Malnutrition and infection: complex mechanisms and global impacts

Nutritional Risk Screening and Body Composition in COVID-19 Patients Hospitalized in an Internal Medicine Ward

BACKGROUND

Malnutrition in patients hospitalized in internal medicine wards is highly prevalent and represents a prognostic factor of worse outcomes. Previous evidence suggested the prognostic role of the nutritional status in patients affected by the coronavirus disease 2019 (COVID-19). We aim to investigate the nutritional risk in patients with COVID-19 hospitalized in an internal medicine ward and their clinical outcomes using the Nutritional Risk Screening 2002 (NRS-2002) and parameters derived from bioelectrical impedance analysis (BIA).

METHODS

Retrospective analysis of patients with COVID-19 aimed at exploring: 1) the prevalence of nutritional risk with NRS-2002 and BIA; 2) the relationship between NRS-2002, BIA parameters and selected outcomes: length of hospital stay (LOS); death and need of intensive care unit (ICU); prolonged LOS; and loss of appetite.

RESULTS

Data of 90 patients were analyzed. Patients at nutritional risk were 92% with NRS-2002, with BIA-derived parameters: 88% by phase angle; 86% by body cell mass; 84% by fat-free mass and 84% by fat mass (p-value ≤0.001). In ROC analysis, NRS had the maximum sensitivity in predicting the risk of death and need of ICU and a prolonged hospitalization showing moderate-low specificity; phase angle showed a good predictive power in terms of AUC. NRS-2002 was significantly associated with LOS (β 12.62, SE 5.79). In a multivariate analysis, blood glucose level and the early warning score are independent predictors of death and need of ICU (OR 2.79, p ≤0.001; 1.59, p-0.029, respectively).

CONCLUSION

Present findings confirm the clinical utility of NRS-2002 to assess nutritional risk in patients with COVID-19 at hospital admission and in predicting LOS, and that bioimpedance does not seem to add further predictive value. An early detection of nutritional risk has to be systematically included in the management of COVID-19 patients hospitalized in internal medicine wards.

GeneXpert assay - A cutting-edge tool for rapid tissue diagnosis of tuberculous lymphadenitis

BACKGROUND

The most prevalent clinical entity of extra pulmonary tuberculosis is tuberculous lymphadenitis. However, it resembles other granulomatous conditions pathologically and obtaining tissue for microbiological diagnosis is also difficult. Thus it is a challenging task for diagnosis and early initiation of management. Fine needle aspiration cytology and biopsy are the diagnostic methods generally used to obtain the lymph node samples for histopathological and microbiological diagnosis. Mycobacterium culture on Lowenstein-Jensen medium remains the gold standard for definitive diagnosis, but its major limitations is a prolonged turn-around time of 2-4 weeks. The GeneXpert Mtuberculosis/RIF assay is a novel molecular diagnostic method for rapid diagnosis of tuberculosis and rifampicin resistance in clinical specimens.

METHODS

This was a cross sectional analytical study conducted on 67 cases of suspected tubercular lymphadenitis at R.L Jalappa Hospital and Research Centre, Tamaka, Kolar. The study was carried out between December 2017 to June 2019. The samples were collected using excision biopsy and subjected to GeneXpert Mtuberculosis/RIF assay and histopathology. Further, sensitivity, specificity, positive predictive value and negative predictive value was measured and compared with histopathology.

RESULTS

The average age of the patients was 37.04 ± 19.27 and majority was males. The lymph nodes were predominantly present in cervical region. Histopathology analysis reveals 46 positive cases of tuberculosis Lymphadenitis and GeneXpert Mtuberculosis/RIF assay detects 42 cases of tuberculosis Lymphadenitis. In the present study, GeneXpert Mtuberculosis/RIF assay had a sensitivity of 82.60% and specificity of 85% when compared to histopathology. Further the PPV and NPV was found to be 92.68% and 68% respectively. GeneXpert Mtuberculosis/RIF showed 2 cases of rifampicin resistance out of 67 cases. In this study, the GeneXpert Mtuberculosis/RIF showed the results in 0.79 days.

CONCLUSION

The present study showed that GeneXpert Mtuberculosis/RIF is a simple and reliable technique for diagnosing tuberculosis Lymphadenitis with high specificity and sensitivity as compared histopathology. Further, the methods elicit rapid diagnosis and also detected rifampicin resistance. It is thus a reliable and useful diagnostic modality in rapid detection of the causative agent and initiation of appropriate category anti-tubercular therapy when necessary.

Geriatric Nutritional Risk Index as a Screening Tool to Identify Patients with Malnutrition at a High Risk of In-Hospital Mortality among Elderly Patients with Femoral Fractures-A Retrospective Study in a Level I Trauma Center

BACKGROUND

Malnutrition is frequently underdiagnosed in geriatric patients and is considered to be a contributing factor for worse outcomes during hospitalization. In addition, elderly patients who undergo trauma are often malnourished at the time of incurring fractures. The geriatric nutritional risk index (GNRI), calculated based on the serum albumin level and the ratio of present body weight to ideal body weight, was proposed for the assessment of the nutritional status of elderly patients with various illnesses. This study aimed to investigate whether the GNRI has a prognostic value that links the nutritional status and mortality outcomes of elderly patients who have previously undergone trauma with femoral fractures.

METHODS

From January 1, 2009 to December 31, 2019, a total of 678 elderly patients with femoral fractures were categorized into four nutritional risk groups: a major-risk group (GNRI <82; group 1, n = 127), moderate-risk group (GNRI 82- <92; group 2, n = 179), low-risk group (GNRI 92-98; group 3, n = 123), and no-risk group (GNRI >98; group 4, n = 249). To minimize the confounding effects of sex, age, preexisting comorbidities, and injury severity of patients on outcome measurements, propensity score-matched patient cohorts were created to assess the impact of patients being in different nutritional risk groups on the in-hospital mortality outcomes against the no-risk group.

RESULTS

The patients in groups 1-3 were significantly older and presented a significantly lower body mass index and lower serum albumin levels than those in group 4. Compared with patients in group 4 (3.6%), a significantly higher mortality rate was found in the patients in group 1 (17.3%, p < 0.001), but not in those in group 2 (6.7%) or group 3 (2.4%). The study of propensity score-matched patient cohorts provided similar results; group 1 patients had significantly higher odds of mortality than group 4 patients (odds ratio, 6.3; 95% confidence interval, 1.34-29.37; p = 0.009), but there were no significant differences in mortality risks among patients in groups 2 and 3 compared with those in group 4.

CONCLUSIONS

This preliminary study suggested that the GNRI may be used as a screening tool to identify patients with malnutrition at a high risk of mortality among elderly patients with femoral fractures. A prospective study is needed to validate the suggestion.

Impact of malnutrition on systemic immune and metabolic profiles in type 2 diabetes

BACKGROUND

While obesity and overweight status are firmly established risk factors for Type 2 diabetes mellitus (T2DM), a substantial proportion of diabetic individuals, especially in Africa and Asia, are often underweight or normal weight. However, very little is known about the immunological and metabolic profiles of these individuals.

METHODS

This study aimed to assess the relationship between malnutrition and Type 2 diabetes mellitus (T2DM). We examined a variety of analytes associated with the immunological and metabolic profiles of T2DM individuals with low (< 18.5 kg/m2) or normal (18.5-24.9 kg/m2) body mass index (BMI). To this end, we measured plasma levels of HbA1c, glucose, insulin, glucagon, adipocytokines and Type 1, Type 2, Type 17, pro-inflammatory and regulatory cytokines in T2DM individuals with low BMI (LBMI) or normal BMI (NBMI) with small sample size n = 44 in each group.

RESULTS

LBMI individuals exhibited significantly higher levels of HbA1c, random blood glucose, insulin and glucagon compared to NBMI individuals. Similarly, LBMI individuals exhibited significantly higher levels of adiponectin and adipsin and significantly lower levels of leptin in comparison to NBMI individuals. LBMI individuals also exhibited significantly lower levels of the Type 1, Type 2, Type 17, pro-inflammatory and regulatory cytokines in comparison to NBMI individuals. Finally, while the metabolic parameters exhibited a significant negative correlation with BMI, the immunological parameters exhibited a significant positive correlation with BMI.

CONCLUSIONS

Malnutrition is associated with a significant modulation of glycemic, hormonal and cytokine parameters in T2DM. Hence, the biochemical and immunological profiles of T2DM is significantly influenced by BMI.

Two measures of systemic inflammation are positively associated with haemoglobin levels in adolescent girls living in rural India: a cross-sectional study

OBJECTIVE

This study tested the hypothesis that systemic inflammation is inversely associated with haemoglobin levels in adolescent girls in India.

METHODS

The study population consisted of adolescent girls aged between 10 and 19 years living in a remote rural region in Maharashtra State, India. Data were collected on anthropometric measures, and a venous blood sample was taken and tested for complete blood count and C-reactive protein (CRP).

RESULTS

Of 679 individuals who were invited to the research site to participate, data were available from 401 participants giving a response rate of 59%. Median blood CRP was 1.26 mg/l (Range 0.00 to 26.33), and 167 (41.6%) participants had CRP level < 1.0 mg/l. The mean haemoglobin was 12.24 g/dl (standard deviation [SD] 1.51), and the mean total white blood cells (WBC) count was 9.02 × 10³ /μl (SD 2.00). With each g/dl increase in blood haemoglobin, the risk of having an elevated CRP of ≥ 1 mg/l increased with an odds ratio of 1.16 (95% CI 1.01 to 1.33, P = 0.03). Total WBC count was also positively associated with blood haemoglobin, increasing by 0.24 × 10³ /μl (95% CI 0.11 to 0.37, P < 0.001) per g/dl increase in haemoglobin. Both analyses were adjusted for age.

CONCLUSIONS

In this population, blood haemoglobin levels were positively associated with two measures of systemic inflammation, contrary to the primary hypothesis being tested. Other unmeasured environmental exposures may modify haemoglobin levels in this population. Understanding this observation may help design better public health interventions to improve the well-being of adolescent girls in India.

Elimination of Hepatic Rodent Plasmodium Parasites by Amino Acid Supplementation

Plasmodium parasites, causative agents of malaria, scavenge host nutrients to sustain their intracellular replication. Modulation of the host's nutritional status can potentially help control infection by limiting the parasite's access to nutrients, or by boosting the immune system. Here, we show that dietary supplementation of mice employing a combination of arginine (R) with two additional amino acids, lysine (K) and valine (V), termed RKV, significantly decreases Plasmodium liver infection. RKV supplementation results in the elimination of parasites at a late stage of their development in the liver. Our data employing genetic knockout mouse models and in vivo depletion of specific cell populations suggest that RKV supplementation boosts the host's overall innate immune response, and that parasite elimination is dependent on MyD88 signaling in immune cells. The immunostimulatory effect of RKV supplementation opens a potential role for dietary supplementation as an adjuvant for prophylaxis or immunization strategies against Plasmodium infection.

Novel sex-specific influence of parental factors on small-for-gestational-age newborns

Since fetal programming is sex-specific, there may also be sex-specific in parental influences on newborn birth weight. We aimed to investigate the influence of parental factors on small-for-gestational-age (SGA) infants of different sexes. Based on a pre-pregnancy cohort, multivariate logistic regression was used. 2275 couples were included for analysis. Significant associations were observed among paternal height, pre-pregnancy body mass index (BMI), and SGA in male infants; among maternal height, pre-pregnancy BMI, and SGA in female infants, and among other maternal factors and SGA in both male and female infants. Such sex specificity may be related to genetic, epigenetic, or hormonal influences between parents and infants. In conclusion, there is a sex specificity in the effect of parental height and pre-pregnancy BMI on SGA. The data suggest that future studies on infants should consider the sex-specific differences between the effects of genetic or environmental factors and infants.

A National Evaluation of Food Insecurity in a Head and Neck Cancer Population

OBJECTIVES/HYPOTHESIS

To determine the food security status of patients with a history of head and neck cancer and compare to other types of cancer.

STUDY DEIGN

A retrospective analysis using the National Health Interview Series.

METHODS

The National Health Interview Series (NHIS) for the calendar years 2014 to 18 was used to elicit food security status (secure, marginally secure/not secure) among adult patients with a history of throat/pharynx head and neck cancer (pHNC), thyroid cancer, and colon cancer. The relationship between food security and the primary site was compared and subanalyses were performed according to sex, race, and ethnicity.

RESULTS

The study population included 199.0 thousand patients with pHNC, with 17.7% (95% confidence interval, 10.5%-28.1%) of pHNC patients reporting their food security status as marginally secure or not secure. Food insecurity was significantly higher among pHNC patients when compared to thyroid cancer (insecurity 10.7%, [7.7%-14.7%]) and colon cancer patients (10.1%, [7.8%-13.2%]). Among pHNC patients, there was no significant difference in rates of food insecurity when stratified by gender, race, or ethnicity. However, black individuals were more likely to have food insecurity with a history of thyroid or colon cancer (P < .042) and Hispanics were more likely to have food insecurity with a history of thyroid cancer (P = .005).

CONCLUSIONS

Food insecurity disproportionally affects patients with a history of pHNC, though there is less demographic variability when compared to other cancer primary sites. Food security assessments should be part of the tailored approach to survivorship management in head and neck cancer.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1539-E1542, 2021.

Disentangling the effects of reproductive behaviours and fertility preferences on child growth in India

We analysed population data from the 2015-16 National Family Health Survey to disentangle the intricate underlying effects of reproductive behaviours and fertility preferences on child growth. We expected birth interval length to be more strongly associated with stunting than sibsize and these effects to be moderated by whether the child was wanted or unintended (mistimed/unwanted). Regression analyses showed strong and equal effects of short birth interval and sibsize on stunting, when adjusted for potential confounders and unobserved between-mother heterogeneity. There were no statistical associations between stunting and mistiming/unwantedness of index children, suggesting the absence of discrimination against such children. We conclude that while fertility preferences have no effect, reproductive behaviours exert significant influence on child growth. Sibsize has been falling for many years in India but birth interval lengths have remained largely unchanged. The results underscore the need for strengthening uptake of reversible contraceptives to enable longer birth intervals.

The influences of low protein diet on the intestinal microbiota of mice

Recent research suggests that protein deficiency symptoms are influenced by the intestinal microbiota. We investigated the influence of low protein diet on composition of the intestinal microbiota through animal experiments. Specific pathogen-free (SPF) mice were fed one of four diets (3, 6, 9, or 12% protein) for 4 weeks (n = 5 per diet). Mice fed the 3% protein diet showed protein deficiency symptoms such as weight loss and low level of blood urea nitrogen concentration in their serum. The intestinal microbiota of mice in the 3% and 12% protein diet groups at day 0, 7, 14, 21 and 28 were investigated by 16S rRNA gene sequencing, which revealed differences in the microbiota. In the 3% protein diet group, a greater abundance of urease producing bacterial species was detected across the duration of the study. In the 12% diet protein group, increases of abundance of Streptococcaceae and Clostridiales families was detected. These results suggest that protein deficiency may be associated with shifts in intestinal microbiota.

Nutritional status, environmental enteric dysfunction, and prevalence of rotavirus diarrhoea among children in Zambia

BACKGROUND

Rotavirus is the most common cause of fatal diarrhoeal disease among children under the age of five globally and is responsible for millions of hospitalizations each year. Although nutritional status and environmental enteric dysfunction (EED) are recognized as important predictors of susceptibility to diarrhoeal disease, no research to date has examined the mechanisms by which undernutrition and EED may protect against prevalence of rotavirus infection.

METHODS

We utilized data collected from a study evaluating the effectiveness of Rotarix™ vaccine against severe gastroenteritis among children under the age of 5 in Zambia. The prevalence of malnutrition, wasting, and stunting at the time of study enrollment was calculated using WHO child growth standards. Commercial ELISA kits were used to assess levels of faecal biomarkers for EED: alpha-1-antitrypsin and myeloperoxidase, and calprotectin. Separate multivariate logistic regression models were used to examine each measure of nutritional status and rotavirus diarrhoea including and excluding adjustment for EED.

RESULTS

In models that did not include adjustment for EED, malnourished children had 0.66 times the odds of having rotavirus diarrhoea compared to children with normal nutritional status (95% CI: 0.42, 1.0; p = 0.07). EED severity score was significantly higher among controls asymptomatic for diarrhoeal disease compared to cases with rotavirus diarrhoea (p = 0.02).

CONCLUSION

The morphological changes associated with EED may confer protection against rotavirus infection and subsequent diarrhoeal disease among children. Further research is critically needed to better understand the complex mechanisms by which nutritional status and EED may impact susceptibility to rotavirus in early life.

Changes in children's asthma prevalence over two decades in Lanzhou: effects of socioeconomic, parental and household factors

Background

The prevalence of childhood asthma may have changed with rapid economic development. This study aims to ascertain potential changes in asthma prevalence in relation to changes in socioeconomic, parental and household factors, based on a comparison between two periods spanning over 20 years in Lanzhou, a large northwestern city of China.

Methods

Cross-sectional studies using the same protocols were performed in Lanzhou, China in 1994–1995 (Period I) and in 2017 (Period II). Children of 6–12 years old from elementary schools were selected by a multistage sampling method. Information on the presence of asthma and asthma-related symptoms of children, socioeconomic status, feeding methods, parental illness and behavior patterns, as well as household characteristics, were collected through a questionnaire survey. Logistic regression models were used to estimate odds ratios of asthma prevalence with regard to socioeconomic, parental and household factors, respectively.

Results

Significant prevalence reductions were observed for paternal smoking, household coal use, and parental asthma, while the prevalence increased significantly for children sleeping in their own rooms or own beds, ventilation use during cooking, and parental occupation and education level after 22 years. In children, the prevalence of ever-diagnosed asthma decreased from 3.2% in period I to 1.5% in Period II (P<0.001); the prevalence of wheeze also decreased from 15.4% to 9.3% (P<0.001). Passive smoking (OR =1.531, 95% CI: 1.032–2.270) and poor household ventilation (OR =1.709, 95% CI: 1.208–2.416) were significantly associated with an increased prevalence of wheeze in Period I, whereas household mold (OR =2.112, 95% CI: 1.203–3.811) was significantly associated with prevalence of wheeze. Parental asthma history was associated with increased prevalence of asthma and asthma-related symptoms. Breastfeeding was significantly associated with reduced risk of asthma in period II children.

Conclusions

The prevalence of asthma and that of asthma-related symptoms were lower in 2017 than in 1994–1995 in school children living in Lanzhou. In 2017 with increased urbanization and industrialization, breastfeeding became a significant protective factor and household mold was a significant risk factor for asthma diagnosis and asthma-related symptoms. Promoting breastfeeding and household mold control is recommended to reduce the risk of childhood asthma in contemporary Lanzhou.

Neuronal changes and cognitive deficits in a multi-hit rat model following cumulative impact of early life stressors

Perinatal protein malnourishment (LP) is a leading cause for mental and physical retardation in children from poor socioeconomic conditions. Such malnourished children are vulnerable to additional stressors that may synergistically act to cause neurological disorders in adulthood. In this study, the above mentioned condition was mimicked via a multi-hit rat model in which pups born to LP mothers were co-injected with polyinosinic:polycytidylic acid (Poly I:C; viral mimetic) at postnatal day (PND) 3 and lipopolysaccharide (LPS; bacterial mimetic) at PND 9. Individual exposure of Poly I:C and LPS was also given to LP pups to correlate chronicity of stress. Similar treatments were also given to control pups. Hippocampal cellular apoptosis, β III tubulin catastrophe, altered neuronal profiling and spatial memory impairments were assessed at PND 180, using specific immunohistochemical markers (active caspase 3, β III tubulin, doublecortin), golgi studies and cognitive mazes (Morris water maze and T maze). Increase in cellular apoptosis, loss of dendritic arborization and spatial memory impairments were higher in the multi-hit group, than the single-hit groups. Such impairments observed due to multi-hit stress mimicked conditions similar to many neurological disorders and hence, it is hypothesized that later life neurological disorders might be an outcome of multiple early life hits.This article has an associated First Person interview with the first author of the paper.

Association of the Clinico-Demographic and Laboratory Profile with Treatment Outcomes in Patients with Drug-Resistant Pulmonary Tuberculosis

Background:

Drug-resistant tuberculosis (DR-TB) is a significant public health problem, especially in the developing and underdeveloped countries; its treatment is relatively expensive, of longer duration, and associated with more adverse effects.

Objective:

The objective of this study was to report the treatment outcomes in patients with DR-TB and determine if a few selected clinico-demographic parameters and baseline laboratory values, done as part of the pre-treatment evaluation, have any impact on sputum culture conversion and outcomes. The aim was to identify the potential factors associated with unfavourable outcomes prior to starting the treatment.

Methods:

A retrospective analysis of data of patients diagnosed with DR-TB admitted at our centre from January 2015 to May 2016 was done. Of the 114 patients included, culture reports were available in 85 and 72 patients at the end of the third and sixth month, respectively. The clinicodemographic and laboratory parameters were compared with the sputum culture report at the end of the third and sixth month and final treatment outcomes.

Results:

Favorable outcome (cured) was seen in 33.3% (38/114) patients. Female gender was associated with delayed sputum culture conversion at three months (P = 0.020). A positive culture at the end of the sixth month was significantly associated with unfavourable outcomes (P = 0.002). A low body mass index (BMI) (15.86 [IQR, 14.10-18.11]) and a higher platelet count (358 × 109/L [IQR, 282-4.85]) at the initiation of treatment were independently and significantly associated with unfavorable outcomes.

Conclusion:

Patients with a low BMI and high platelet count are more likely to have unfavourable treatment outcomes. Identifying patients with these risk factors during the pre-treatment phase, more intensive follow-up during the treatment course could be advocated.

Acinetobacter: An Enemy after Head and Neck Cancer Operations with Microvascular Free Flap Reconstruction?

Background: Patients after head and neck cancer reconstructive surgical procedures are predisposed to have post-operative surgical site infections (SSI) develop. They are very often caused by multi-drug resistant strains, including Acinetobacter baumannii as the most common one. Methods: The aim of the study was to determine important risk factors contributing to SSI of A. baumannii origin. The analysis included 134 head and neck cancer patients after salvage operations with microvascular free flap reconstruction. The A. baumannii was cultured in 27 of all 48 infected patients. Results: The following risk factors were significantly associated with A. baumannii infection: re-hospitalization before reconstructive operation (p = 0.00011), massive blood loss (p = 0.00277), and need of revision surgical procedure (p = 0.00419). Of patients with A. baumannii infection, 48% were hospitalized in a general intensive care unit (ICU) after operation that, together with prolonged intubation, constituted a strong risk factor of that infection (p = 0.01077). Mean time of hospital stay was significantly longer in the A. baumannii group (58 days vs. 35 days; p = 0.02697). Conclusions: Our analysis identified a subset of head and neck cancer patients after salvage operation with microvascular free flap reconstruction who are at high risk of A. baumannii infection developing. Previously hospitalized patients with extensive blood loss and need of surgical revision necessitate increased monitoring for the development of this complication. Mechanical ventilation and hospital stay in an ICU should be shortened maximally or avoided in that challenging group of patients. Early recognition of patients at high risk remains a key point to prevent or limit the spread of A. baumannii infections.

The Microbiota and Malnutrition: Impact of Nutritional Status During Early Life

According to the developmental origins of health and disease hypothesis, our health is determined by events experienced in utero and during early infancy. Indeed, both our prenatal and postnatal nutrition conditions have an impact on the initial architecture and activity of our microbiota. Recent evidence has underlined the importance of the composition of the early gut microbiota in relation to malnutrition, whether it be undernutrition or overnutrition, that is, in terms of both stunted and overweight development. It remains unclear how early microbial contact is linked to the risk of disease, as well as whether alterations in the microbiome underlie the pathogenesis of malnutrition or are merely the end result of it, which indicates that thequestion of causality must urgently be answered. This review provides information on the complex interaction between the microbiota and nutrition during the first 1,000 days of life, taking into account the impact of both undernutrition and overnutrition on the microbiota and on infants' health outcomes in the short- and long-term.

Severe skeletal lesions, osteopenia and growth deficit in a child with pulmonary tuberculosis (mid-20th century, Portugal)

OBJECTIVE

This case-study provides a summary of skeletal lesions seen in a case of diagnosed juvenile pulmonary tuberculosis with extensive multifocal bony lesions.

MATERIALS

Skeleton of a 9-year-old girl who died in the 1940s in Lisbon, Portugal. The remains of this individual are part of the Lisbon skeletal reference collection curated at the National Museum of Natural History and Science.

METHODS

Lesions and paleopathological conditions were identified and documented through macroscopic, radiographic, computed tomographic, and mammographic analysis.

RESULTS

The skeleton shows a variety of lytic lesions on the ribs and thoracic vertebrae including complete destruction of the bodies and fusion of the vertebral arches of four vertebrae, kyphosis, and scoliosis. Further pathological conditions were identified, including bone erosion, premature fusion of the left femoral head and greater trochanter, and abnormal size and shape changes to the lower limbs including loss of bone mass and stunting of the long bones.

CONCLUSIONS

Skeletal lesions are indicative of spondylitis, Pott's disease, and prolonged bedrest.

SIGNIFICANCE

This case is one of the few examples of confirmed juvenile pulmonary tuberculosis with skeletal lesions prior to the antibiotic era. As such, it provides a reference for the skeletal abnormalities which may be observed in archaeological tuberculosis cases.

LIMITATIONS

Pulmonary tuberculosis was recorded as cause of death, however there is no documentation to know the length of illness period or the existence of any comorbidities.

SUGGESTIONS FOR FURTHER RESEARCH

Consideration of multi-focal lesions is recommended when analyzing individuals with suspected tuberculosis.

The efficacy of a compounded micronutrient supplement on the incidence, duration, and severity of the common cold: A pilot randomized, double-blinded, placebo-controlled trial

Purpose

Viral upper respiratory infections are associated with significant health and economic impact. This study sought to determine the efficacy of routine immune system micronutrient supplementation on the incidence, duration and severity of common cold symptoms.

Methods

This pilot study was a randomized, double-blinded, placebo-controlled trial of N = 259 with asymptomatic participants aged 18 to 65 in two cold seasons of 2016 and 2017. The treatment group received an immune system targeted micronutrient caplet, while the placebo group received a micronized cellulose caplet externally identical to the treatment caplet. Weekly surveys were sent electronically to participants to document common cold incidence, duration and severity. Primary statistical results were obtained using mixed-effects logistic regressions to account for longitudinal measurements for participants.

Results

The odds of acquiring an upper respiratory infection, adjusted for potential confounders, was estimated to be 0.74 times lower in the treatment group (p = 0.14). The odds of reporting specific symptoms were statistically lower in the treatment arm compared to the placebo arm for runny nose (OR = 0.53, p = 0.01) and cough (OR = 0.51, p = 0.04). Shorter durations of runny nose and cough were also observed in the treatment arm compared to placebo (both p < 0.05). There was no significant difference in severity of symptoms in either group. The observed proportion of reported cold symptoms in the treatment group was lower compared to the placebo group between late January and February in two consecutive cold seasons. Given the physical, workplace and economic impact of upper respiratory infections, this low cost and low risk intervention should be further studied with more robust investigation and meticulous experimental design.

Comparing the effects of whey and casein supplementation on nutritional status and immune parameters in patients with chronic liver disease: a randomised double-blind controlled trial

Protein supplementation may be beneficial for patients with chronic liver disease (CLD). This study compared the effects of whey protein isolate (WP) and casein (CA) supplementation on nutritional status and immune parameters of CLD patients who were randomly assigned to take 20 g of WP or CA twice per d as a supplement for 15 d. Body composition, muscle functionality and plasmatic immunomarkers were assessed before and after supplementation. Patients were also classified according to the model for end-stage liver disease (MELD) into less (MELD < 15) and more (MELD ≥ 15) severe disease groups. Malnutrition, determined by the Subjective Global Assessment at baseline, was observed in 57·4 % and 54·2 % of patients in the WP and CA groups, respectively (P = 0·649). Protein intake was lower at baseline in the WP group than in the CA group (P = 0·035), with no difference after supplementation (P = 0·410). Both the WP and CA MELD < 15 groups increased protein intake after supplementation according to the intragroup analysis. No differences were observed in body composition, muscle functionality, most plasma cytokines (TNF, IL-6, IL-1β and interferon-γ), immunomodulatory proteins (sTNFR1, sTNFR2, brain-derived neurotrophic factor and glial cell line-derived neurotrophic factor) or immunomodulatory hormones (adiponectin, insulin and leptin) after supplementation in the WP groups at the two assessed moments. WP supplementation increased the levels of interferon-γ-induced protein-10/CXCL10 (P = 0·022), eotaxin-1/CCL11 (P = 0·031) and monocyte chemoattractant protein-1/CCL2 (P = 0·018) and decreased IL-5 (P = 0·027), including among those in the MELD ≥ 15 group, for whom IL-10 was also increased (P = 0·008). Thus, WP consumption by patients with CLD impacted the immunomodulatory responses when compared with CA with no impact on nutritional status.

Role of Leptin in Inflammation and Vice Versa

Inflammation is an essential immune response for the maintenance of tissue homeostasis. In a general sense, acute and chronic inflammation are different types of adaptive response that are called into action when other homeostatic mechanisms are insufficient. Although considerable progress has been made in understanding the cellular and molecular events that are involved in the acute inflammatory response to infection and tissue injury, the causes and mechanisms of systemic chronic inflammation are much less known. The pathogenic capacity of this type of inflammation is puzzling and represents a common link of the multifactorial diseases, such as cardiovascular diseases and type 2 diabetes. In recent years, interest has been raised by the discovery of novel mediators of inflammation, such as microRNAs and adipokines, with different effects on target tissues. In the present review, we discuss the data emerged from research of leptin in obesity as an inflammatory mediator sustaining multifactorial diseases and how this knowledge could be instrumental in the design of leptin-based manipulation strategies to help restoration of abnormal immune responses. On the other direction, chronic inflammation, either from autoimmune or infectious diseases, or impaired microbiota (dysbiosis) may impair the leptin response inducing resistance to the weight control, and therefore it may be a cause of obesity. Thus, we are reviewing the published data regarding the role of leptin in inflammation, and the other way around, the role of inflammation on the development of leptin resistance and obesity.

Developing a model for prevention of malnutrition among children under 5 years old

Background

Serious consequences leading to the increase of infectious diseases and mortality of children justifies the importance of interventions for eradication of malnutrition. Thus, this study aimed to provide a model for the prevention of malnutrition among children under 5 years old (CU5) in Iran.

Methods

This paper is part of a bigger study, conducted in 2017 using a mixed methods approach. A model for prevention of malnutrition in CU5 was proposed based on the earlier steps, with the cooperation and consultation of experts and specialists. In the final step, a Delphi method was used to determine the validity of the proposed model.

Results

The main dimensions of the prevention model of malnutrition for CU5 in Iran included four level: basic causes, interventions, outcomes and impact. The proposed interventions are presented based on twelve areas: structural, intersectoral, political, economic, sanitary, health-oriented, research, educational/cultural, evaluation related, production, infrastructures and legal. Based on these areas, 118 solutions were finally selected for the final model. This model is designed based on the current conditions in different regions of Iran, the factors related to child malnutrition, affective context on policy making, the content of previous policies, the process of policy making in Iran, and key stakeholders and actors in policy making.

Conclusion

In order to prevent malnutrition, the causing factors should be identified and resolved. The adopted policies should be, more seriously, based on the presence of key stakeholders and actors. Most of the existing nutritional problems among children are because of inappropriate consumerism culture and habits in families and its transfer to children.

Malaria and Parasitic Neglected Tropical Diseases: Potential Syndemics with COVID-19?

The COVID-19 pandemic, caused by SARS-CoV-2, have surpassed 5 million cases globally. Current models suggest that low- and middle-income countries (LMICs) will have a similar incidence but substantially lower mortality rate than high-income countries. However, malaria and neglected tropical diseases (NTDs) are prevalent in LMICs, and coinfections are likely. Both malaria and parasitic NTDs can alter immunologic responses to other infectious agents. Malaria can induce a cytokine storm and pro-coagulant state similar to that seen in severe COVID-19. Consequently, coinfections with malaria parasites and SARS-CoV-2 could result in substantially worse outcomes than mono-infections with either pathogen, and could shift the age pattern of severe COVID-19 to younger age-groups. Enhancing surveillance platforms could provide signals that indicate whether malaria, NTDs, and COVID-19 are syndemics (synergistic epidemics). Based on the prevalence of malaria and NTDs in specific localities, efforts to characterize COVID-19 in LMICs could be expanded by adding testing for malaria and NTDs. Such additional testing would allow the determination of the rates of coinfection and comparison of severity of outcomes by infection status, greatly improving the understanding of the epidemiology of COVID-19 in LMICs and potentially helping to mitigate its impact.

Molecular Mechanism Contributing to Malnutrition and Sarcopenia in Patients with Liver Cirrhosis

Liver cirrhosis is frequently accompanied by disease-related malnutrition (DRM) and sarcopenia, defined as loss of skeletal muscle mass and function. DRM and sarcopenia often coexist in cirrhotic patients and are associated with increased morbidity and mortality. The clinical manifestation of both comorbidities are triggered by multifactorial mechanisms including reduced nutrient and energy intake caused by dietary restrictions, anorexia, neuroendocrine deregulation, olfactory and gustatory deficits. Maldigestion and malabsorption due to small intestinal bacterial overgrowth, pancreatic insufficiency or cholestasis may also contribute to DRM and sarcopenia. Decreased protein synthesis and increased protein degradation is the cornerstone mechanism to muscle loss, among others mediated by disease- and inflammation-mediated metabolic changes, hyperammonemia, increased myostatin and reduced human growth hormone. The concise pathophysiological mechanisms and interactions of DRM and sarcopenia in liver cirrhosis are not completely understood. Furthermore, most knowledge in this field are based on experimental models, but only few data in humans exist. This review summarizes known and proposed molecular mechanisms contributing to malnutrition and sarcopenia in liver cirrhosis and highlights remaining knowledge gaps. Since, in the prevention and treatment of DRM and sarcopenia in cirrhotic patients, more research is needed to identify potential biomarkers for diagnosis and development of targeted therapeutic strategies.

Nasopharyngeal colonisation with Streptococcus pneumoniae in malnourished children: a systematic review and meta-analysis of prevalence

BACKGROUND

Streptococcus pneumoniae is an intermittent commensal organism in the nasopharynx. Colonisation is a prerequisite for disease and malnourished children are especially susceptible to severe infection. This systematic review examines published prevalence rates of pneumococcal colonisation in the upper respiratory tract of chronically malnourished children <5 y of age.

METHODS

A systematic literature search was performed using MEDLINE, PubMed, Web of Science and Scopus. After screening, relevant studies were assessed for quality using Strengthening the Reporting of Observational Studies in Epidemiology criteria. Colonisation data were extracted and a random effects model was used to pool prevalence estimates.

RESULTS

Nine studies were included. The prevalence rate of S. pneumoniae colonisation in malnourished children during the first month of life ranged from 1.0 to 2.0%, increasing at 2 mo to 53.9-80.0%. Carriage remained similar from 3 to 60 mo at 64.1-88.0%. Meta-analysis showed a pooled prevalence of 67.2% in infants 0-3 mo of age (95% confidence interval [CI] 55.6 to 78.7), 77.9% in infants 3-6 mo of age (95% CI 68.1 to 87.7) and 77.8% in infants 6-60 mo of age (95% CI 73.9-81.6%).

CONCLUSIONS

In malnourished children, it is plausible that rates of pneumococcal colonisation are higher than in healthy, well-nourished children. Knowledge of colonisation rates can inform policies on vaccination and ancillary interventions during treatment of malnutrition. Future studies should assess the impact of reducing colonisation on disease rates or transmission in these 'at-risk' individuals.

Impact of old age on the association between in-center extended-hours hemodialysis and mortality in patients on incident hemodialysis

With the global problem of aging, it has become more difficult to improve the prognosis of older dialysis patients. Extended-hours hemodialysis offers longer treatment time compared to conventional hemodialysis regimen and provides favorable metabolic status, hemodynamic stability, and increased dietary intake. Despite prior studies reporting that in-center extended-hours hemodialysis can reduce the mortality rate, the treatment impact on elderly patients remains unclear. Therefore, we examined the association between extended-hours hemodialysis compared to conventional hemodialysis and all-cause mortality. Survival analyses using Cox proportional hazard model with multivariable adjustments and propensity-score based method were performed to compare mortality risk between 198 consecutive patients who started in-center extended-hours hemodialysis (Extended-HD) and 1407 consecutive patients who initiated conventional hemodialysis. The median age was 67.1 years in the Extended-HD group and 70.7 years in the conventional hemodialysis group. Extended-HD was associated with lower all-cause mortality in overall patients and the subgroup >70 years (adjusted hazard ratios of 0.60 [95% CI, 0.39–0.91] and 0.35 [95% CI, 0.18–0.69], respectively). There was a significant interaction between age >70 years and Extended-HD. In conclusion, extended-hours hemodialysis was associated with a lower mortality rate, especially in elderly patients.

Dietary Regulation of Memory T Cells

Memory T cells are a fundamental component of immunological memory, providing rapid and potent host protection against secondary challenges. As such, memory T cells are key targets in the design of vaccination strategies and cancer immunotherapies, making it critical to understand the factors and mechanisms that regulate their biology. Diet is an environmental feature that impacts virtually all aspects of host physiology. However, the influence of specific dietary regiments and nutritional components on the immune system is only just starting to be uncovered. This article will review literature regarding the impact of diet and nutrition on memory T cell development, maintenance and function. It was recently shown that caloric restriction without undernutrition enhances memory T cell function, while diets high in fiber are also beneficial. However, memory T cell responses are dysfunctional in extreme nutritional states, such as undernutrition and diet-induced obesity. Therefore, diet and host nutritional status are major regulators of memory T cell biology and host fitness. To define the dietary balance required to promote optimal memory T cell responses could allow for the implementation of rational diet-based therapies that prevent or treat disease. Furthermore, that certain dietary regiments can enhance memory T cell function indicates the possibility of harnessing the underlying mechanisms in the design of novel vaccination strategies and cancer immunotherapies.

Multimodal Role of Amino Acids in Microbial Control and Drug Development

Amino acids are ubiquitous vital biomolecules found in all kinds of living organisms including those in the microbial world. They are utilised as nutrients and control many biological functions in microorganisms such as cell division, cell wall formation, cell growth and metabolism, intermicrobial communication (quorum sensing), and microbial-host interactions. Amino acids in the form of enzymes also play a key role in enabling microbes to resist antimicrobial drugs. Antimicrobial resistance (AMR) and microbial biofilms are posing a great threat to the world's human and animal population and are of prime concern to scientists and medical professionals. Although amino acids play an important role in the development of microbial resistance, they also offer a solution to the very same problem i.e., amino acids have been used to develop antimicrobial peptides as they are highly effective and less prone to microbial resistance. Other important applications of amino acids include their role as anti-biofilm agents, drug excipients, drug solubility enhancers, and drug adjuvants. This review aims to explore the emerging paradigm of amino acids as potential therapeutic moieties.

Nutrition and Athlete Immune Health: New Perspectives on an Old Paradigm

Respiratory and gastrointestinal infections limit an athlete's availability to train and compete. To better understand how sick an athlete will become when they have an infection, a paradigm recently adopted from ecological immunology is presented that includes the concepts of immune resistance (the ability to destroy microbes) and immune tolerance (the ability to dampen defence yet control infection at a non-damaging level). This affords a new theoretical perspective on how nutrition may influence athlete immune health; paving the way for focused research efforts on tolerogenic nutritional supplements to reduce the infection burden in athletes. Looking through this new lens clarifies why nutritional supplements targeted at improving immune resistance in athletes show limited benefits: evidence supporting the old paradigm of immune suppression in athletes is lacking. Indeed, there is limited evidence that the dietary practices of athletes suppress immunity, e.g. low-energy availability and train- or sleep-low carbohydrate. It goes without saying, irrespective of the dietary preference (omnivorous, vegetarian), that athletes are recommended to follow a balanced diet to avoid a frank deficiency of a nutrient required for proper immune function. The new theoretical perspective provided sharpens the focus on tolerogenic nutritional supplements shown to reduce the infection burden in athletes, e.g. probiotics, vitamin C and vitamin D. Further research should demonstrate the benefits of candidate tolerogenic supplements to reduce infection in athletes; without blunting training adaptations and without side effects.

Malnutrition and inflammation in hemodialysis patients: Comparative evaluation of neutrophil reactive oxygen formation

BACKGROUND

Impaired phagocytic function has been established in uremic patients. Chemotaxis, particle ingestion, and free radical and metabolic activity were all found to be disturbed in dialysis patients. Malnutrition is common among hemodialysis (HD) patients, with an estimated prevalence of 40% to 70%. Malnutrition-Inflammation Score (MIS) appears to be a useful tool for risk stratification of chronic HD patients. We assessed the correlation between MIS and phagocyte function in HD patients.

METHODS

Forty-four chronic HD patients were enrolled from the dialysis unit. The patients were divided into two groups according to the MIS: 1 to 12 (normal-mild) and 13 to 30 (severely malnourished). Hydrogen peroxide release by polymorphonuclear leukocytes was evaluated using the dihydrorhodamine 123 method. Phagocytic activity of neutrophils was evaluated after stimulation with Escherichia coli bacteria and phorbol 12-myristate 13-acetate (PMA) (positive control).

RESULTS

Neutrophil oxidative activity in all HD patients versus healthy controls was significantly lower in median fluorescence intensity (MdFI)-E. coli and MdFI-PMA. We found significant correlations among MdFI-PMA and calculated MIS and other nutritional parameters in chronic HD patients.

CONCLUSIONS

Impaired phagocytic function was identified in chronic HD patients. The severity of the impairment was associated with nutrition and inflammation parameters, as well as Malnutrition-Inflammation Score.

A Retrospective Case-Control Study of the Relationship between the Gut Microbiota, Enteropathy, and Child Growth

The microbial communities residing in the child gut are thought to play an important role in child growth, although the relationship is not well understood. We examined a cohort of young children from Mirzapur, Bangladesh, prospectively over 18 months. Four fecal markers of environmental enteropathy (EE) (high levels of alpha-1-antitrypsin, calprotectin, myeloperoxidase, and neopterin) were examined and anthropometric measures obtained from a cohort of 68 children. The 16S rRNA gene of bacterial DNA was sequenced from stool samples and used to estimate amplicon sequence variants (ASVs). We age-matched children with poor growth to children with normal growth within 1 month and compared the change in abundance and diversity of ASVs over time. Elevated EE markers and poor linear growth in children were associated with changes in microbial communities in the gut. There were increased amounts of Escherichia/Shigella and Proteobacteria and decreased amounts of Prevotella associated with poorly growing children consistent with the mounting evidence supporting the relationship between intestinal inflammation, child growth, and changes in gut microbiota composition. Future research is needed to investigate this association among young children in low- and middle-income countries.

The nutrition risk index is associated with bacteremia within 30 days after autologous stem cell transplantation in patients with multiple myeloma

OBJECTIVES

To assess whether the nutrition risk index (NRI) is associated with the risk of bacteremia within the first days after autologous stem cell transplantation (ASCT) in patients with multiple myeloma (MM).

MATERIALS AND METHODS

Retrospective cohort study of adult patients with MM taken to ASCT at the Hospital Universitario San Ignacio (Bogotá, Colombia) between 2005 and 2019. The outcome of interest was the incidence of bacteremia at 30 days. Multivariate analysis was used to identify whether the NRI was associated with bacteremia, controlling by different confounding variables.

RESULTS

One hundred and twenty-four patients with a median age of 58.5 years (IQR: 54-64) were included. 47.1% were in stage ISS III. 36.0% had moderate or severe malnourishment (NRI < 97.5). 11.2% presented bacteremia in the first 30 days after transplantation. In the univariate analysis, the NRI < 97.5 was associated with bacteremia (OR: 1.88; 95% CI: 1.30-2.72, P = .001); however, this association was not significant in the multivariate analysis, unlike the presence of mucositis (OR: 11.59; 95% CI: 1.9-68.3, <0.01), one or more previous lines of therapy (OR: 12.0; 95% CI: 2.1-67.4; P < .01), and duration of aplasia (OR: 1.70; 95% CI: 1.2-2.4, P < .01).

CONCLUSIONS

Patients with moderate or severe malnourishment have a higher incidence of bacteremia in the 30 days post-ASCT in patients with MM. Additional risk factors associated with bacteremia include the presence of mucositis, one or more previous lines of therapy, and the duration of aplasia.

Low body mass index has minimal impact on plasma levels of cytokines and chemokines in tuberculous lymphadenitis

Malnutrition, due to low body mass index (LBMI), is considered to be one of the key risk factors for tuberculosis (TB) development. The link between pro and anti-inflammatory cytokines and BMI has been studied in active pulmonary TB. However, the association of BMI with cytokines and chemokines in TB lymphadenitis (TBL) has not been examined. Hence, we wanted to examine the plasma levels of different cytokines and chemokines in TBL individuals with LBMI, normal BMI (NBMI) and high BMI (HBMI). LBMI with TBL disease is associated with enhanced systemic levels of type 1 (tumor necrosis factor alpha [TNFα], interleukin-2 [IL-2]) and type 2 (IL-4, IL-13) cytokines in comparison with NBMI and/or HBMI. However, other pro-inflammatory (IFNγ, IL-1β, IL-17A, IL-6, IL-7, IL-12, G-CSF, and GM-CSF) and anti-inflammatory (IL-5 and IL-10) cytokines were not significantly different among the TBL individuals with different BMI status. Likewise, no significant differences were observed in the CC (CCL-1, CCL-2/MCP-1, CCL3/MIP1α, CCL4/MIP-1β, CCL11/eotaxin) and CXC (CXCL-1/GRO-⍺, CXCL2/GRO-β, CXCL9/MIG, CXCL10/IP-10, CXCL11/ITAC 1) chemokine profile among the TBL individuals with different BMI. Hence, our data implies that TBL individuals with LBMI are characterized by minimal effects on plasma cytokines and chemokines in TBL.

Efficacy of compositing with snail meat powder on protein nutritional quality of sorghum-wheat buns using a rat bioassay

BACKGROUND

Protein energy malnutrition (PEM) is an important health burden in most developing countries mainly in sub-Saharan Africa, where it contributes to high rates of child morbidity and mortality. This study evaluated the efficacy of compositing with snail meat powder (SMP) on protein nutritional quality of sorghum-wheat buns using a rat bioassay. Nine diets -seven isonitrogenous diets, based on six variations of buns and a reference diet made using skimmed milk powder, in addition to the basal diet meant to estimate the endogenous nitrogen excretion and a 16% protein rehabilitation diet - were fed to male weanling albino rats. Protein efficiency ratio (PER), and food efficiency ratio (FER), net protein retention ratio (NPRR), apparent protein digestibility (APD), and true protein digestibility (TPD), protein digestibility corrected amino acid score (PDCAAS), and digestible indispensable amino acid score (DIAAS) indices of protein quality were determined.

RESULTS

Fortification with SMP significantly (P < 0.05) enhanced PER from 0.21% to 2.70%, FER from 0.02% to 0.27%, APD from 81.17% to 88.28%, and TPD from 87.48% to 95.38%. PDCAAS and DIAAS increased from 45% to 78% and 44% to 69% respectively in unfortified buns to buns fortified with 25% SMP.

CONCLUSION

Complementary diets fortified with SMP promote growth and rehabilitate emaciated rats, whereas unfortified diet did not support weight gain. Thus, supplementation of buns with SMP might enhance a faster recovery in children affected by PEM. © 2020 Society of Chemical Industry.

Increased host ATP efflux and its conversion to extracellular adenosine is crucial for establishing Leishmania infection

Intracellular survival of Leishmania donovani demands rapid production of host ATP for its sustenance. However, a gradual decrease in intracellular ATP in spite of increased glycolysis suggests ATP efflux during infection. Accordingly, upon infection, we show here that ATP is exported and the major exporter was pannexin-1, leading to raised extracellular ATP levels. Extracellular ATP shows a gradual decrease after the initial increase, and analysis of cell surface ATP-degrading enzymes revealed induction of the ectonucleotidases CD39 and CD73. Ectonucleotidase-mediated ATP degradation leads to increased extracellular adenosine (eADO), and inhibition of CD39 and CD73 in infected cells decreased adenosine concentration and parasite survival, documenting the importance of adenosine in infection. Inhibiting adenosine uptake by cells did not affect parasite survival, suggesting that eADO exerts its effect through receptor-mediated signalling. We also show that Leishmania induces the expression of adenosine receptors A2AR and A2BR, both of which are important for anti-inflammatory responses. Treating infected BALB/c mice with CD39 and CD73 inhibitors resulted in decreased parasite burden and increased host-favourable cytokine production. Collectively, these observations indicate that infection-induced ATP is exported, and after conversion into adenosine, propagates infection via receptor-mediated signalling.

rs6127698 polymorphism in the MC3R gene and susceptibility to multifocal tuberculosis in southern Chinese Han population

OBJECTIVE

To investigate the relationship between melanocortin-3 receptor (MC3R) gene polymorphism and tuberculosis (TB) susceptibility in Han population in southern China.

METHODS

A total of 341 patients with TB (173 with pulmonary TB and 168 with multifocal TB) and 359 healthy controls were enrolled. Genotyping was performed by PCR and DNA sequencing, and detection of protein was performed by western blot.

RESULTS

The distributions of genotype and allele frequencies of rs6127698 differed significantly between the pulmonary and multifocal TB groups, and between the multifocal TB and control groups. The GG genotype was significantly more common among multifocal TB patients than among pulmonary TB patients (P = .009) and those in the control group (P = .001) under the recessive model. GG+GT genotype was more common in multifocal TB than in pulmonary TB (P < .01) and control group (P < .01) under the dominant model. G allele was more common in multifocal TB than in pulmonary TB (P < .0167) and control group (P < .0167). Patients with multifocal TB had an increased expression of MC3R protein than healthy controls (P < .05).

CONCLUSIONS

In the southern Chinese Han population, the MC3R rs6127698 polymorphism, which accompanying an increased expression of MC3R protein,was associated with susceptibility to multifocal TB. Presence of the G allele increased the risk of developing multifocal TB.

Impact of Malnutrition on Outcomes Following Transcatheter Aortic Valve Implantation (from a National Cohort)

Malnutrition is associated with increased mortality in open cardiac surgery, but its impact on transcatheter aortic valve implantation (TAVI) is unknown. This study utilized the National Readmissions Database to evaluate the impact of malnutrition on mortality, complications, length of stay (LOS), 30-day readmission, and total charges following TAVI. Adult patients undergoing isolated TAVI for severe aortic stenosis were identified using the 2011 to 2016 National Readmissions Database, which accounts for 56.6% of all US hospitalizations. The malnourished cohort included patients with nutritional neglect, cachexia, protein calorie malnutrition, postsurgical nonabsorption, weight loss, and underweight status. Multivariable models were utilized to evaluate the impact of malnutrition on selected outcomes. Of 105,603 patients, 5,280 (5%) were malnourished. Malnourished patients experienced greater mortality (10.4% vs 2.2%, p <0.001), postoperative complications (49.2% vs 22.6%, p <0.001), 30-day readmission rates (21.4 vs 14.9%, p <0.001), index hospitalization charges ($331,637 vs $208,082, p <0.001), and LOS (16.4 vs 6.2 days, p <0.001) relative to their nourished counterparts. On multivariable analysis, malnutrition remained a significant, independent predictor of increased index mortality (Adjusted odds ratio (AOR) = 2.68, p <0.001), complications (AOR = 2.09, p <0.001), and 30-day readmission rates (AOR = 1.34, p <0.001). Malnutrition was most significantly associated with infectious complications at index hospitalization (AOR = 3.88, p <0.001) and at 30-day readmission (AOR = 1.43, p <0.027). In conclusion, malnutrition is independently associated with increased mortality, complications, readmission, and resource utilization in patients undergoing TAVI. Preoperative risk stratification and malnutrition modification may improve outcomes in this vulnerable population.

Risk factors for child food contamination in low-income neighbourhoods of Maputo, Mozambique: An exploratory, cross-sectional study

In low‐ and middle‐income countries, food may be a critical transmission route for pathogens causing childhood diarrhoea, but basic food hygiene is often overlooked in public health strategies. Characterising child food contamination and its risk factors could help prioritise interventions to reduce foodborne diarrhoeal disease, especially in low‐income urban areas where the diarrhoeal disease burden is often high. This cross‐sectional study comprised a caregiver questionnaire coupled with food sampling, and food preparation observations, among the study population of an ongoing sanitation trial in Maputo. The aim was to determine the prevalence of child food contamination and associated risk factors. The prevalence of Enterococcus spp., as an indicator of faecal contamination, was estimated in food samples. Risk factor analyses were performed through zero‐inflated negative binomial regression on colony counts. A modified hazard analysis and critical control point approach was used to determine critical control points (CCPs) that might effectively reduce risk. Fifty‐eight linked caregiver questionnaires and food samples were collected, and 59 food preparation observations were conducted. The prevalence of enterococci in child foods exceeding 10 colony forming units per gram was 53% (95% confidence interval [40%, 67%]). Risk factors for child food contamination were identified, including type of food, food preparation practices, and hygiene behaviours. CCPs included cooking/reheating of food and food storage and handling. This exploratory study highlights the need for more research into diarrhoeagenic pathogens and foodborne risks for children living in these challenging urban environments.

Engaging hospitalised patients in their nutrition care using technology: development of the NUTRI-TEC intervention

Background

Nutrition is vital for health and recovery during hospitalisation, however most patients fail to meet minimum dietary requirements and up to 50% of patients are malnourished in hospital. When patients participate in nutrition care, their dietary intakes are improved. Advances in health information technology (HIT) have broadened the ways by which patients can participate in care. Our team has developed an innovative, HIT-based intervention (called NUTRI-TEC; engaging patients in their nutrition care using technology), facilitating patient participation in their nutrition care in hospital. This paper aims to describe the systematic and iterative process by which the intervention was developed.

Methods

NUTRI-TEC development was informed by the Medical Research Council guidance for developing complex interventions and underpinned by theoretical frameworks and concepts (i.e. integrated knowledge translation and patient participation in care), existing evidence and a rigorous program of research. The intervention was co-developed by the multidisciplinary research team and stakeholders, including health consumers (patients), health professionals and industry partners. We used an iterative development and evaluation cycle and regularly tested the intervention with hospital patients and clinicians.

Results

The NUTRI-TEC intervention involves active patient participation in their nutrition care during hospitalisation. It has two components: 1) Patient education and training; and 2) Guided nutrition goal setting and patient-generated dietary intake tracking. The first component includes brief education on the importance of meeting energy/protein requirements in hospital; and training on how to use the hospital’s electronic foodservice system, accessed via bedside computer screens. The second component involves patients recording their food intake after each meal on their bedside computer and tracking their intakes relative to their goals. This is supported with brief, daily goal-setting sessions with a health care professional.

Conclusions

NUTRI-TEC is a HIT intervention designed to enable patient participation in their nutrition care in hospital. As research on HIT interventions to engage patients in health care in the hospital setting is in its infancy, and as gaps and inconsistencies in the development of such interventions exist, this paper will inform future development of HIT-based interventions in the hospital setting.

Incidence, clinical profile, and risk factors for serious bacterial infections in children hospitalized with fever in Ujjain, India

Background

Fever is a cause for concern for both parents and the treating pediatrician and a common reason for antibiotic overuse. However, the proportion of children hospitalized for fever with serious bacterial infection (SBI) is uncertain. We aimed to evaluate the epidemiological, clinical, hematological, and biochemical risks for SBI among the children admitted with fever.

Method

This prospective study was conducted in a rural teaching hospital in India on consecutive children, aged 3 months–12 years, presenting with fever 100 °F (37.7 °C) or higher. The presence of SBI was confirmed with one of the following criteria: (a) a positive blood culture; (b) roentgenographically confirmed pneumonia with high titres of C-reactive protein; (c) a culture-confirmed urinary tract infection; (d) enteric fever diagnosed clinically in addition to either a positive blood culture or high Widal titers; and (e) meningitis diagnosed clinically in addition to either a positive blood culture or cerebrospinal fluid culture. A predefined questionnaire was filled.

Results

A total of 302 children were included in the study, out of which 47% (95% CI 41.4–52.7%) presented with SBI. The factors associated with confirmed SBI in bivariate analysis were history of previous hospitalization, history of chronic illness, history of medication in the previous 1 week, a partially immunized child, history of common cold, moderate-grade fever, toxic look, significant lymphadenopathy, absence of BCG scar, delayed development, irritability, breathlessness, respiratory distress, poor feeding, significant weight loss, suspected urinary tract infection, hyponatremia, hypokalemia, and abnormal leucocyte count. The final generalized logistic regression model revealed partially immunized child (RR 4.26), breathlessness (RR 1.80), weight loss (RR 2.28), and suspected urinary tract infection (RR 1.95) as risk factors for the increased risk of SBI.

Conclusion

The study identified multiple risk factors for SBI. Pediatricians can be made aware of these risk factors. Further studies are warranted to identify age-specific risk factors for SBI because most clinicians depend on clinical signs and symptoms to identify SBI.

Risk Factors for Stunting in Children under the Age of 5 in Rural Guatemalan Highlands

Background

Previously, a study conducted by UNICEF found that malnutrition affects approximately 80% of the indigenous children in Guatemala.

Objective

Identify prevalence and risk factors for stunted growth in communities surrounding Lake Atitlán, Guatemala.

Methods

Height-for-age measurements of children under the age of five, N = 84, determined stunting prevalence and presumed burden of malnutrition in this region of the Guatemalan highlands. Mothers of a subset of this sample, N = 29, were interviewed to assess factors contributing to stunting. Analysis assessed the following risk factors: inadequate nutrition, increased infectious disease risk, high rate self-report illness, inadequate breastfeeding, and inadequate utilization of prenatal care.

Findings

The majority of children under the age of five were stunted (65.6%) and likely malnourished. ANOVA analysis showed significant differences in mean height-for-age Z scores (HAZs) between groups with and without adequate nutrition (F = 7.069, p = 0.013), as well has with and without high rates of self-report illness (F = 6.894, p = 0.014). Both groups with inadequate nutrition (mean HAZs = -2.9, 95% CI = [-3.58, -2.24]) and high rates of self-report illness (mean HAZs = -2.8, 95% CI = [-3.13, -2.38]) had mean HAZs that are indicative of stunting. No other risk factors were associated with stunting.

Conclusion

These pilot study results offer methods by which to obtain baseline data for assessing nutritional and public health interventions to improve stunting and malnutrition status as well as the health outcomes of children in rural, indigenous communities.

Nutritional and health status of children 15 months after integrated school garden, nutrition, and water, sanitation and hygiene interventions: a cluster-randomised controlled trial in Nepal

Background

It has been suggested that specific interventions delivered through the education sector in low- and middle-income countries might improve children’s health and wellbeing. This cluster-randomised controlled trial aimed to evaluate the effects of a school garden programme and complementary nutrition, and water, sanitation and hygiene (WASH) interventions on children’s health and nutritional status in two districts of Nepal.

Methods

The trial included 682 children aged 8–17 years from 12 schools. The schools were randomly allocated to one of three interventions: (a) school garden programme (SG; 4 schools, n = 172 children); (b) school garden programme with complementary WASH, health and nutrition interventions (SG+; 4 schools, n = 197 children); and (c) no specific intervention (control; 4 schools, n = 313 children). The same field and laboratory procedures were employed at the baseline (March 2015) and end-line (June 2016) surveys. Questionnaires were administered to evaluate WASH conditions at schools and households. Water quality was assessed using a Delagua kit. Dietary intake was determined using food frequency and 24-h recall questionnaire. Haemoglobin levels were measured using HemoCue digital device and used as a proxy for anaemia. Stool samples were subjected to a suite of copro-microscopic diagnostic methods for detection of intestinal protozoa and helminths. The changes in key indicators between the baseline and end-line surveys were analysed by mixed logistic and linear regression models.

Results

Stunting was slightly lowered in SG+ (19.9 to 18.3%; p = 0.92) and in the control (19.7 to 18.9%). Anaemia slightly decreased in SG+ (33.0 to 32.0%; p < 0.01) and markedly increased in the control (22.7 to 41.3%; p < 0.01), a minor decline was found in the control (43.9 to 42.4%). Handwashing with soap before eating strongly increased in SG+ (from 74.1 to 96.9%; p = 0.01, compared to control where only a slight increase was observed from 78.0 to 84.0%). A similar observation was made for handwashing after defecation (increase from 77.2 to 99.0% in SG+ versus 78.0 to 91.9% in control, p = 0.15).

Conclusions

An integrated intervention consisting of school garden, WASH, nutrition and health components (SG+) increased children’s fruit and vegetable consumption, decreased intestinal parasitic infections and improved hygiene behaviours.

Trial registration

ISRCTN17968589 (date assigned: 17 July 2015).

Ameliorating Food and Nutrition Security in Farm Households: Does Informatization Matter?

Improving food and nutrition security in Sub-Saharan Africa’s farm households has become a prominent priority subject for researchers and policymakers alike. Interestingly, it is realized through enhancement in dietary diversity and quality. To this end, better access to food and information is considered a prerequisite. Given that mobile phone coverage offers new prospects for increasing rural households’ access to information, can informatization (mobile phone used as a concrete example) possibly influence dietary diversity and quality? Cross-sectional data collected from farm households in Zambia is used to address this topic by applying the ordinary least square and endogenous switching regression (ESR). Household dietary diversity score was constructed based on a 7-days recall approach to measure consumption patterns. Our robust regression result indicates that mobile phone use positively and significantly influences dietary diversity and quality. Particularly, gender-disaggregated regression reveals that male-headed households have stronger positive associations than their counterparts. We also find that in comparison to non-adopters, adopters consume three more foods weekly. This is attributable to the income gains and increased frequency in information access on account of mobile phone adoption. Conversely, average consumption would increase by two more foods weekly if mobile phones were adopted in non-adopting households. Therefore, our study puts forwards substantial empirical evidence to warrant policy formulation directed at promoting informatization among farm households. Eventually, this could possibly recuperate dynamism in agricultural food production as food and nutrition security in farm households ameliorates.

A fruit diet rather than invertebrate diet maintains a robust innate immunity in an omnivorous tropical songbird

Diet alteration may lead to nutrient limitations even in the absence of food limitation, and this may affect physiological functions, including immunity. Nutrient limitations may also affect the maintenance of body mass and key life‐history events that may affect immune function. Yet, variation in immune function is largely attributed to energetic trade‐offs rather than specific nutrient constraints.

To test the effect of diet on life‐history traits, we tested how diet composition affects innate immune function, body mass and moult separately and in combination with each other, and then used path analyses to generate hypotheses about the mechanistic connections between immunity and body mass under different diet compositions.

We performed a balanced parallel and crossover design experiment with omnivorous common bulbuls Pycnonotus barbatus in out‐door aviaries in Nigeria. We fed 40 wild‐caught bulbuls ad libitum on fruits or invertebrates for 24 weeks, switching half of each group between treatments after 12 weeks. We assessed innate immune indices (haptoglobin, nitric oxide and ovotransferrin concentrations, and haemagglutination and haemolysis titres), body mass and primary moult, fortnightly. We simplified immune indices into three principal components (PCs), but we explored mechanistic connections between diet, body mass and each immune index separately.

Fruit‐fed bulbuls had higher body mass, earlier moult and showed higher values for two of the three immune PCs compared to invertebrate‐fed bulbuls. These effects were reversed when we switched bulbuls between treatments after 12 weeks. Exploring the correlations between immune function, body mass and moult, showed that an increase in immune function was associated with a decrease in body mass and delayed moult in invertebrate‐fed bulbuls, while fruit‐fed bulbuls maintained body mass despite variation in immune function. Path analyses indicated that diet composition was most likely to affect body mass and immune indices directly and independently from each other. Only haptoglobin concentration was indirectly linked to diet composition via body mass.

We demonstrated a causal effect of diet composition on innate immune function, body mass and moult: bulbuls were in a better condition when fed on fruits than invertebrates, confirming that innate immunity is nutrient specific. Our results are unique because they show a reversible effect of diet composition on wild adult birds whose immune systems are presumably fully developed and adapted to wild conditions—demonstrating a short‐term consequence of diet alteration on life‐history traits.

Associations between intestinal parasitic infections, anaemia, and diarrhoea among school aged children, and the impact of hand-washing and nail clipping

Objective

In marginalized setting, under-nutrition and illnesses due to infectious agents create a vicious circle. In our previous study, we reported that easy-to-do hand hygiene interventions were effective in preventing intestinal parasite infections (IPIs) and reduce the rate of anaemia among school-aged children. The aim of this study was to assess the pattern of associations between IPIs, anaemia and diarrhoea among the school-aged children and to explore if the observed impact of hand-washing and nail clipping interventions in our findings was similar across children with different baseline demographic and disease characteristics. The study was based on the analysis of data that was collected during the randomized controlled trial and hence have used the same study participants and study area.

Results

Children with IPIs had a much higher chance of also being anaemic (AOR 2.09, 95% CI 1.15–3.80), having diarrhoea (AOR 2.83, 95% CI 1.57–5.09), and vice versa. Anaemia and diarrhoea were very strongly related (AOR 9.62, 95% CI 5.18–17.85). Overall, hand-washing with soap at key times and weekly nail clipping were efficacious in preventing intestinal parasite re-infection among children despite the differences in baseline demographic characteristics.

Trial registration: NCT01619254 (June 09/2012)