Amyloid fibril systems reduce, stabilize and deliver bioavailable nanosized iron

Iron-deficiency anaemia (IDA) is a major global public health problem. A sustainable and cost-effective strategy to reduce IDA is iron fortification of foods, but the most bioavailable fortificants cause adverse organoleptic changes in foods. Iron nanoparticles are a promising solution in food matrices, although their tendency to oxidize and rapidly aggregate in solution severely limits their use in fortification. Amyloid fibrils are protein aggregates initially known for their association with neurodegenerative disorders, but recently described in the context of biological functions in living organisms and emerging as unique biomaterial building blocks. Here, we show an original application for these protein fibrils as efficient carriers for iron fortification. We use biodegradable amyloid fibrils from β-lactoglobulin, an inexpensive milk protein with natural reducing effects, as anti-oxidizing nanocarriers and colloidal stabilizers for iron nanoparticles. The resulting hybrid material forms a stable protein-iron colloidal dispersion that undergoes rapid dissolution and releases iron ions during acidic and enzymatic in vitro digestion. Importantly, this hybrid shows high in vivo iron bioavailability, equivalent to ferrous sulfate in haemoglobin-repletion and stable-isotope studies in rats, but with reduced organoleptic changes in foods. Feeding the rats with these hybrid materials did not result in abnormal iron accumulation in any organs, or changes in whole blood glutathione concentrations, inferring their primary safety. Therefore, these iron-amyloid fibril hybrids emerge as novel, highly effective delivery systems for iron in both solid and liquid matrices.

A comparison of magnetoencephalography, MRI, and V-EEG in patients evaluated for epilepsy surgery

PURPOSE

To determine the efficacy and relative contribution of several diagnostic methods [ictal and interictal scalp and intracranial EEG, magnetic resonance imaging (MRI), and magnetoencephalography (MEG)] in identifying the epileptogenic zone for resection.

METHODS

This was a prospective study using a masked comparison-to-criterion standard. Fifty-eight consecutive patients with refractory partial epilepsy from two university comprehensive epilepsy programs were studied. Patients who were evaluated for and underwent epilepsy surgery were recruited. The main outcome measure was the efficacy of each diagnostic method to identify the resected epileptogenic zone, when referenced to surgical outcome.

RESULTS

MEG (52%) was second only to ictal intracranial V-EEG in predicting the epileptogenic zone for the entire group of patients who had an excellent surgical outcome (seizure free or rare seizure). In a subanalysis, for patients who had temporal lobe surgery, this same relation was seen (MEG, 57%, ictal intracranial V-EEG, 62%). With extratemporal resection, ictal (81%) and interictal (75%) intracranial EEG were superior to MEG (44%) in predicting the surgery site in those patients with an excellent outcome. Finally, for all patients who had a good surgical outcome, MEG (52%) was better than ictal (33%) or interictal (45%) scalp VEEG in predicting the site of surgery.

CONCLUSIONS

These results indicate that MEG is a very promising diagnostic method and raise the possibility that it may obviate the need for invasive EEG in some cases or reduce the length of scalp EEG evaluation in others.

Acute neuroradiologic findings in young children with inflicted or noninflicted traumatic brain injury

Acute CT/MRI findings were examined in a prospective, longitudinal study of 60 children 0-6 years of age hospitalized for moderate to severe traumatic brain injury (TBI). TBI was categorized as either inflicted (n = 31) or noninflicted (n = 29). Glasgow Coma Scale scores and perinatal history were comparable in both groups. Acute CT/MRI studies were visually inspected by a radiologist blind to group membership. Compared with the noninflicted TBI group, the inflicted TBI group had significantly elevated rates of subdural interhemispheric and convexity hemorrhages as well as signs of pre-existing brain abnormality, including cerebral atrophy, subdural hygroma, and ex vacuo ventriculomegaly. Intraparenchymal hemorrhage, shear injury, and skull fractures were more frequent after non-inflicted TBI. Subarachnoid hemorrhage and infarct/edema occurred with comparable frequency in both groups. Characteristic acute neuroimaging findings of inflicted TBI included multiple extraaxial hemorrhages in addition to the mild atrophy, subdural hygromas, and ventriculomegaly that suggest prior brain abnormality.

Patterns and predictors of personal exposure to indoor air pollution from biomass combustion among women and children in rural China

Indoor air pollution (IAP) from domestic biomass combustion is an important health risk factor, yet direct measurements of personal IAP exposure are scarce. We measured 24-h integrated gravimetric exposure to particles < 2.5 μm in aerodynamic diameter (particulate matter, PM₂.₅) in 280 adult women and 240 children in rural Yunnan, China. We also measured indoor PM₂.₅ concentrations in a random sample of 44 kitchens. The geometric mean winter PM₂.₅ exposure among adult women was twice that of summer exposure [117 μg/m³ (95% CI: 107, 128) vs. 55 μg/m³ (95% CI: 49, 62)]. Children's geometric mean exposure in summer was 53 μg/m³ (95% CI: 46, 61). Indoor PM₂.₅ concentrations were moderately correlated with women's personal exposure (r=0.58), but not for children. Ventilation during cooking, cookstove maintenance, and kitchen structure were significant predictors of personal PM₂.₅ exposure among women primarily cooking with biomass. These findings can be used to develop exposure assessment models for future epidemiologic research and inform interventions and policies aimed at reducing IAP exposure.

PRACTICAL IMPLICATIONS

Our results suggest that reducing overall PM pollution exposure in this population may be best achieved by reducing winter exposure. Behavioral interventions such as increasing ventilation during cooking or encouraging stove cleaning and maintenance may help achieve these reductions.

Immunophenotype characterization of rat mesenchymal stromal cells

BACKGROUND

Mesenchymal stromal cells (MSC) have shown diverse therapeutic potential. While characterization of human and mouse MSC has seen significant advances, rat bone marrow-derived MSC (rBM-MSC) remain under-characterized. We detail the isolation, expansion, differentiation, and detailed immunocharacterization of rBM-MSC.

METHODS

Rat MSC were isolated and expanded in multipotent adult progenitor cell (MAPC) media, and cell-surface marker expression through 10 passages was used to characterize the population and multipotency was confirmed via differentiation.

RESULTS

By passage 3, rBM-MSC were found to be CD11b-, CD45-, CD29+, CD49e+, CD73+, CD90+, CD105+ and Stro-1+, without the use of cell sorting. Media selection was responsible for the isolation of a nearly homogeneous population of rBM-MSC. The rBM-MSC immunophenotype changed by passage 10, showing decreases in CD73, CD105 and Stro-1 expression.

DISCUSSION

Detailed characterization of cell populations facilitates accurate and reproducible cell therapy investigation. Given the expanding body of research involving rBM-MSC, these results advance our ability to compare rBM-MSC populations.

Effects of iron and n-3 fatty acid supplementation, alone and in combination, on cognition in school children: a randomized, double-blind, placebo-controlled intervention in South Africa

BACKGROUND

Little is known about the combined effects of iron and n-3 (omega-3) fatty acid (FA) supplementation on cognitive performance. The provision of either DHA/EPA or iron alone in rats with combined iron and n-3 FA deficiency has been reported to exacerbate cognitive deficits associated with deficiency.

OBJECTIVE

We investigated the effects of iron and DHA/EPA supplementation, alone and in combination, in children with poor iron and n-3 FA status.

DESIGN

In a 2-by-2 factorial trial, children with iron deficiency (ID) (n = 321; aged 6-11 y) were allocated to receive 1) iron (50 mg) plus DHA/EPA (420/80 mg), 2) iron plus placebo, 3) placebo plus a mixture of DHA and EPA (DHA/EPA), or 4) placebo plus placebo as oral supplements (4/wk) for 8.5 mo. Cognition was assessed at baseline and endpoint by using the Hopkins Verbal Learning Test (HVLT) and subscales of the Kaufman Assessment Battery for Children.

RESULTS

Both iron and DHA/EPA significantly increased weight-for-age z scores. Iron increased the number of words recalled at HVLT recall 2 (intervention effect: 0.90; 95% CI: 0.18, 1.62), and in anemic children, iron increased scores in the Atlantis Delayed test (1.51; 95% CI: 0.03, 2.99) and HVLT recall 2 (2.02; 95% CI: 0.55, 3.49). DHA/EPA showed no benefit in any of the cognitive tests but decreased Atlantis test scores (-2.48; 95% CI: -3.99, -0.96) in children who were anemic at baseline and decreased Atlantis delayed scores (-0.9; 95% CI: -1.45, -0.36) in girls with ID, whereas boys tended to perform better.

CONCLUSIONS

In children with poor iron and n-3 FA status, iron supplementation improved verbal and nonverbal learning and memory, particularly in children with anemia. In contrast, DHA/EPA supplementation had no benefits on cognition and impaired working memory in anemic children and long-term memory and retrieval in girls with ID.

Progressive multifocal leukoencephalopathy in persons infected with human immunodeficiency virus, San Francisco, 1981-1989

Progressive multifocal leukoencephalopathy (PML), a rare neurological disease, has been sporadically reported in persons infected with human immunodeficiency virus (HIV), the causative agent of acquired immune deficiency syndrome (AIDS). From January 1981 through February 1989, in San Francisco, we identified 94 HIV-infected persons with PML, of whom 48 (51%) were pathologically confirmed (as required for AIDS case reporting). These 48 patients were significantly older when diagnosed with AIDS (20% older than 50 years) than patients with AIDS without PML. The remaining 46 (49%) patients, diagnosed clinically and by neuroimaging, did not differ significantly from definitive patients in demographic or survival characteristics after PML diagnosis. We detected antibodies to JC virus, the causative agent of PML, in 9 of 14 (64%) AIDS-related patients with PML, and in 9 of 14 (64%) matched control subjects, suggesting that determination of JC virus antibody status before AIDS diagnosis does not reliably indicate which patients will contract PML. Our study shows that the proportion of patients with AIDS who contracted PML remained stable between 1981 and 1988, but increased in the first 2 months of 1989. Our findings further indicate that PML in HIV-infected patients may be underestimated by as much as 50%.

Urinary iodine concentrations indicate iodine deficiency in pregnant Thai women but iodine sufficiency in their school-aged children

The median urinary iodine concentration (UI) in school-aged children is recommended for assessment of iodine nutrition in populations. If the median UI is adequate in school-aged children, it is usually assumed iodine intakes are also adequate in the remaining population, including pregnant women. But iodine requirements sharply increase during pregnancy. In this study, our aim was to measure UI in pairs of pregnant women and their school-aged children from the same family, who were sharing meals, to directly assess whether a household food basket that supplies adequate iodine to school-aged children also meets the needs of pregnant women. UI was measured in spot urine samples from pairs (n = 302) of healthy pregnant mothers and their school-aged children in metropolitan Bangkok, Thailand. A dietary questionnaire was completed. The UI [median (range)] in the pregnant women {108 (11-558) microg/L [0.85 (0.086-4.41) micromol/L]} were lower than those of their school-aged children {200 (25-835) microg/L [1.58 (0.20-6.52) micromol/L]} (P < 0.001), indicating optimal iodine status in the children but mild-to-moderate iodine deficiency in their pregnant mothers. The estimated iodine intakes in the 2 groups were in the range of 130-170 microg/d. There was a modest positive correlation between UI in the pairs (r = 0.253; P < 0.01). A higher frequency of seafood meals was a significant predictor of UI in both groups, but household use of iodized salt was not. These data suggest the median UI in school-aged children should not be used as a surrogate for monitoring iodine status in pregnancy in central Thailand; pregnant women should be directly monitored.

A micronutrient powder with low doses of highly absorbable iron and zinc reduces iron and zinc deficiency and improves weight-for-age Z-scores in South African children

Micronutrient powders (MNP) are often added to complementary foods high in inhibitors of iron and zinc absorption. Most MNP therefore include high amounts of iron and zinc, but it is no longer recommended in malarial areas to use untargeted MNP that contain the Reference Nutrient Intake for iron in a single serving. The aim was to test the efficacy of a low-iron and -zinc (each 2.5 mg) MNP containing iron as NaFeEDTA, ascorbic acid (AA), and an exogenous phytase active at gut pH. In a double-blind controlled trial, South African school children with low iron status (n = 200) were randomized to receive either the MNP or the unfortified carrier added just before consumption to a high-phytate maize porridge 5 d/wk for 23 wk; primary outcomes were iron and zinc status and a secondary outcome was somatic growth. Compared with the control, the MNP increased serum ferritin (P < 0.05), body iron stores (P < 0.01) and weight-for-age Z-scores (P < 0.05) and decreased transferrin receptor (P < 0.05). The prevalence of iron deficiency fell by 30.6% (P < 0.01) and the prevalence of zinc deficiency decreased by 11.8% (P < 0.05). Absorption of iron from the MNP was estimated to be 7-8%. Inclusion of an exogenous phytase combined with NaFeEDTA and AA may allow a substantial reduction in the iron dose from existing MNP while still delivering adequate iron and zinc. In addition, the MNP is likely to enhance absorption of the high native iron content of complementary foods based on cereals and/or legumes.

Embedding trees in the rationals

An example is presented of a simple algebraic statement whose truth cannot be decided within the framework of ordinary mathematics, i.e., the statement is independent of the usual axiomatizations of set theory. The statement asserts that every tree-like ordering of power equal to or less than the first uncountable cardinal can be embedded homomorphically into the rationals.

Population-based screening for rare mutations: high-throughput DNA extraction and molecular amplification from Guthrie cards

To determine the population-based frequency of a rare mutation (the 121ins2 mutation in the surfactant protein B gene), we developed high-throughput techniques to extract reliably and rapidly amplifiable DNA from Guthrie cards. Using a 3-mm punch from each of 10,044 Guthrie cards obtained from the Missouri Department of Health, we extracted DNA with deionized water by heating in the presence of 2% Chelex in a 96-well format. Average yield of DNA from each punch was 52.6 +/- 21 microg. Using 36mer primers and a 10-microL reaction volume, we amplified a 354-bp fragment of the surfactant protein B gene that contained the mutation and identified the mutation by its susceptibility to restriction enzyme digestion with SfuI. The procedure required 5 h per 96 samples but only 2 h of technician time. The amplification rate on the first attempt was 99.2%. Based on detection of eight individuals heterozygous for the mutation (confirmed by direct sequencing), we estimate the allele frequency to be 0.8/1000 individuals, an estimate not significantly different from previous estimates based on independent methods. High-throughput DNA extraction and amplification will permit establishment of DNA banks as well as efficient estimation of population-based genotype frequency for both rare and common genetic disorders.

Biochemical, biophysical, and pharmacological characterization of bacterially expressed human agouti-related protein

The agouti-related protein gene (Agrp) is a novel gene implicated in the control of feeding behavior. The hypothalamic expression of Agrp is regulated by leptin, and overexpression of Agrp in transgenic animals results in obesity and diabetes. By analogy with the known actions of agouti, these data suggest a role for the Agrp gene product in the regulation of melanocortin receptors expressed in the central nervous system. The availability of recombinant, highly purified protein is required to fully address this potential interaction. A nearly full-length form of AGRP (MKd5-AGRP) was expressed in the cytosolic or soluble fraction of Escherichia coli and appeared as large intermolecular disulfide-bonded aggregates. Following oxidation, refolding, and purification, this protein was soluble, and eluted as a single symmetric peak on RP-HPLC. Circular dichroism studies indicated that the purified protein contains primarily random coil and beta-sheet secondary structure. Sedimentation velocity studies at neutral pH demonstrated that MKd5-AGRP is monomeric at low micromolar concentrations. Mobility shifts observed using SDS-PAGE under reducing and nonreducing conditions for bacterially expressed and mammalian expressed AGRP were identical, an indication of a similar disulfide structure. The purification to homogeneity of a second, truncated form of AGRP (Md65-AGRP) which was expressed in the insoluble or inclusion body fraction is also described. Both forms act as competitive antagonists of alpha-melanocyte stimulating hormone (alpha-MSH) at melanocortin-3 (MC-3) and melanocortin-4 receptors (MC-4). The demonstration that AGRP is an endogenous antagonist with respect to these receptors is a unique mechanism within the central nervous system, and has important implications in the control of feeding.

Foraging behaviour in domestic pigs (Sus scrofa): remembering and prioritizing food sites of different value

This experiment investigated whether domestic pigs can remember the locations of food sites of different relative value, and how a restricted retrieval choice affects their foraging behaviour. Nine juvenile female pigs were trained to relocate two food sites out of a possible eight in a spatial memory task. The two baited sites contained different amounts of food and an obstacle was added to the smaller amount to increase handling time. On each trial, a pig searched for the two baited sites (search visit). Once it had found and eaten the bait, it returned for a second (relocation) visit, in which the two same sites were baited. Baited sites were changed between trials. All subjects learnt the task. When allowed to retrieve both baits, the subjects showed no preference for retrieving a particular one first (experiment 1). When they were allowed to retrieve only one bait, a significant overall preference for retrieving the larger amount emerged across subjects (experiment 2). To test whether this preference reflected an avoidance of the obstacle with the smaller bait, 15 choice-restricted control trials were conducted. In control trials obstacles were present with both baits. Pigs continued to retrieve the larger bait, indicating they had discriminated between the two food sites on the basis of quantity or profitability and adjusted their behaviour accordingly when the relocation choice was restricted. This suggests for the first time that domestic pigs have the ability to discriminate between food sites of different relative value and to remember their respective locations.

A dose-response crossover iodine balance study to determine iodine requirements in early infancy

BACKGROUND

Optimal iodine intake during infancy is critical for brain development, but no estimated average requirement (EAR) is available for this age group.

OBJECTIVE

We measured daily iodine intake, excretion, and retention over a range of iodine intakes in early infancy to determine the minimum daily intake required to achieve iodine balance.

DESIGN

In a dose-response crossover study, we randomly assigned healthy infants (n = 11; mean ± SD age 13 ± 3 wk) to sequentially consume over 33 d 3 infant formula milks (IFMs) containing 10.5, 19.3, and 38.5 μg I/100 kcal, respectively. Each IFM was consumed for 11 d, consisting of a 6-d run-in period followed by a 4-d balance period and 1 run-out day.

RESULTS

Iodine intake (mean ± SD: 54.6 ± 8.1, 142.3 ± 23.1, and 268.4 ± 32.6 μg/d), excretion (55.9 ± 8.6, 121.9 ± 21.7, and 228.7 ± 39.3 μg/d), and retention (-1.6 ± 8.3, 20.6 ± 21.6, and 39.8 ± 34.3 μg/d) differed among the low, middle, and high iodine IFM groups (P < 0.001 for all). There was a linear relation between daily iodine intake and both daily iodine excretion and daily iodine retention. Zero balance (iodine intake = iodine excretion, iodine retention = 0 μg/d) was achieved at a daily iodine intake of 70 μg (95% CI: 60, 80 μg).

CONCLUSION

Our data indicate the iodine requirement in 2- to 5-mo-old infants is 70 μg/d. Adding an allowance for accumulation of thyroidal iodine stores would produce an EAR of 72 μg and a recommended dietary allowance of 80 μg. This trial was registered at clinicaltrials.gov as NCT02045784.

Pediatric oligodendrogliomas

Pediatric oligodendrogliomas are infrequently occurring brain tumors and frequently thought of as benign. The literature examining treatment and outcome in this select population is sparse. A retrospective analysis of pediatric oligodendrogliomas treated at MD Anderson Cancer Center between 1973 and 1992 was performed. Oligodendrogliomas were histologically graded according to the method of Smith. Survival data were estimated with Kaplan-Meier curves. Mean follow-up was 39.7 months. Nineteen children had histologically verified oligodendrogliomas and mixed oligodendroglioma/astrocytoma (M:F = 11:8; age range 1-18 years, mean = 13.1). Presenting symptoms included seizures (n = 10), headache (n = 3), visual field defects (n = 2), weakness (n = 2), cranial nerve palsy (n = 1) and decreased school performance (n = 1). All patients underwent craniotomy: 13 subtotal resections, 5 gross total resections and 1 biopsy. Twelve children had adjuvant therapy including radiation (n = 12), chemotherapy (n = 5) or both (n = 5). The 5-year survival was 65%. Seizure frequency was reduced in 30%. Children with oligodendrogliomas do not have a benign course, but younger children (<12 years) have a better prognosis. Histologic classification correlates with survival. Completeness of resection was not found to be a factor relating to survival. No conclusions can be drawn concerning adjuvant therapy because of selection bias.

Optimization of a New Mass Spectrometry Method for Measurement of Breast Milk Iodine Concentrations and an Assessment of the Effect of Analytic Method and Timing of Within-Feed Sample Collection on Breast Milk Iodine Concentrations

BACKGROUND

Breast milk iodine concentration (BMIC) may be an indicator of iodine status during lactation, but there are few data comparing different analytical methods or timing of sampling. The aims of this study were: (i) to optimize a new inductively coupled plasma mass spectrometry (ICP-MS) method; and (ii) to evaluate the effect of analytical method and timing of within-feed sample collection on BMIC.

METHODS

The colorimetric Sandell-Kolthoff method was evaluated with (a) or without (b) alkaline ashing, and ICP-MS was evaluated using a new (129)I isotope ratio approach including Tellurium (Te) for mass bias correction (c) or external standard curve (d). From iodine-sufficient lactating women (n = 97), three samples were collected within one breast-feeding session (fore-, mid-, and hind-feed samples) and BMIC was analyzed using (c) and (d).

RESULTS

Iodine recovery from NIST SRM1549a whole milk powder for methods (a)-(d) was 67%, 24%, 105%, and 102%, respectively. Intra- and inter-assay coefficients of variation for ICP-MS comparing (c) and (d) were 1.3% versus 5.6% (p = 0.04) and 1.1% versus 2.4% (p = 0.33). The limit of detection (LOD) was lower for (c) (0.26 μg/kg) than it was for (d) (2.54 μg/kg; p = 0.02). Using (c), the median [95% confidence interval (CI) obtained by bootstrap] BMIC (μg/kg) in foremilk (179 [CI 161-206]) and in mid-feed milk (184 [CI 160-220]) were not significantly different (p = 0.017), but were higher than in hindmilk (175 [CI 153-216]; p < 0.001). In foremilk using (d), BMIC was 199 ([CI 182-257]; p < 0.001 vs. (c)). The variation in BMIC comparing (c) and (d) (13%) was greater than variation within feeding (5%; p < 0.001).

CONCLUSIONS

Because of poor recoveries, (a) and (b) should not be used to measure BMIC. Compared with (d), (c) has the advantages of higher precision and a lower LOD. In iodine-sufficient women, BMIC shows low variation within a breast-feeding session, so timing of sampling is not a major determinant of BMIC.

Nutrition during pregnancy and early development (NuPED) in urban South Africa: a study protocol for a prospective cohort

BACKGROUND

Adequate nutrition during pregnancy is important to ensure optimal birth outcomes, maternal health and offspring development. However, little is known about the dietary intake and nutritional status of pregnant women residing in urban South Africa. Therefore, the Nutrition during Pregnancy and Early Development (NuPED) cohort study was initiated to assess early nutrition-related exposures predictive of early childhood development in urban South Africa.

METHODS

The aims of this prospective cohort study are: 1) to assess dietary intake and nutritional status of urban pregnant women in Johannesburg, South Africa, and 2) to determine associations with birth outcomes, measures of maternal health, as well as measures of offspring health and development. Pregnant women (< 18 weeks' gestation) (n = 250) are being recruited from primary healthcare clinics in Johannesburg and are followed-up at a provincial hospital. Participants' dietary intake and nutrient status (focus on micronutrients and fatty acids) are assessed at < 18, 22 and 36 weeks' gestation. Additional assessments during pregnancy include anthropometric and blood pressure measurements, obstetric ultrasound screens, and assessments of food security, maternal fatigue, prenatal depression, allergy, immune function, morbidity and gestational diabetes. At birth, maternal and neonatal health is assessed and an umbilical cord blood sample collected. Maternal and offspring health is followed-up at 6 weeks, as well as at 6, ≈7.5 and 12 months after birth. Follow-up assessments of mothers include anthropometric measures, diet history, nutrient status, blood pressure, breast milk composition, and measures of postnatal depression and fatigue. Follow-up assessments of the offspring include feeding practices, nutrient status, measures of growth, psychomotor, socio-emotional and immune development, morbidity, allergy, as well as analysis of the gut microbiome and the epigenome.

DISCUSSION

Ensuring adequate nutrition during pregnancy is one of the key actions endorsed by the South African Government to promote optimal early childhood development in an effort to eradicate poverty. The results from this study may serve as a basis for the development of context-specific nutritional interventions which can improve birth outcomes and long-term quality of life of the mother and her offspring.

Leveraging ongoing research to evaluate the health impacts of South Africa's salt reduction strategy: a prospective nested cohort within the WHO-SAGE multicountry, longitudinal study

INTRODUCTION

Attempting to curb the rising epidemic of hypertension, South Africa implemented legislation in June 2016 mandating maximum sodium levels in a range of manufactured foods that contribute significantly to population salt intake. This natural experiment, comparing two African countries with and without salt legislation, will provide timely information on the impact of legislative approaches addressing the food supply to improve blood pressure in African populations. This article outlines the design of this ongoing prospective nested cohort study.

METHODS AND ANALYSIS

Baseline sodium intake was assessed in a nested cohort of the WHO Study on global AGEing and adult health (WHO-SAGE) wave 2 (2014-2015), a multinational longitudinal study on the health and well-being of adults and the ageing process. The South African cohort consisted of randomly selected households (n=4030) across the country. Spot and 24-hour urine samples are collected in a random subsample (n=1200) and sodium, potassium, creatinine and iodine analysed. Salt behaviour and sociodemographic data are captured using face-to-face interviews, alongside blood pressure and anthropometric measures. Ghana, the selected control country with no formal salt policy, provided a nested subsample (n=1200) contributing spot and 24-hour urine samples from the SAGE Ghana cohort (n=5000). Follow-up interviews and urine collection (wave 3) in both countries will take place in 2017 (postlegislation) to assess change in population-level sodium intake and blood pressure.

ETHICS AND DISSEMINATION

SAGE was approved by the WHO Ethics Review Committee (reference number RPC149) with local approval from the North-West University Human Research Ethics Committee and University of the Witwatersrand Human Research Ethics Committee (South Africa), and University of Ghana Medical School Ethics and Protocol Review Committee (Ghana). The results of the study will be published in peer-reviewed international journals, presented at national and international conferences, and summarised as research and policy briefs.

Maternal iron-deficiency is associated with premature birth and higher birth weight despite routine antenatal iron supplementation in an urban South African setting: The NuPED prospective study

Background

Recent studies are suggesting a U-shaped relationship between antenatal iron exposure and birth outcomes. Little is known about the iron status and associated birth outcomes of pregnant women in South Africa. Our aim was to assess iron status at early, mid- and late pregnancy, and to determine associations with gestational age and birth weight in women in Johannesburg, South Africa.

Methods

In this prospective study of 250 pregnant women, we measured haemoglobin, biomarkers of iron status and inflammation at <18, 22 and 36 weeks of gestation, plus birth weight and gestational age at delivery. Associations of anaemia and iron status with birth outcomes were determined using regression models adjusted for confounders.

Results

At enrolment, the prevalence of anaemia, iron depletion (ID) and iron deficiency erythropoiesis (IDE) was 29%, 15% and 15%, respectively, and increased significantly with pregnancy progression. Anaemia and ID at 22 weeks, as well as IDE at 36 weeks were associated with higher birth weight (β = 135.4; 95% CI: 4.8, 266.1 and β = 205.4; 95% CI: 45.6, 365.1 and β = 178.0; 95% CI: 47.3, 308.7, respectively). Women in the lowest ferritin quartile at 22 weeks gave birth to babies weighing 312 g (95% CI: 94.8, 528.8) more than those in the highest quartile. In contrast, IDE at 22 weeks was associated with a higher risk for premature birth (OR: 3.57, 95% CI: 1.24, 10.34) and women in lower haemoglobin quartiles at <18 weeks had a shorter gestation by 7 days (β = -6.9, 95% CI: -13.3, -0.6) compared to those in the highest quartile.

Conclusion

Anaemia, ID and IDE prevalence increased during pregnancy despite routine iron supplementation. ID and anaemia at mid-pregnancy were associated with higher birth weight, while IDE was associated with premature birth. These results suggest that current antenatal screening and supplementation practices in South Africa need to be revisited.

Effects of wheat-flour biscuits fortified with iron and EDTA, alone and in combination, on blood lead concentration, iron status, and cognition in children: a double-blind randomized controlled trial

BACKGROUND

Lead is a common neurotoxicant and its absorption may be increased in iron deficiency (ID). Thus, iron fortification to prevent ID in populations is a promising lead mitigation strategy. Two common fortificants are ferrous sulfate (FeSO₄) and ferric sodium EDTA (NaFeEDTA). EDTA can chelate iron and lead.

OBJECTIVES

Our study objective was to determine the effects of iron and EDTA, alone and in combination, on blood lead (BPb) concentration, iron status, and cognition.

DESIGN

In this 2 × 2 factorial, double-blind placebo-controlled trial, 457 lead-exposed Moroccan children were stratified by school and grade and randomly assigned to consume biscuits (6 d/wk at school) containing 1) ∼8 mg Fe as FeSO₄, 2) ∼8 mg Fe as NaFeEDTA that contained ∼41 mg EDTA, 3) ∼41 mg EDTA as sodium EDTA (Na₂EDTA), or 4) placebo for 28 wk. The primary outcome was BPb concentration; secondary outcomes were iron status and cognitive outcomes from subtests of the Kaufman Assessment Battery for Children and the Hopkins Verbal Learning Test. These outcomes were measured at baseline and endpoint. All data were analyzed by intention-to-treat.

RESULTS

The adjusted geometric mean BPb concentration at baseline was 4.3 μg/dL (95% CI: 4.2, 4.3 μg/dL), and at endpoint these values were 3.3 μg/dL (95% CI: 3.1, 3.5 μg/dL) for FeSO₄, 2.9 μg/dL (95% CI: 2.7, 3.0 μg/dL) for NaFeEDTA, 3.3 μg/dL (95% CI: 3.1, 3.5 μg/dL) for EDTA, and 3.7 μg/dL (95% CI: 3.5, 3.9 μg/dL) for placebo. We found an effect of iron (P = 0.009) and EDTA (P = 0.012) for reduced BPb concentrations at endpoint, but no iron × EDTA interaction. Iron fortification improved iron status, but there were no positive effects of iron or EDTA on cognitive test scores.

CONCLUSIONS

Food fortification with iron and EDTA additively reduces BPb concentrations. Our findings suggest that NaFeEDTA should be the iron fortificant of choice in lead-exposed populations. This trial was registered at clinicaltrials.gov as NCT01573013.

Use of immunoglobulins in prevention and treatment of infection in critically ill patients: review and critique

The study of the use of standard intravenous immunoglobulin (IVIG) preparations as adjunctive therapy for seriously ill patients is motivated by the need to restore immunoglobulin G depleted because of trauma or surgery and/or by the need to provide patients with specific antibodies to various microorganisms. Whereas no clinical studies have shown that standard IVIG has therapeutic efficacy, some data suggest that its prophylactic use is beneficial. Antisera or IVIG prepared from individuals who are hyperimmunized with the biologically active, highly conserved core portion of the endotoxin of gram-negative bacteria confer variable degrees of protection in animal models and clinical trials. Two clinical trials with use of monoclonal antibodies to core lipopolysaccharide have been completed. Only subsets of patients with gram-negative sepsis were protected by the monoclonal antibodies, but the results of the studies were discrepant in regard to the specific characteristics of patients who benefited from the administration of these antibodies. Further studies will be necessary to establish whether this therapy can be recommended for critically ill patients.

How will South Africa's mandatory salt reduction policy affect its salt iodisation programme? A cross-sectional analysis from the WHO-SAGE Wave 2 Salt & Tobacco study

OBJECTIVE

The WHO's global targets for non-communicable disease reduction recommend consumption of<5 g salt/day. In 2016, South Africa was the first country to legislate maximum salt levels in processed foods. South Africa's salt iodisation fortification programme has successfully addressed iodine deficiency but information is dated. Simultaneous monitoring of sodium reduction and iodine status is required to ensure compatibility of the two public health interventions.

DESIGN/SETTING/PARTICIPANTS

A nested cohort design within WHO's 2015 Study on global AGEing and adult health (n=2887) including individuals from households across South Africa. Randomly selected adults (n=875) provided 24-hour and spot urine samples for sodium and iodine concentration analysis (the primary and secondary outcome measures, respectively). Median 24-hour urinary iodine excretion (UIE) and spot urinary iodine concentrations (UIC) were compared by salt intakes of <5g/day, 5-9g/dayand >9 g/day.

RESULTS

Median daily sodium excretion was equivalent to 6.3 g salt/day (range 1-43 g/day); 35% had urinary sodium excretion values within the desirable range (<5 g salt/day), 37% had high values (5-9 g salt/day) and 28% had very high values (>9 g salt/day). Median UIC was 130 µg/L (IQR=58-202), indicating population iodine sufficiency (≥100 µg/L). Both UIC and UIE differed across salt intake categories (p<0.001) and were positively correlated with estimated salt intake (r=0.166 and 0.552, respectively; both p<0.001). Participants with salt intakes of <5 g/day were not meeting the Estimated Average Requirement for iodine intake (95 µg/day).

CONCLUSIONS

In a nationally representative sample of South African adults, the association between indicators of population iodine status (UIC and UIE) and salt intake, estimated using 24-hour urinary sodium excretion, indicate that low salt intakes may compromise adequacy of iodine intakes in a country with mandatory iodisation of table salt. The iodine status of populations undergoing salt reduction strategies needs to be closely monitored to prevent re-emergence of iodine deficiency.

Breast-Milk Iodine Concentrations, Iodine Status, and Thyroid Function of Breastfed Infants Aged 2-4 Months and Their Mothers Residing in a South African Township

OBJECTIVE

Lactating women and their infants are susceptible to iodine deficiency and iodine excess. In South Africa, no data exist on the iodine status and thyroid function of these vulnerable groups.

METHODS

In a cross-sectional study, urinary iodine concentrations (UIC), thyroid function, and breast-milk iodine concentrations (BMIC) were assessed in 100 lactating women from a South African township and their 2-4-month-old breastfed infants. Potential predictors of UIC, thyroid function, and BMIC, including household salt iodine concentrations (SIC) and maternal sodium excretion, were also investigated.

RESULTS

The median (25th-75th percentile) UIC was 373 (202-627) μg/L in infants and 118 (67-179) μg/L in mothers. Median household SIC was 44 (27-63) ppm. Household SIC and maternal urinary sodium excretion predicted UIC of lactating mothers. Median BMIC was 179 (126-269) μg/L. Age of infants, SIC, and maternal UIC predicted BMIC. In turn, infant age and BMIC predicted UIC of infants. Forty-two percent of SIC values were within the South African recommended salt iodine fortification level at production of 35-65 ppm, whilst 21% of SIC were >65 ppm. Thyroid-stimulating hormone, total thyroxine, and thyroglobulin concentrations in the dried whole blood spot specimens from the infants were 1.3 (0.8-1.9) mU/L, 128±33 mmol/L, and 77.1 (56.3-105.7) μg/L, respectively, and did not correlate with infant UIC or BMIC.

CONCLUSION

Our results suggest that the salt fortification program in South Africa provides adequate iodine to lactating women and indirectly to their infants via breast milk. However, monitoring of salt iodine content of the mandatory salt iodization program in South Africa is important to avoid over-iodization of salt.