Multiomics study of nonalcoholic fatty liver disease

Nonalcoholic fatty liver (NAFL) and its sequelae are growing health problems. We performed a genome-wide association study of NAFL, cirrhosis and hepatocellular carcinoma, and integrated the findings with expression and proteomic data. For NAFL, we utilized 9,491 clinical cases and proton density fat fraction extracted from 36,116 liver magnetic resonance images. We identified 18 sequence variants associated with NAFL and 4 with cirrhosis, and found rare, protective, predicted loss-of-function variants in MTARC1 and GPAM, underscoring them as potential drug targets. We leveraged messenger RNA expression, splicing and predicted coding effects to identify 16 putative causal genes, of which many are implicated in lipid metabolism. We analyzed levels of 4,907 plasma proteins in 35,559 Icelanders and 1,459 proteins in 47,151 UK Biobank participants, identifying multiple proteins involved in disease pathogenesis. We show that proteomics can discriminate between NAFL and cirrhosis. The present study provides insights into the development of noninvasive evaluation of NAFL and new therapeutic options.

Timing of paediatric orchidopexy in universal healthcare systems: international administrative data cohort study

BACKGROUND

International guidelines in 2008 recommended orchidopexy for undescended testis at 6-12 months of age to reduce the risk of testicular cancer and infertility. Using administrative data from England, Finland, Ontario (Canada), Scotland and Sweden (with data from Victoria (Australia) and Iceland in supplementary analyses), the aim of this study was to investigate compliance with these guidelines and identify potential socioeconomic inequities in the timing of surgery before 1 and 3 years.

METHODS

All boys born in 2003-2011 with a diagnosis code of undescended testis and procedure codes indicating orchidopexy before their fifth birthday were identified from administrative health records. Trends in the proportion of orchidopexies performed before 1 and 3 years of age were investigated, as were socioeconomic inequities in adherence to the guidelines.

RESULTS

Across all jurisdictions, the proportion of orchidopexies occurring before the first birthday increased over the study period. By 2011, from 7·6 per cent (Sweden) to 27·9 per cent (Scotland) of boys had undergone orchidopexy by their first birthday and 71·5 per cent (Sweden) to 90·4 per cent (Scotland) by 3 years of age. There was limited evidence of socioeconomic inequities for orchidopexy before the introduction of guidelines (2008). Across all jurisdictions for boys born after 2008, there was consistent evidence of inequities in orchidopexy by the first birthday, favouring higher socioeconomic position. Absolute differences in these proportions between the highest and lowest socioeconomic groups ranged from 2·5 to 5·9 per cent across jurisdictions.

CONCLUSION

Consistent lack of adherence to the guidelines across jurisdictions questions whether the guidelines are appropriate.

Health education and cholera in rural Guinea-bissau

OBJECTIVE

The study was undertaken to explore local ideas about cholera and the diffusion of official health educational messages for cholera prevention and to assess whether such messages contributed to changed behavior in the population.

METHODS

During the ongoing cholera epidemic in 1994 in Guinea-Bissau, West Africa, a roster of all adult residents in a rural community was established. From this roster of 458 adults, 53 of 60 randomly chosen residents were interviewed for qualitative data on cholera and its prevention.

RESULTS

Local preventive rituals performed contributed to high awareness of the epidemic. Radio and word-of-mouth communication were the most important sources of information on cholera, whereas posters and television did not effectively reach the population. All persons with cholera rapidly sought care. Thirty-four (64%) of 53 participants recalled at least one preventive measure; specifically, treatment of water with lemon was mentioned by 21 (40%) of respondents. None of the respondents could explain how cholera is transmitted to humans.

CONCLUSIONS

To improve compliance with recommended preventive measures, these should take local conceptions of diseases into account and be few in number, practical, and effective. The impact of the radio could be increased if those who hear the message are urged to spread the recommendation, especially to women who take care of food, water, and general hygiene in the household.

HBO and gas gangrene. A case report

A 58-year old man, in a mediocre health condition, was admitted into Landspitallin Fossvogur, the University of Reykjavik City Hospital, Iceland, because of fever, chills, local pain and swelling due to the presence of a big old wound in his left heel. The first clinical appearance showed a gas gangrene of the area. The patient immediately underwent a surgical debridement and a fasciotomy, and antibiotic intravenous therapy and hyperbaric oxygen therapy (HBOT) were started. During the treatment the patient suffered for a multi-organ failure syndrome (MOFS), was admitted in ICU and survived. A total of 52 HBO sessions were performed and one month since the admission into the hospital the patient received a skin transplant. He achieved a complete restitutio ad integrum after 78 days of hospitalization. Gas gangrene is a fulminating infection caused by the genus of Clostridia. If not treated, it leads to the death of the host. The actual treatment for gas gangrene includes surgery, antibiotics, general resuscitative measures and HBOT.

Epidemic cholera in Guinea-Bissau: the challenge of preventing deaths in rural West Africa

OBJECTIVES

An epidemiologic investigation was conducted to identify factors associated with cholera mortality in a rural African setting and interventions likely to prevent deaths in future epidemics.

METHODS

The authors reviewed surveillance data from rural Biombo, Guinea-Bissau, interviewed family members of persons who died of cholera, and conducted a case-control study in the catchment area of a health center with a high case:fatality ratio (CFR).

RESULTS

Forty-three deaths occurred among the 1169 persons who reported to health centers with cholera during the epidemic (CFR = 3.7%). Delayed rehydration and over-hydration probably contributed to 10 of these deaths. An additional 19 cholera deaths occurred outside health centers. In the case-control study, persons with cholera who died were 5.4 times (95% CI = 1.0-53.4) more likely to be in poor health or intoxicated at illness onset than persons with cholera who survived. Fatal cases were 6.0 times (95% CI = 1.1-60.8) more likely to not attend the health center than survivors.

CONCLUSIONS

The low overall CFR in Biombo, compared to CFRs reported during other epidemics in sub-Saharan Africa, suggests that medical care provided at rudimentary rural health centers prevented numerous deaths. Additional deaths may be prevented by strengthening the infrastructure of health services in the rural areas and by enhanced public education regarding the need for persons with cholera to promptly seek medical care.

First do no harm: making oral rehydration solution safer in a cholera epidemic

Oral rehydration solution (ORS) is lifesaving therapy for cholera and pediatric diarrhea. During a cholera epidemic in Guinea-Bissau, we evaluated the microbiologic quality of ORS prepared at a hospital and tested a simple intervention using special vessels for disinfecting tap water with bleach and for preparing, storing, and dispensing ORS. Few coliform bacteria and Escherichia coli were recovered from tap water; however, pre-intervention ORS contained numerous bacteria including E. coli and toxigenic Vibrio cholerae O1. In contrast, ORS samples from intervention vessels had few or no coliform bacteria, no E. coli, and no V. cholerae. Mean pre-intervention counts of coliform bacteria (3.4 x 10(7) colony-forming units [cfu]/100 ml) and E. coli (6.2 x 10(3) cfu) decreased significantly during the intervention period to 3.6 x 10(2) cfu and 0 cfu, respectively (P < 0.001). This simple system using bleach disinfectant and special storage vessels prevents bacterial contamination of ORS and reduces the risk of nosocomial transmission of cholera and other enteric pathogens.

Funerals during the 1994 cholera epidemic in Guinea-Bissau, West Africa: the need for disinfection of bodies of persons dying of cholera

The 1994 cholera epidemic in Guinea-Bissau resulted in 15,878 reported cases and 306 deaths. Early in the epidemic, although the health ministry mandated that the bodies of persons dying of cholera be disinfected, outbreaks occurred in several villages following funerals in the region of Biombo. To determine the influence of disinfection and funeral activities on cholera transmission, we analysed surveillance data and conducted a case-control study following a funeral. The attack rate during the week following funerals was higher in villages where bodies were not disinfected (risk ratio = 2.6, 95% confidence interval [CI] 1.9-3.8). Cholera was strongly associated with eating at a funeral with a non-disinfected corpse (odds ratio [OR] = 14.5, 95% CI 0.9-786) and with touching (i.e., transporting, washing) the body (OR = 36.2, 95% CI 2.6-1769). During cholera epidemics, in addition to other cholera prevention activities, health officials should inform community leaders about the risk of cholera transmission during funerals, meals should not be served at funerals, and bodies of persons dying of cholera should be disinfected.

Selective compartmentalization of gammadelta-T lymphocytes in human breastmilk

In human breastmilk, T lymphocytes with gammadelta-receptor (TCR) are more frequent than those with alphabeta-TCR, in comparison with peripheral blood. Differential representation has also been demonstrated for subpopulations of gammadelta-T cells. Reactivity was visualized with three monoclonal antibodies against Vdelta1, Vdelta2 and Vgamma2 on T cells from the breastmilk and peripheral blood of 12 women who had recently given birth. Confirming the results with Vdelta1, it was found that Vdelta1 (p < 0.01) and Vgamma2 (p < 0.05) but not Vdelta2 were overrepresented on T cells in milk as compared with blood. This selective compartmentalization seems to reflect the homing of certain cells to the mammary gland.

[Cystadenoma of the pancreas. Three case reports and a review.]

Cystic neoplasms of the pancreas are pathologically divided into macrocystic and microcystic adenomas. Macrocystic adenomas are multilocular, composed of large cysts (>2 cm), with or without septa, lined with columnar mucin-producing epithelium. This type has malignant potential. The microcystic adenomas are composed of many tiny cysts (<2 cm) lined by small cuboidal cells containing glycogen but little or no mucin. This adenoma is completely benign and is therefore important to differentiate from the former. Cystadenomas represent 10-15% of cystic lesions of the pancreas. Roughly one-half of the cystadenomas of the pancreas are found to be microcystic. The remainder is accounted for by the mucinous cystic neoplasms, either macrocystic adenomas or cystadenocarcinomas. These adenomas occur most frequently in middle aged women. Upper abdominal pain and weight loss are often the presenting symptoms. An abdominal mass can often be palpated during physical examination of these patients. Ultrasound and CT of the abdomen are the most useful diagnostic tools in the evaluation of cystic lesions of the pancreas. CT can also be helpful in differentiating microcystic from macrocystic adenomas. It is possible to do a CT or ultrasound guided percutaneous aspiration for diagnosis of the lesions. This technique permits preoperative cytologic and biochemical analysis of the cyst content. Surgery however is often necessary for accurate diagnosis where the tumor is biopsied for histology. The primary pancreatic lesions to be considered in the differential diagnosis include pseudocyst, whether of inflammatory or traumatic origin, congenital cysts, ductal adenocarcinoma or islet cell tumors. Some agree that surgical resection may not be mandatory if an accurate diagnosis of microcystic adenoma can be made. Others emphasize that all pancreatic cystadenomas can have malignant potential and that total excision should be the treatment of choice. Both macrocystic adenomas and cystadenocarcino notmas have a slow and indolent course and tend to be well resectable in spite of late diagnosis. Three cases of pancreatic cystadenomas have been diagnosed in Iceland since 1972. These cases are presented here with a review of the literature.

Does age at the start of breast feeding influence infantile diarrhoea morbidity? A case-control study in periurban Guinea-Bissau

Colostrum protects the newborn from intestinal infection by its content of secretory immunoglobulin A and other immediately acting factors. It may also induce maturation of the child's gastrointestinal immune defences, thus contributing to the protection against diarrhoeal disease later in infancy. To test this hypothesis, a case-control study on breast feeding and diarrhoea was carried out in a periurban community in Guinea-Bissau. The child's age at the start of breast feeding was ascertained soon after birth (n = 279). Subsequent cases of acute diarrhoea (n = 66) were identified at 3-monthly examinations, and four concurrent controls were randomly selected among attendants. Three separate estimates of association showed that the cases tended to have started breast feeding later after birth than the diarrhoea-free controls, but no single test was statistically significant. Early breast feeding might have consequences for diarrhoeal morbidity after the neonatal period.

Age at breast feeding start and postneonatal growth and survival

Colostrum has important anti-infective properties. It may also somehow promote the development of the child's immunological system. Discarding colostrum, as practised in some cultures, could thus have adverse health consequences beyond the neonatal period. To test this hypothesis, the age at breast feeding start of 734 healthy newborns in urban Guinea-Bissau was ascertained. The children were then prospectively followed up to 3 years of age. Eighty nine deaths occurred during the study. The probability of death in the age interval 28 days to 3 years was about 20%. The child's age at breast feeding start had no statistical impact on postneonatal growth or survival. As a single measure, early breast feeding start is not likely to make much difference for the long term growth or survival of children living under material poverty conditions.

Colostrum and ideas about bad milk: a case study from Guinea-Bissau

The study aims to explore ideas about bad milk found among women in Guinea-Bissau. Interviews were held with 20 elderly knowledgeable rural women. Interinformant agreement was high within each ethnic group studied. All the informants recognized colostrum but disliked its consistency. Depending on ethnical background, it was considered good, of no special value or harmful to the newborn baby. Further, all the informants held that mature breast milk could turn bad, e.g. in case of mother's sickness or adultery. Suspected bad milk can be diagnosed by putting an ant into it to observe if it dies. The condition of bad milk can be treated by various procedures. The findings are discussed in relation to similar ideas existing in other societies and to views on the quality of maternal milk held in the industrialized countries. It is proposed that the idea of producing bad milk may be an important determinant of breastfeeding performance generally. Restrictions imposed on the breastfeeding woman, with the intention of producing healthier breast milk, may actually contribute to a decline in breastfeeding.

Determinants of delayed initiation of breastfeeding: a community and hospital study from Guinea-Bissau

A prospective study on the timing of breastfeeding start in Bissau was undertaken in a periurban community (n = 734), and at the Central Hospital (n = 414). Only single, full-term, healthy children born by the vaginal route were included, the purpose being to characterize mothers who delay breastfeeding start for reasons not related to disease. Multivariate failure-time analysis (Cox' regression) was used to relate the child's age at breastfeeding start to a set of independent variables. In the community, those tending to delay breastfeeding start were mothers from the largest ethnic group in the country, mothers who had given birth at times other than the evening hours (6-12 pm) and mothers who had not attended antenatal clinics. At the hospital, delayed initiation was found among young mothers and mothers from one sparsely represented ethnic group. The most important determinant of delayed breastfeeding start was negative cultural ideas about colostrum.

Rotavirus serology and breast-feeding in young children in rural Guinea-Bissau

One hundred and forty-four children aged 9-20 months living in 14 villages in a rural area of Guinea-Bissau were examined for circulating rotavirus antibodies twice in a 15-month period. An immunofluorescence technique was used. About 3/4 of the children seroconverted, independent of age on entering the study. The age-specific proportion of seropositivity increased from 4/40 (10%) at 9-11 months to 26/29 (90%) at 33-35 months of age. All the initially seropositive children retained detectable antibodies to rotavirus. The relative risk of seroconversion was 1.4 times (95% confidence interval 1.0-2.0) more common among children living in villages by the mainroad as compared to those living off the road. Contact rate is probably dependent on population density and mobility but not on age. Breast-feeding, decreasing sharply through the age interval covered by the follow-up (9-35 months), had no apparent influence on seroconversion at the ages concerned.

Follow-up of the antibody response to measles vaccine in a rural area of Guinea-Bissau

One hundred and fourty-four children who either were already immune or had been successfully immunized against measles were reexamined after 16 months. All still had circulating Elisa antibodies at a clearly detectable level. Titres were higher in the group of children stated to have had measles prior to the immunization. None of the children had measles after immunization. Boostering by the wild virus may have occurred, whereas no evidence of a booster effect from the vaccine was found. About one third of the children were underweight. Plasmodium falciparum parasitaemia rate, and also its seasonality, varied with the location of the child's homestead. Even children exposed to mesoendemic P. falciparum malaria and moderate malnutrition can be successfully immunized with a conventional live attenuated measles vaccine from 8 months of age, which probably results in a lasting protection.

Augmented antibody response to live attenuated measles vaccine in children with Plasmodium falciparum parasitaemia

The impact of malarial infection on the humoral immunological response to measles virus antigen was studied in 184 children aged 8-19 months in Guinea-Bissau. Pre- and post-immunization measles serology was performed using dried blood on absorbent paper and the ELISA technique. Blood smears obtained at the time of vaccination and 2 and 4 weeks afterwards were examined for malaria parasites. Pre-vaccination antibodies to measles were found in 44 out of 184 children (24%). Plasmodium falciparum was identified in 62 of the 132 initially non-immune children who completed the study. The rate of seroconversion was 127 out of 132 (96%). Post-immunization measles antibody titres were significantly higher in the vaccinees with P. falciparum than in those without malaria parasites in the blood.