE3C_LCE3B-del allele and CHE due to allergic contact dermatitis. In this subtype, 19/37 patients (51.4%) were homozygous deletion carriers, 11/37 (29.7%) were heterozygous carriers, and just 7/37 (18.9%) were wild-type individuals. Compared to the other CHE subgroups and the healthy control group (homozygous, 88/268 [32.83%]; heterozygous, 133/268 [49.63%]; and wild-type, 47/268 [17.54%]), the prevalence of LCE3C_LCE3B-del in these patients reached statistical significance (P = .03977), as did homozygous deletion carrier status (P = .01044 for other subtypes and P = .02695 for controls).

CONCLUSIONS

A deletion of LCE genes may promote the development of allergic contact dermatitis, which is a form of CHE involving delayed-type hypersensitivity.

Filaggrin mutations may confer susceptibility to chronic hand eczema characterized by combined allergic and irritant contact dermatitis

BACKGROUND

The pathogenesis of chronic hand eczema (CHE) is multifactorial and involves both endogenous predisposition and environmental triggers.

OBJECTIVES

Filaggrin is a structural protein of the cornified envelope and important for the formation of the epidermal skin barrier. The aim of this investigation was to evaluate the role of mutations in the filaggrin gene (FLG) in the development of CHE.

METHODS

In total, 122 German patients with clearly defined CHE subtypes were screened for the FLG variants R501X and 2282del4 by polymerase chain reaction and restriction enzyme digest analysis. The prevalence of these variants in CHE patients was compared with that in 95 healthy individuals.

RESULTS

Overall, allele frequency and the number of mutation carriers were similar in both the CHE and control groups. When classified according to clearly defined CHE subtypes, however, the nonfunctional FLG variants showed an association with CHE involving an aetiological combination of contact allergy and irritant factors [P = 0.04; P (exact test) = 0.06; P (difference in rates) = 0.09; 95% confidence interval (CI) 0-56.8)], or with excessive daily exposure to water and irritants [P = 0.003; P (difference in rates) < 0.001; 95% CI 29.3-67.9].

CONCLUSION

Heterozygosity for nonfunctional mutations in the FLG gene may contribute to the manifestation and maintenance of a particular CHE subtype that is characterized by the combination of allergic and irritant contact dermatitis.

Dominant lesional T cell receptor rearrangements persist in relapsing psoriasis but are absent from nonlesional skin: evidence for a stable antigen-specific pathogenic T cell response in psoriasis vulgaris

In a previous study we reported that clonally expanded T cell receptor beta-chain rearrangements characterized the T cell receptor usage in skin lesions of psoriasis vulgaris and indicated antigen-specific T cell selection. To assess the relevance of clonal T cell expansion for disease progression, we now determined if select clonal T cell receptor rearrangements persisted over time and were present in nonlesional skin. Sequential biopsies were taken from psoriatic skin lesions of two patients. V-D-J junctional regions of T cell receptor beta-chain variable region gene families 2, 3, 6, 13S1, and BV17 were cloned and sequenced, as these particular BV gene families are preferentially selected in psoriatic skin lesions. The lesional T cell receptor rearrangements were compared with the T cell receptor usage in nonlesional skin and in blood. Several T cell receptor beta-chain rearrangements with high transcript frequency in the first lesional biopsy were again found in sequential lesional biopsies taken as much as 3 y later from psoriasis relapses. Only T cell receptor beta-chain rearrangements with low transcript abundance showed variability in that several clones appeared for the first time or disappeared. Although nonlesional skin also exhibited a restricted T cell receptor usage with clonal T cell receptor rearrangements, the T cell receptor usage in lesional and nonlesional skin differed nearly completely. The select lesional recurrence of identical T cell receptor rearrangements reveals that inflammation in psoriasis involves the same clonally expanded T cell populations and the same antigens over prolonged periods of time. It hereby suggests that specifically recruited and locally expanded T cell clones are permanently involved in psoriatic inflammation and may play a crucial part in disease perpetuation.

Analysis of the TCRBV repertoire of T cells in normal, human skin: evidence for a restricted diversity

Alpha beta T cells constitute an important component in the first line of immunologic defense in human skin. In order to determine the local selection forces driving T cell diversity, we studied the T cell receptor repertoire in normal human skin and compared it with that of matched blood samples. Using semiquantitative reverse transcription-polymerase chain reaction the expression of T cell receptor beta-chain V genes was determined. The majority of skin, but not blood T cells, revealed a bias towards usage of T cell receptor beta-chain V2 and V6. Whereas sequencing of T cell receptor beta-chain V2 and V6 polymerase chain reaction products showed a heterogeneous clonal distribution within these beta-chain V gene families, the analysis of other selected either over- or underrepresented beta-chain V gene families (BV3, BV12, BV13S1, BV17) revealed numerous identical T cell receptor beta-chain V transcript sequences that were not detected in blood. Restricted T cell receptor diversity in terms of beta-chain V gene preferences or clonal expansion was observed in skin samples of donors from all ages (0.5-87 y). Hence, the repertoire of T cells in normal human skin is apparently subjected to skin-specific selection throughout life. According to our data, this process could involve superantigens, which favor polyclonal accumulation of T cells using certain beta-chain V genes, as well as antigens, which induce clonal T cell expansion. Our results furthermore indicate, that T cell receptor beta-chain V repertoire restrictions do not necessarily result from disease-associated activation of the skin immune system, but could reflect regular mechanisms of immunologic homeostasis within the epithelial surface of the body.

Selection of conserved TCR VDJ rearrangements in chronic psoriatic plaques indicates a common antigen in psoriasis vulgaris

Psoriasis vulgaris is a common HLA-associated inflammatory skin disease. Although its etiology is still unknown, it is thought to involve T cell-mediated inflammatory mechanisms. In examining the lesional psoriatic TCR beta chain (TCRB) usage in a pair of identical twins concordant for psoriasis, we observed repetitive TCR VDJ rearrangements which indicated antigen-specific oligoclonal T cell expansion. Several of these TCRB rearrangements were identical or highly homologous in the amino acid composition of the complementarity determining region 3 (CDR3), suggesting that T cells with these TCR might be important for disease manifestation. This conclusion was strengthened by TCR analysis of other psoriasis patients. Several repetitive lesional TCRB rearrangements were found that were similar to the conserved CDR3 seen in the twins. Since TCR antigen specificity is largely determined by the beta chain CDR3, selection of T cells with conserved TCRB CDR3 motifs could indicate the presence of a common antigen as a major target of the lesional psoriatic immune response.

Evidence for an antigen-specific cellular immune response in skin lesions of patients with psoriasis vulgaris

Psoriasis vulgaris is an inflammatory skin disease characterized by excessively increased keratinocyte proliferation. Several lines of evidence support the idea that T cells infiltrating psoriatic skin lesions play a vital role in the pathogenesis of the disease. To establish whether lesional accumulation and activation of T lymphocytes reflect a specific local immune response, the TCR beta-chain variable (V beta) region gene usage was studied in chronic psoriatic plaques, normal skin, and paired blood lymphocytes. By semiquantitative PCR, we found that overexpression of either or both V beta 2 and V beta 6 gene families characterized the TCR repertoires of normal skin and psoriatic skin lesions. However, sequence analysis of the complementarity-determining region 3 (CDR3) of these V beta gene families demonstrated a marked TCR oligoclonality only in psoriatic lesions, not in normal skin or in blood lymphocytes. The amino acid sequences of the lesional TCR clones revealed that certain conserved junctional motifs were shared by different patients. A second biopsy taken from one of the psoriasis patients 18 mo later from a different anatomical site disclosed that the same TCR clones were again dominating. These data suggest that lesional psoriatic T lymphocytes expressing the prevailing TCR V beta genes represent an oligoclonal T cell subset that expanded from a few progenitor T cells in response to Ag in the skin of psoriasis patients. They are derived from a polyclonal T cell population that, by the expression of V beta 2 or V beta 6 TCR, appears to be predisposed for homing to the skin.

Evidence for an antigen-specific cellular immune response in skin lesions of patients with psoriasis vulgaris

Psoriasis vulgaris is an inflammatory skin disease characterized by excessively increased keratinocyte proliferation. Several lines of evidence support the idea that T cells infiltrating psoriatic skin lesions play a vital role in the pathogenesis of the disease. To establish whether lesional accumulation and activation of T lymphocytes reflect a specific local immune response, the TCR beta-chain variable (V beta) region gene usage was studied in chronic psoriatic plaques, normal skin, and paired blood lymphocytes. By semiquantitative PCR, we found that overexpression of either or both V beta 2 and V beta 6 gene families characterized the TCR repertoires of normal skin and psoriatic skin lesions. However, sequence analysis of the complementarity-determining region 3 (CDR3) of these V beta gene families demonstrated a marked TCR oligoclonality only in psoriatic lesions, not in normal skin or in blood lymphocytes. The amino acid sequences of the lesional TCR clones revealed that certain conserved junctional motifs were shared by different patients. A second biopsy taken from one of the psoriasis patients 18 mo later from a different anatomical site disclosed that the same TCR clones were again dominating. These data suggest that lesional psoriatic T lymphocytes expressing the prevailing TCR V beta genes represent an oligoclonal T cell subset that expanded from a few progenitor T cells in response to Ag in the skin of psoriasis patients. They are derived from a polyclonal T cell population that, by the expression of V beta 2 or V beta 6 TCR, appears to be predisposed for homing to the skin.

T lymphocytes derived from skin lesions of patients with psoriasis vulgaris express a novel cytokine pattern that is distinct from that of T helper type 1 and T helper type 2 cells

In various immunological disorders the pathomechanisms of tissue damage are causally associated with specific patterns of locally produced cytokines. To study the molecular and cellular mechanisms involved in the manifestation of psoriasis vulgaris we have assessed the cytokine mRNA profile expressed in lesional psoriatic skin and in T cell clones (TCC) that were established from skin lesions of patients with psoriasis. As demonstrated by use of the polymerase chain reaction (PCR), psoriasis lesions consistently exhibit transcription of a complex pattern of cytokines. It includes mediators selectively produced by T lymphocytes [interferon (IFN)-gamma, tumor necrosis factor (TNF)-beta, interleukin (IL)-2, IL-3 and IL-5] as well as cytokines secreted by various cell types [transforming growth factor (TGF)-alpha/-beta, TNF-alpha, IL-6/-8 and granulocyte-macrophage-colony stimulating factor], while IL-4 is missing. With the exception of TGF-alpha, this cytokine profile was also observed in lesional psoriatic T cell clones yielding supernatants mitogenic for keratinocytes in vitro (MTCC), but not in T cell clones yielding supernatants that inhibited keratinocyte proliferation (STCC). The congruent cytokine expression of psoriatic skin lesions and MTCC emphasizes that inflammation in psoriasis is driven by a sofar unrecognized regulatory T cell subset that may serve to control epidermal regeneration and convey immunosurveillance over epithelial surfaces. It is characterized by the combined expression of IFN-gamma, TGF-beta, IL-2 and IL-5 in the absence of IL-4 and by its selective capacity to enhance keratinocyte proliferation. This newly defined combination of regulatory properties of a distinct T cell population cannot be reconciled with an immune response of the T helper cells (TH)0, TH1 or TH2 type.

The activity of S-thiomethyl modified creatine kinase is due to the regeneration of free thiol at the active site

Creatine kinase modified by S-methyl methanethiosulfonate and devoid of reactive thiol group has been reported to retain about 18-40% of the activity of the native enzyme. It has now been found that during the reaction catalyzed by the modified enzyme the rate increases with time and if the reaction is allowed to continue sufficiently long, the enzyme eventually recovers full activity. The presence of substrates is not required for the reactivation as suitable dilution after removal of MMTS in excess leads to complete reactivation of the MMTS modified enzyme with the simultaneous regeneration of reactive thiol per each dimeric molecule as shown by determinations with DTNB and IAN. The addition of MMTS during the course of reactivation again inactivates the reactivated enzyme. The activity recovery is therefore due to the regeneration of reactive thiol and it appears that the active-site thiols are essential for the activity of rabbit muscle creatine kinase.

T cell clones from psoriasis skin lesions can promote keratinocyte proliferation in vitro via secreted products

Psoriasis vulgaris has been recognized lately as an immunologically mediated inflammatory skin disease. To analyze the pathogenetic role of T lymphocytes in the generation of psoriatic skin lesions, 105 T cell clones (TCC) and 10 T cell lines (TCL) were differentially isolated from dermis and epidermis of psoriatic skin specimens. Supernatants prepared from these T cells were studied for their effects on keratinocyte proliferation in vitro. Conditioned media from 14 of 77 epidermal TCC, 7 of which were CD8+, and from 8 of 28 dermal TCC, 5 of which were CD8+, reproducibly enhanced keratinocyte proliferation, with more pronounced mitogenic activities found in dermal TCC. Another 9 epidermal and 3 dermal TCC did not affect keratinocyte growth and supernatants from the remaining clones, as well as from the 5 epidermal and 5 dermal TCL, inhibited keratinocyte replication to varying degrees. Both mitogenic and suppressive activities were largely abolished by addition of an antiserum to interferon-gamma (IFN-gamma), while addition of epidermal growth factor or irradiated psoriatic TCL had little effect on the activities of the supernatants. These studies reveal that a subpopulation of lesional psoriatic T lymphocytes is capable of enhancing keratinocyte proliferation in vitro via secreted products. Their mitogenic capacity most likely requires IFN-gamma, but the ultimate effect is apparently determined by the presence of additional cytokines. Activation of T cells secreting such combinations of factors in vivo may contribute to the keratinocyte alterations characteristic of psoriatic skin lesions.

[Blunt abdominal trauma--sonographic findings]

Results of sonographic investigations from 435 patients with blunt abdominal trauma or polytrauma admitted to a traumatology service are given. Complete evaluation of the abdominal organs was impeded in 94 cases by meteorism or other factors like immobility or hyperactivity of inebriated patients. Evaluation of the pancreas was inhibited in most of these cases. In 33 cases lesions of an organ could be verified during surgery. In one case the false positive diagnosis of "spleen rupture" led to operation. Suspicion of free fluid in the abdominal cavity (5 cases) could not be verified in any of the cases during a second investigation and was deemed to be negligible. Rupture of the spleen was diagnosed in 12 out of 14 cases, renal contusion in 7 out of 7 cases. Liver-, bowel- and mesenteric lesions were occasionally diagnosed indirectly (evidence for free fluid). Quality assessment did not reveal a difference between day time or nocturnal work shifts provided the investigators were experienced in sonography.

Immunocytochemical studies on several developmental stages of Dipetalonema viteae (Filarioidea)

The binding of antibodies to infective larvae (L3), eggs, uterine contents and blood microfilariae was demonstrated by light microscopy employing the peroxidase-antiperoxidase (PAP) method. Antigen-antibody reactions were located on the shell of filarial eggs as well as on the cuticle and the interior of L3 and microfilariae. Using sera from Meriones unguiculatus, Mastomys natalensis and golden hamsters infected with D. viteae obtained at 7, 14, 21 and 28 weeks p.i. it was observed that the intensity of the immunostaining on several developmental stages of the filariae decreased with increasing duration of infection. This effect was more pronounced in the case of M. unguiculatus and M. natalensis than in the case of golden hamsters. For detection of surface antigenicity the simple procedure of drying the test material on microscopic slides proved to be time saving and equally specific as compared to the embedding in Epon of the filarial stages and the successive preparation of semithin sections. However, embedded filarial stages presented more intensive immunostaining than nonembedded stages. Moreover, sections allowed to demonstrate antigen-antibody reactions on the cuticle as well as inside the body cavity of the stages.

Immunocytochemical and ultrastructural studies on Dipetalonema viteae (Filarioidea)

The antigenic properties of adult male and female of Dipetalonema viteae were studied by immunocytochemistry. Using antisera of the rodents Meriones unguiculatus and Mastomys natalensis infected with D. viteae, the binding of antibodies to sections of filariae embedded in Epon was assayed by the peroxidase-antiperoxidase (PAP) technique and by electron microscopy. The optimal staining intensity was obtained with an antiserum dilution of 1:5000. Control sera were obtained from sex and age matched uninfected animals. Female D. viteae showed maximal antigen-antibody reactions within the uterus: in the inner uterus wall, in the "nutrient channels" between the maturing eggs and the differentiating microfilariae, on the eggshells, in the cuticula of microfilariae and in the spermatheca on the cell membrane of the mature spermatozoa. Male filariae showed binding of antibodies in the vesicula seminalis: in the nucleus and the nuclear membrane of primary spermatocytes and on maturing spermatids. Less pronounced antigen-antibody reactions in the cuticula, muscle and intestine were observed in both sexes. The PAP-technique offers significant improvements in comparison with other techniques, e.g., immunofluorescence, used to detect antigens on filariae: the PAP-technique has an increased sensitivity with a concomitant reduction in nonspecific background and can be used for both light and electron microscopy; moreover, PAP-treated tissues can be stored indefinitely at room temperature.

Protein composition of various developmental stages of dipetalonema viteae (Filarioidea)

The protein composition of various developmental stages of Dipetalonema viteae was analysed on polyacrylamide slab gels in the presence of sodium-dodecylsulphate. When the total proteins of adult male and female parasites, microfilariae, eggs, and third-stage larvae were compared, apparent qualitative similarities between mature and immature filariae were observed. However, several stage specific components were also identified.

Immunocytochemical studies on Dipetalonema viteae (Filarioidea)

The antigenic properties of adult male and female worms of the nematode Dipetalonema viteae (Filarioidea) were studied by immunocytochemistry. Using sera of rodents infected with this parasite, the binding of antibodies to sections of worms embedded in Epon was assayed by the peroxidase-antiperoxidase (PAP) technique and by light microscopy. In female worms antigen-antibody reactions were located in the uterine fluid, the inner uterus wall, the circumference of the microfilariae and in the egg shell. Male D. viteae showed binding of antibodies in the vesica seminalis and in the vas deferens. Both sexes has also less pronounced antigenic activities in cuticula, muscle and intestine.

Vitamin D-dependent calcium-binding protein. Immunochemical studies and synthesis by placental tissue in vitro

A protein similar to rat intestinal calcium-binding protein (CaBP) has been identified in both mouse placenta and mouse small intestine. The mouse protein had a molecular weight of approximately 10,000, exhibited cation-binding properties, and demonstrated immunologic identity with vitamin D-dependent rat CaBP. Under normal dietary conditions, the concentrations of CaBP in mouse placenta and intestine increased 6- and 3-fold, respectively, during the third trimester of pregnancy in parallel with the fetal demands for skeletal mineral. Studies of in vitro protein synthesis indicated that CaBP was synthesized by placental tissue. Slices of mouse or rat placental tissue (12-18-day gestation) were incubated with [3H]leucine and the biosynthesis of placental CaBP was quantified by an immunoprecipitation method using rabbit antiserum to rat intestinal CaBP. Sodium dodecyl sulfate gel electrophoresis of the radioactive immune complex revealed a single 3H-labeled peak corresponding to the molecular weight of rat and mouse CaBP (10,050). The amount of CaBP synthesized by mouse placental tissue was dependent upon gestational age of the placenta and reflected the in vivo changes in placental CaBP content observed during gestation. These data indicate that CaBP is synthesized by placenta and provide an in vitro model for studying the developmental control of placental CaBP synthesis.