The Pellagra Problem

OBJECTIVE

To investigate the clinical value of Fuzheng Guben anticancer decoction combined with taxol in treating ovarian carcinoma (OC).

METHODS

The medical records of 80 OC patients treated in the First People's Hospital of Fuyang Hangzhou (January 2018–January 2021) were retrospectively analyzed, and the patients were split into the control group and the experimental group according to the treatment regimen, with 40 cases each. Those in the control group accepted the taxol chemotherapy, and on this basis, those in the experimental group took the Fuzheng Guben anticancer decoction, so as to compare its clinical efficacy and complication incidence.

RESULTS

No statistical between-group differences in patients' general information were observed (P > 0.05); compared with the control group, the disease objective remission rate of the experimental group was greatly higher (P < 0.05); before and after treatment, the changes in CD8⁺ were not significant, indicating no statistically significant between-group differences (P > 0.05), and after treatment, CD3⁺, CD4⁺, and CD4⁺/CD8⁺ were obviously higher than before and were obviously higher in the experimental group than in the control group (P < 0.05); after treatment, the CA125, CA199, and CEA levels were obviously lower than before and were significantly lower in the experimental group than in the control group (P < 0.05); the mean survival of the experimental group was significantly higher than that of the control group (19.80 ± 5.84 vs. 14.075 ± 5.12 months, P < 0.05); and between the two groups, the incidence rate of adverse reactions of the experimental group was remarkably lower (P < 0.05).

CONCLUSION

On the basis of taxol chemotherapy, jointly applying Fuzheng Guben anticancer decoction can significantly improve the clinical efficacy of OC, help to improve patients' immune function, lower the complication incidence rate, and prolong the mean survival.

[Pellagra-originally described in the Austrian Empire 250 years ago became a fatal endemic in some provinces]

Pellagra is characterized by "dermatitis - diarrhea - dementia - death". Various causes were discussed over the course of two centuries. The initial presumption was that the sun caused changes in exposed areas of the body. The "Zeïsts" blamed the maize (corn), which forms the main constituent in the diet of poor peoples, for being an insufficient nutrient and thus causing the pellagra in such indigent populations. The "Toxikozeïsts", however, regarded toxins produced by innocuous bacteria and fungi in unripe or in ripe but badly stored maize or in maize flour or in poorly baked maize bread as the cause of pellagra. Pellagra as an allergic disease was also discussed. Self-experiments of Goldberger's group in 1916 and finally Elvehjem's detection of niacin deficiency in maize in 1937 solved the problem.In the Austrian empire and (from 1867 on) in the Austro-Hungarian monarchy, pellagra was diagnosed and combated in the provinces of Küstenland, Tirolia and Bukovina and in Hungary. Originally believing in the noxiousness of maize in the poor population, extensive measures were planned and partially executed. Primarily measures for providing salubrious maize products were planned for the population, such as public bakeries and eating houses, kilns and storage houses for maize. For the treatment of pellagra patients, so-called pellagrosaria and auxiliary hospitals were established and the number of general practitioners was increased. It was also important to educate the population about preventing pellagra by consuming proper food. Pellagra funds to sustain the measures were established. In the provinces, pellagra commissions, chaired by the governor and consisting of twelve experts of the relevant medical branches, were appointed as an advisory and expert body.

Louis Sambon and the Clash of Pellagra Etiologies in Italy and the United States, 1905-14

This article explores the extent to which the bacterial concept of disease acted as an obstacle to the understanding of deficiency diseases, by focusing on explorations into the cause of pellagra in the early twentieth century. In 1900, pellagra had been epidemic in Italy for 150 years and was soon to become so in the United States, yet the responses of medical investigators differed substantially. To account for these, the article reconstructs the sharply contrasting reactions to a provocative theory proposed by Louis Sambon. Applying a tropical diseases approach to pellagra, Sambon argued that pellagra had nothing at all to do with maize consumption, as the Italians had long thought, but was caused by the bite of a parasite-carrying insect. Italian pellagrologists, involved in a dogmatic quest for a toxin in maize, and with pellagra rates there on the decline, marginalized the Sambon hypothesis. By contrast, in the United States, with pellagra on the rise, the dominant infectious paradigm put Sambon center stage, his proposed etiology shaping the earliest American investigations. When the deficiency disease concept gained currency in 1913, the relatively closed world of Italian pellagrology was wrong-footed, while the more open-ended U.S. community was better able to follow up the new lead. The article discusses what these shifts and the resulting controversies reveal about the medical contexts. The actor-centered approach, with reaction to Sambon's intervention as a kind of test-case, is the key to understanding these controversies and why they mattered.

The Thompson-McFadden Commission and Joseph Goldberger: contrasting 2 historical investigations of pellagra in cotton mill villages in South Carolina

As pellagra reached epidemic proportions in the United States in the early 20th century, 2 teams of investigators assessed its incidence in cotton mill villages in South Carolina. The first, the Thompson-McFadden Commission, concluded that pellagra was likely infectious. The second, a Public Health Service investigation led by Joseph Goldberger, concluded that pellagra was caused by a dietary deficiency. In this paper, we recount the history of the 2 investigations and consider how the differences between the 2 studies' designs, measurements, analyses, and interpretations led to different conclusions. Because the novel dietary assessment strategy was a key feature of the Public Health Service's study design, we incorporated simulated measurement error in a reanalysis of the Public Health Service's data to assess whether this specific difference affected the divergent conclusions.

Pellagra

Pellagra was first described in the 18th century as an epidemic in the poverty-stricken Spanish countryside by Gaspar Casal. Pellagra did not appear in the United States until the turn of the 20th century. It then ravaged the Southern United States and was not eliminated until the 1940s. This short report will redact the descriptions of pellagra in two early textbooks of dermatology. The first, published in 1897 before cases of pellagra were recognized in the United States, and, the second, published in 1915 in the midst of the epidemic. The text published in 1915 described in detail the medical signs and symptoms of pellagra particularly as they relate to the skin, as well as speculations as to its cause. The complicated story of the socioeconomic situation of the Southern United States and the hunt for the cause of pellagra will also be discussed briefly.

Pellagra: a rare complication of anorexia nervosa

Pellagra is a potentially fatal, nutritional disease with cutaneous, gastrointestinal, and neuropsychiatric manifestations. Because of the diversity of pellagra's signs and symptoms, diagnosis is difficult without an appropriate index of suspicion. A case of pellagra in a 14-year-old girl with anorexia nervosa is presented. Signs and symptoms of pellagra were resolved after niacin therapy and dietary treatment.

Low and deficient niacin status and pellagra are endemic in postwar Angola

BACKGROUND

Outbreaks of pellagra were documented during the civil war in Angola, but no contemporary data on the incidence of pellagra or the prevalence of niacin deficiency were available.

OBJECTIVE

The objective was to investigate the incidence of pellagra and the prevalence of niacin deficiency in postwar Angola and their relation with dietary intake, poverty, and anthropometric status.

DESIGN

Admissions data from 1999 to 2004 from the pellagra treatment clinic in Kuito, Angola, were analyzed. New patients admitted over 1 wk were examined, and urine and blood samples were collected. A multistage cluster population survey collected data on anthropometric measures, household dietary intakes, socioeconomic status, and clinical signs of pellagra for women and children. Urinary excretion of 1-methylnicotinamide, 1-methyl-2-pyridone-5-carboxymide, and creatinine was measured and hemoglobin concentrations were measured with a portable photometer.

RESULTS

The incidence of clinical pellagra has not decreased since the end of the civil war in 2002. Low excretion of niacin metabolites was confirmed in 10 of 11 new clinic patients. Survey data were collected for 723 women aged 15-49 y and for 690 children aged 6-59 mo. Excretion of niacin metabolites was low in 29.4% of the women and 6.0% of the children, and the creatinine-adjusted concentrations were significantly lower in the women than in the children (P < 0.001, t test). In children, niacin status was positively correlated with the household consumption of peanuts (r = 0.374, P = 0.001) and eggs (r = 0.290, P = 0.012) but negatively correlated with socioeconomic status (r = -0.228, P = 0.037).

CONCLUSIONS

The expected decrease in pellagra incidence after the end of the civil war has not occurred. The identification of niacin deficiency as a public health problem should refocus attention on this nutritional deficiency in Angola and other areas of Africa where maize is the staple.

Social consequence of disease in the American South, 1900-World War II

The early 20th century Southerner lived in a disease environment created by a confluence of poverty, climate and the legacy of slavery. A deadly trio of pellagra, hookworm and malaria enervated the poor Southerner--man, woman and child--creating a dull, weakened people ill equipped to prosper in the modem world. The Northern perceptions of the South as a backward and sickly region were only compounded by the realization that her population was malnourished, infected by worms, and continually plagued by agues and fevers. As historian John Duffy concluded, "As a chronically debilitating disease, it [malaria] shared with the other two the responsibility for the term 'lazy Southerner".

Epidemiologists explain pellagra: gender, race, and political economy in the work of Edgar Sydenstricker

Between 1900 and 1940, at least 100,000 individuals in the southern United States died of pellagra, a dietary deficiency disease. Although half of these pellagra victims were African-American and more than two-thirds were women, contemporary observers paid little attention to these gender and racial differences in their analyses of disease. This article reviews the classic epidemiological studies of Joseph Goldberger and Edgar Sydenstricker, who argued that pellagra was deeply rooted in the political economy of cotton monoculture in the South. The methods that Sydenstricker brought to epidemiology from early work on political economy obscured the role of gender inequalities in pellagra, and his focus on economic underdevelopment led him to ignore the prominent role of African-Americans as pellagra's principal victims. Research methods and traditions, no less than more overt ideologies, played a role in maintaining the subordinate social position of women and African-Americans in the southern United States.

Effectiveness of food fortification in the United States: the case of pellagra

OBJECTIVES

We evaluated the possible role of niacin fortification of the US food supply and other concurrent influences in eliminating the nutritional deficiency disease pellagra.

METHODS

We traced chronological changes in pellagra mortality and morbidity and compared them with the development of federal regulations, state laws, and other national activities pertaining to the fortification of cereal-grain products with niacin and other B vitamins. We also compared these changes with other concurrent changes that would have affected pellagra mortality or morbidity.

RESULTS

The results show the difficulty of evaluating the effectiveness of a single public health initiative such as food fortification without controlled experimental trials. Nonetheless, the results provide support for the belief that food fortification played a significant role in the elimination of pellagra in the United States.

CONCLUSIONS

Food fortification that is designed to restore amounts of nutrients lost through grain milling was an effective tool in preventing pellagra, a classical nutritional deficiency disease, during the 1930s and 1940s, when food availability and variety were considerably less than are currently found in the United States.

Pellagra in the United States: a historical perspective

Pellagra was in existence for nearly two centuries in Europe before being recognized in the United States, where it was first reported in 1902. Over the next two decades, pellagra occurred in epidemic proportions in the American South. Poverty and consumption of corn were the most frequently observed risk factors. Since the exact cause and cure of pellagra was not known, a culture of "pellagraphobia" formed among the public. Patients were shunned and ostracized. The medical community implicated spoiled corn as the cause of pellagra, which had economic repercussions for agriculturists. Joseph Goldberger, MD, of the United States Public Health Service eventually solved the secret of the malady: faulty diet. Goldberger was able to prevent and induce pellagra by dietary modification, a landmark event in the annals of medicine, nutrition, and epidemiology. His work and the social history of that period are reviewed.

Stages in the recognition of epidemic pellagra in the United States: 1865-1960

Recognition of the U.S. pellagra "epidemic" in the early part of this century occurred in stages. The recognition process distorted impressions of magnitude, rate of spread, and virulence. Unrecognized cases: Endemic pellagra developed from dietary deficiencies after the Civil War. Initially, cases were misdiagnosed as other more traditional disorders. Tradition and authority inhibited recognition. Recognition of severe cases: Beginning in 1907, outbreaks were reported in asylums. Existing severe cases came rapidly to medical attention, inflating the apparent rate of spread. Recognized cases had a fulminant course and a high case fatality. Expanded spectrum: Milder cases were increasingly recognized, leading to an exaggerated rate of increase in number of cases and a decrease in case fatality and apparent virulence. Greater sensitivity resulted largely from a shift in diagnostic thresholds, with loss of specificity and increase in false positive diagnoses. Standardization of diagnosis: Although no suitable diagnostic marker test was developed, diagnosis was ultimately standardized by development of a workable case definition and by assessment of response to an effective therapy (nicotinic acid) applied to presumptive cases.

An outbreak of pellagra related to changes in dietary niacin among Mozambican refugees in Malawi

Between February and October 1990, 18,276 cases of pellagra dermatitis (due to niacin deficiency) were reported among 285,942 Mozambican refugees in Malawi. Overall, 6.3% of the refugee population developed pellagra and the attack rate was 7.8 times higher among women than men. This outbreak followed a 5-month cessation of groundnut distribution (the major source of niacin) to refugees. A matched-pair case-control study confirmed the protective role of the daily consumption of groundnuts (Odds Ratio [OR] = 0.08), as well as the independent role of garden ownership (OR = 0.34), and home maize milling (OR = 0.3). Recommended corrective action included early case finding and treatment, distribution of niacin tablets, prompt identification of groundnut supply on the world market, fortification with niacin of the food ration and diversification of the food basket through access to local markets.

Politics and pellagra: the epidemic of pellagra in the U.S. in the early twentieth century

The epidemic of pellagra in the first half of this century at its peak produced at least 250,000 cases and caused 7,000 deaths a year for several decades in 15 southern states. It also filled hospital wards in other states, which had a similar incidence but refused to report their cases. Political influences interfered, not only with surveillance of the disease, but also in its study, recognition of its cause, and the institution of preventive measures when they became known. Politicians and the general public felt that it was more acceptable for pellagra to be infectious than for it to be a form of malnutrition, a result of poverty and thus an embarrassing social problem. Retrospectively, a change in the method of milling cornmeal, degermination, which began shortly after 1900, probably accounted for the appearance of the epidemic; such a process was suggested at the time, but the suggestion was ignored.

Outbreak of pellagra among Mozambican refugees--Malawi, 1990

Micronutrient deficiency disorders, including pellagra, have emerged as major problems in refugee populations that depend on international relief assistance for food supplies. This report summarizes an investigation of pellagra that occurred among Mozambican refugees in Malawi during 1990.

The relationship of pellagra to corn and the low availability of niacin in cereals

The poorest inhabitants of an area generally eat the narrowest range of foods, and one staple (which serves as a cheap source of calories) dominates. In turn, the specific type of malnutrition seen in that area depends upon that predominant staple and how it is processed before consumption. Corn, used here in the sense of "Indian corn" or maize, was brought to Europe from America, and over the period 1750-1850 became the typical peasant's staple in many of the areas bordering the Mediterranean. By the end of that period, it had also come to be recognized that pellagra had become a serious, chronic disease in these same countries, flaring up each spring amongst the poorest people living on diets containing much corn and very little animal food (i.e., meat, eggs or dairy products) or wine and being generally in a state of wretchedness. Nothing of the sort was seen in areas where wheat and rice were the staple foods, even when they were highly milled. Most scientists agreed on this association with corn, though not on what was the true cause-and-effect relationship. Research in the present century has shown that pellagra is primarily due to a dietary deficiency of niacin. However, the niacin content of different foods did not tie in well with their pellagra-preventive value. But then it was discovered that a second nutrient, tryptophan, could act as precursor of the vitamin with approximately one sixtieth of the activity of the actual vitamin. The "niacin equivalent" values of foods (calculated from their content of both nutrients) show a much better correlation with their pellagra-preventive value. Thus, mature corn is lower in niacin content than are wheat and rice; also the mixed proteins of corn are lower in their tryptophan content. What is not explained by the calculation of "niacin equivalent" is the general freedom from pellagra of the peasants in Mexico and Central America, where corn has been the staple for millenia and where poverty, the consequent lack of animal foods in the diet, and general misery, have been fully equal to the conditions in Europe. It has been known for 40 years that analytical values for the niacin content of foods depended greatly on the method of extraction used, with the highest values being obtained after treatment with alkali. We have confirmed with rat growth assays that the niacin in corn, wheat and rice is only about one-third available to this species, even after ordinary cooking at neutral pH.(ABSTRACT TRUNCATED AT 400 WORDS)

[Pellagra: a disease resurging in Zaire. A study of 231 cases (author's transl)]

231 cases of pellagra among 8,000 consulting patients has been observed from May 1977 to June 1978 in the Dermatological Dispensary of the Hospital G.E.C.A.-Mines of Lumbumbashi (Zaire). This disease by nutritional deficiency can be easily recognized especially through its dermatological symptomatology. It occurs mainly in young patients fed solely on maize, but the most severe cases have been observed in prisoners. Three age groups seem particularly prone to pellagra: children after weaning, pubescent adolescents in quick growing age, grown-up women during pregnancy and lactation. Vitaminotherapy is effective in a few days; a simultaneous treatment of intestinal parasites has to be required. The incidence of this endemic pellagra worsened after the war of May 1978, reaching 7 p. 100 among the population around the main towns of the province Shaba.