Protocol for integrated solutions for healthy birth, growth and development: a cluster-randomised controlled trial to evaluate the effectiveness of a mixed nutrition intervention package in reducing child undernutrition in Lao People's Democratic Republic

INTRODUCTION

While Lao People's Democratic Republic has seen economic gains in recent years, one-third of children aged 5 years and under are stunted. There is a need for evidence around clinically effective and cost-effective integrated nutrition-specific and nutrition-sensitive interventions in the local context.

METHODS AND ANALYSIS

We aim to conduct a cluster-randomised control trial to test the effectiveness of an integrated package of community-based nutrition-specific and nutrition-sensitive interventions compared with the standard government package of nutrition actions. The trial will be in six districts within the province of Vientiane. We will recruit pregnant women in their third trimester and follow the children born to them every 6 months until 18 months of age. A total of 256 villages (serviced by 34 health centres) will be randomised to a control arm or an intervention arm using a minimisation algorithm. The primary outcome is the prevalence of stunting among children aged 6, 12 and 18 months. The secondary outcomes include prevalence of low birth weight and wasting among children aged 6, 12 and 18 months. Analyses for the primary and secondary outcomes will be conducted at the mother-infant dyad level and adjusted for the cluster randomisation. The difference in prevalence of low birth weight, wasting and stunting between control and intervention groups will be assessed using Pearson's χ2 tests and 95% CIs for the group difference, adjusted for clustering.

ETHICS AND DISSEMINATION

The trial protocol was approved by the Alfred Human Research Ethic Committee (Ref: 227/16) and the Lao National Ethics Committee for Health Research (Ref: 81). The trial was registered with the Australian New Zealand Clinical Trials Registry on 28 April 2020 (ACTRN12620000520932). The results will be disseminated at different levels: study participants; the local community; other Lao stakeholders including policymakers; and an international audience.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trials Registry: ACTRN12620000520932.

Antimicrobial resistance in the Pacific Island countries and territories

Antimicrobial resistance (AMR) is a critical global health threat with a disproportionate impact on low-income and middle-income countries (LMICs) due to their higher burden of infections, reduced laboratory surveillance infrastructure and fewer regulations governing antimicrobial use among humans or animals. While there have been increasing descriptions of AMR within many LMICs in WHO's Western Pacific and South East Asian regions, there remains a paucity of data from Pacific Island countries and territories (PICTs). The PICTs represent 22 predominantly middle-income countries and territories with a combined population of 12 million people and 20 official languages, spread over hundreds of separate islands spanning an area corresponding to more than 15% of the earth's surface. Our paper outlines the present state of the evidence regarding AMR in PICTs-discussing the present estimates of AMR and their accompanying limitations, important drivers of AMR, as well as outlining key priorities and potential solutions for tackling AMR in this region. Significant areas for action include developing National Action Plans, strengthening laboratory surveillance systems and educational activities targeted at both healthcare workers and the wider community. Ensuring adequate funding for AMR activities in PICTs is challenging given competing health and environmental priorities, in this context global or regional funding initiatives such as the Fleming Fund can play a key role.

Adverse effects of amphotericin B in children; a retrospective comparison of conventional and liposomal formulations

AIMS

Lipid formulations of amphotericin B, rather than conventional amphotericin (c-amB), are increasingly used despite limited data comparing these preparations in children. Data on the incidence of adverse effects with amphotericin B at standard doses are scarce. This study aimed to compare the adverse effects associated with standard doses of c-amB and liposomal amphotericin (l-amB) in children.

METHODS

Children admitted to the Royal Children's Hospital Melbourne and treated with c-amB or l-amB between January 2010 and September 2013 were included. Clinical and laboratory data were retrospectively extracted from medical records to compare amphotericin-related infusion reactions, nephrotoxicity (glomerulotoxicity and tubulopathy) and hepatotoxicity.

RESULTS

Seventy-six children received c-amB and 39 received l-amB. Standard drug administration (recommended dose and infusion time) occurred in 74% (56/76) of patients on c-amB and 85% (33/39) on l-amB. In these 89 children, infusion-related reactions were similar for both c-amB and l-amB (23% (13/56) vs. 9% (3/33); P = 0.15); none occurred in children aged <90 days. There was no difference in amphotericin-associated glomerulotoxicity (c-amB 14% (8/56) vs. l-amB 21% (7/33); P = 0.40) or in the median maximum potassium requirements (c-amB 3.1 vs. l-amB 2.3 mmol kg^-1  d^-1 ; P = 0.29). Hepatotoxicity occurred more frequently with l-amB than c-amB (83% (24/29) vs. 56% (20/36); P = 0.032).

CONCLUSIONS

When appropriately administered, l-amB was associated with more hepatotoxicity than c-amB, with no difference in infusion-related reactions or nephrotoxicity. Differences in adverse effects between the preparations is not as marked in children as reported in adults.

The development of One Health approaches in the Western Pacific

The Western Pacific Region, the most populous of six regional groupings of World Health Organization (WHO) member states, has seen the emergence of a series of novel zoonotic infections in the last decade. This has focused attention on addressing underlying risks and vulnerabilities in the complex interactions among people, animals, and environments as a better way to counter emerging diseases. This “One Health” approach is pertinent to the region because, it is a “hot spot” for the emergence of novel diseases from wildlife, because unexpected epidemics of re-emerging zoonotic diseases have caused morbidity and mortality in urban and periurban communities, and because it remains a sanctuary for well-known zoonotic infections. In this chapter, selected regional, multicountry, and national steps to operationalize One Health are discussed. While the region is well positioned to exploit the opportunities that have come with outbreaks of new diseases, the array of disconnected and overlapping initiatives from various consortia, donors, research institutes, and UN agencies is to some extent impeding the development of better ways of managing both new and old infections for the local, regional, and global good.

Are hard-to-reach populations being reached with immunization services? Findings from the 2005 Papua New Guinea national immunization coverage survey

OBJECTIVE

To measure immunization coverage among children aged 12-23 months in Papua New Guinea (PNG) and to assess if and why there are differences between hard-to-reach and more accessible communities.

METHODS

WHO cluster sampling methodology was employed to measure immunization coverage in PNG's four regions. Survey data were re-analyzed according to a local assessment of geographical accessibility indicated by census unit type: urban, rural and hard-to-reach. Census units were designated as hard-to-reach if they were five or more km from a health centre.

FINDINGS

Nationwide coverage for most antigens falls below the national target of 80% although there are regional differences with Islands performing the best. Late doses are a major concern: just 4% were fully immunized with valid ("on time") doses by 1 year of age. Coverage was lower in both rural and remote communities: at 6 months 48% of children from urban units had received three valid doses of DTP-3 but only 16% in rural areas and 13% in hard-to-reach communities. Reasons for failure to immunize varied: 21% of mothers said their child was not immunized because distance, travel conditions or cost of transportation prevented access to local health centres; 27% cited a lack of knowledge or misconceptions about immunization; while 29% believed it was because of an issue with the health system.

CONCLUSIONS

Throughout PNG there is an urgent need to increase immunization coverage and to ensure that children are immunized on time according to the schedule. Both coverage and timeliness of doses are worse for children living in hard-to-reach and rural areas. Achieving national immunization targets requires improvements in health service delivery, including outreach, especially for remote and rural communities, as well as greater community education and social mobilisation in support of immunization services.

Global control of hepatitis B virus: does treatment-induced antigenic change affect immunization?

Since its widespread introduction, the hepatitis B vaccine has become an essential part of infant immunization programmes globally. The vaccine has been particularly important for countries where the incidence of hepatitis B virus-related hepatocellular carcinoma is high. Effective treatment options for individuals with chronic hepatitis B infection were limited until 1998 when lamivudine, the first nucleoside analogue drug, was introduced. As a single treatment agent, however, lamivudine has a significant drawback: it induces lamivudine-resistant hepatitis B virus strains that may pose a risk to the global hepatitis B immunization programme. Mutations associated with drug treatment can cause changes to the surface antigen protein, the precise part of the virus that the hepatitis B vaccine mimics. However, the emergence of antiviral drug-associated potential vaccine escape mutants (ADAP-VEMs) in treated patients does not necessarily pose a significant, imminent threat to the global hepatitis B immunization programme. Nonetheless, there is already evidence that current treatment regimens have resulted in the selection of stable ADAP-VEMs. Treatment is currently intended to prevent the long-term complications of hepatitis B virus infection, with little consideration given to potential adverse public health impacts. To address individual and public health concerns, trials are urgently needed to find the optimal combination of existing drugs that are effective but do not induce the emergence of ADAP-VEMs. This paper examines the mechanism of antiviral drug-selected changes in the portion of the viral genome that also affects the surface antigen, and explores their potential impact on current hepatitis B immunization programmes.

Systematic review of the nutritional supplement Perna Canaliculus (green-lipped mussel) in the treatment of osteoarthritis

Complementary treatments for osteoarthritis (OA) are sought by patients for symptomatic relief and to avoid the iatrogenic effects of non-steroidal anti-inflammatories. This systematic review evaluates the efficacy of the nutritional supplement Perna Canaliculus (green-lipped mussel, GLM) in the treatment of OA and substantially adds to previous work by focussing solely on GLM use in OA as well providing a re-analysis of the original trial data. Randomized or quasi-randomized controlled trials (comparative, placebo-controlled or crossover) were considered for inclusion from Cochrane Library, Medline, Embase, Amed, Cinahl, Scopus and NeLH databases where adults with OA of any joint were randomized to receive either GLM vs. placebo, no additional intervention (usual care), or an active intervention. The methodological quality of the trials was assessed using the JADAD scale. Four RCTs were included, three placebo controlled, the fourth a comparative trial of GLM lipid extract vs. stabilized powder extract. No RCTs comparing GLM to conventional treatment were identified. All four studies assessed GLM as an adjunctive treatment to conventional medication for a clinically relevant time in mild to moderate OA. All trials reported clinical benefits in the GLM treatment group but the findings from two studies cannot be included in this review because of possible un-blinding and inappropriate statistical analysis. The data from the two more rigorous trials, in conjunction with our re-analysis of original data suggests that GLM may be superior to placebo for the treatment of mild to moderate OA. As a credible biological mechanism exists for this treatment, further rigorous investigations are required to assess efficacy and optimal dosage.

Complications of 278 consecutive abdominoplasties

The case notes of 278 consecutive patients who underwent abdominoplasty, during a five-year period, in one institution under the care of four surgeons were reviewed. Patient details, early and late complications and revision procedures were noted. Seventy-five percent of patients had a 'full' abdominoplasty with undermining to costal cartilage and repositioning of the umbilicus and 23% had 'mini abdominoplasties', 2% were revision operations. Eighteen percent of patients suffered from early complications the most common of which were seroma (5%), haematoma (3%), infection (3%), skin or fat necrosis (2.5%) and delayed healing (2%). Twenty-five percent of patients had late complications which were often relatively minor. These included 'dog ears' (12%), localised fatty excess (10%) and unsatisfactory scars (8%). Twenty-four percent of patients underwent revision surgery. Most commonly further liposuction (12%), dog ear revision (10%) and scar revision (5%). Analysis failed to reveal significant risk factors. Despite an apparently high complication and revision rate the subjective impression is of a satisfied patient cohort.

Understanding male sexual behaviour in planning HIV prevention programmes: lessons from Laos, a low prevalence country

METHODS

Focus group discussions were conducted with a range of young men in Vientiane, Laos; interviews were conducted with male sex workers. A questionnaire survey was conducted with a purposive sample of 800 young men.

RESULTS

Most young men initiate sex at an early age and have multiple sex partners. Married men are more likely to pay for sex and most sex for money is negotiated in non-brothel settings. Despite high reported condom use for last intercourse with a casual partner, decisions on condom use are subjective. Many men have extramarital sex when their partner is pregnant and post partum. 18.5% of men report having had sex with another man; most of these men also report having sex with women. Moreover, more men report having had anal sex with a woman than with a man.

CONCLUSIONS

Although not a probability sample survey, this study of a broad range of young men in Vientiane reveals sexual behaviours that could lead to accelerated HIV transmission. Education should emphasise the need to use condoms in all sexual encounters outside the primary relationship. This needs special emphasis when the partner is pregnant or post partum. Advice on safe sex with other men needs to be integrated into all sexual health education for young men.

Demographics and macroeconomic effects in aesthetic surgery in the UK

Media interest in aesthetic surgery is substantial and suggestions of demographic changes such as reductions in age or an increase in the number of male patients are common. In spite of this, there is no peer reviewed literature reporting demographics of a contemporary large patient cohort or of the effect of macroeconomic indicators on aesthetic surgery in the UK. In this study, computer records 13006 patients presenting between 1998 and the first quarter of 2003 at a significant aesthetic surgery centre were analysed for procedures undergone, patient age and sex. Male to female ratios for each procedure were calculated and a comparison was made between unit activity and macroeconomic indicators. The results showed that there has been no significant demographic change in the procedures studied with patient age and male to female ratio remaining constant throughout the period studied for each procedure. Comparison with macroeconomic indicators suggested increasing demand for aesthetic surgery in spite of a global recession. In conclusion, media reports of large scale demographic shifts in aesthetic surgery patients are exaggerated. The stability of unit activity in spite of falling national economic indicators suggested that some units in the UK might be relatively immune to economic vagaries. The implications for training are discussed.

Endoscopic removal of periorbital lesions

In this article, the authors describe the technique, indications and contra-indications for removing various periorbital lesions with an endoscope. The principal reason for using this technique is the excellent postoperative cosmesis. Seven patients in total had lesions removed in this manner. The only complication noted was some leakage of the contents of a dermoid cyst intraoperatively. Cosmesis postoperatively was excellent in all cases. None of the cases had to be converted to an 'open' procedure.

The use of autologous autoclaved bone in orbital reconstruction after exenteration for invasive cutaneous carcinoma

PURPOSE

To describe a technique for reconstructing the orbital bony architecture after invasion by tumour.

METHODS

Orbital bone invaded by tumour was osteotomized (post-exenteration), autoclaved to remove tumour cells, and then refixated in order to re-establish the normal orbital anatomy.

RESULTS

Despite some shrinkage of the bone fragment in the autoclaving process, after refixation the contour and topography of the bony orbit was essentially normal.

CONCLUSION

Autoclaved bone can be used to reconstruct the exenterated orbit; it is a fast and technically simple strategy for maintaining orbital anatomy when faced with bony invasion by tumour.

A comparison of three methods of repairing the hard palate

OBJECTIVE

To compare growth, speech, and nasal symmetry outcomes of three methods of hard palate repair.

PATIENTS

Consecutive available records of children born with unilateral bony complete cleft lip and palate over the period 1972 to 1992.

INTERVENTIONS

Identical management of lip, nose, alveolus, and soft palate. Hard palate repair by Cuthbert Veau (CV) from 1972 to 1981, von Langenbeck (vL) from 1982 to 1989, or medial Langenbeck (ML) from 1989 to 1991.

OUTCOME MEASURES

For growth: GOSLON yardstick or 5-year model index. For speech: articulation test. Nasal anemometry. For nasal symmetry: Coghlan computer-based assessment. All these measures were developed during the period of data collection but not for this project.

RESULTS

There was a strong trend toward more favorable anteroposterior maxillary growth with the change from CV to vL to ML techniques. This fell short of statistical significance because of the small sample size. There was a significant reduction in cleft-related articulation faults (p =.01) considered to be related to improved arch form. In the absence of improved rates of velopharyngeal insufficiency or nasal symmetry, increased surgical experience was discounted as a significant contribution to improved growth and articulation outcomes.

CONCLUSIONS

Reduced periosteal undermining and residual exposed palatal shelf from CV to vL to ML improved incisor relationships and articulation.

Will screening for breast cancer reduce mortality? Evidence from the first year of screening in Avon

In the first year of screening in Avon, 93 malignant lesions were detected of which one-half were impalpable. Of the impalpable lesions, one-half were in situ or showed areas of microinvasion only. One-fifth of the malignant lesions were invasive tumours of special histological type which are known to carry a good prognosis even when not detected by screening. One-quarter of the lesions had clinical or pathological features which would be expected to confer a poor prognosis. Only 16 invasive ductal carcinomas measuring 1 cm or less in diameter were detected--a small proportion of the total number of malignant lesions. Although these early figures suggest that the effect of screening on mortality from breast cancer may be small, continued high-quality screening and careful detailed analysis are essential to determine the effect of screening on the mortality from breast cancer and the effect on the population as a whole.