An Open Trial of Trimethoprim Alone against Cyclospora Infections

Cyclospora is a coccidian parasite that infects the upper intestine and causes a prolonged illness consisting of fatigue, anorexia, and diarrhea. Untreated infections can last for several weeks.1 Trimethoprim-sulfamethoxazole (co-trimoxazole) was found to be an effective treatment for Cyclospora infections in a 1994 study performed in Nepal.2 However, people with known allergies to sulfa drugs cannot take co-trimoxazole. A number of antibiotics have been tried against Cyclospora infections without success, including norfloxacin, tinidazole, diloxanide furoate, and quinacrine hydrochloride. Azithromycin was not successful in a small open trial in 1993.3 Trimethoprim is not chemically related to sulfa, and allergy to co-trimoxazole is usually attributed to the sulfamethoxazole component. In order to find a treatment for people infected with Cyclospora who are allergic to sulfa drugs, we undertook an open trial of trimethoprim alone, in a dose of 200 mg twice a day for 7 days.

Is Blastocystis hominis a cause of diarrhea in travelers? A prospective controlled study in Nepal

Although the pathogenicity of Blastocystis hominis has been extensively debated in the medical literature, controlled studies of the association between B. hominis and diarrhea are lacking. We conducted a case-control study among expatriates and tourists in Kathmandu, Nepal, in which we compared the prevalence of the organism among patients with diarrhea to that among a control group without diarrhea. B. hominis was detected in 56 (30%) of 189 patients with diarrhea, compared with 40 (36%) of 112 asymptomatic controls. Patients with diarrhea were significantly more likely to have > or = 10 B. hominis organisms per high-power (400x) field than were controls. However, among the 25 patients with this concentration of organisms, other enteric pathogens were detected in 17 (68%). Only 8 (4%) of 189 patients with diarrhea had > or = 10 B. hominis organisms per high-power field detected in the absence of other pathogens, compared with 5 (5%) of 112 asymptomatic controls. Thus, B. hominis in higher concentrations was not associated with diarrhea. There were no specific symptoms associated with B. hominis infection, and the presence of higher concentrations of the organism in stool was not associated with more-severe symptoms. Despite the high prevalence of the organism among travelers and expatriates in Nepal, the results of this study suggest that B. hominis does not cause diarrhea in this population.

Placebo-controlled trial of co-trimoxazole for Cyclospora infections among travellers and foreign residents in Nepal

Cyclospora is a coccidian (previously referred to as cyanobacterium-like bodies) that has been implicated in cases of prolonged diarrhoea. The average duration of symptoms is more than three weeks, and no specific treatment has been shown to shorten the illness. A case report suggested that co-trimoxazole may be effective. Expatriate persons with gastrointestinal complaints and cyclospora detected on examination of faeces were recruited from two clinics in Kathmandu, Nepal, between May and August, 1994. Participants were assigned in a randomised, double-blinded manner to receive either cotrimoxazole (160 mg trimethoprim, 800 mg sulphamethoxazole) or placebo tablets twice daily for 7 days. Of 40 patients included in the study, 21 received cotrimoxazole and 19 placebo. There were no significant differences between these two groups in age, sex, time in Nepal, duration or severity of illness, or presence of other enteric pathogens. After 3 days, 71% of patients receiving co-trimoxazole still had cyclospora detected, compared with 100% of patients receiving placebo (p = 0.016). After 7 days, cyclospora was detected in 1 (6%) of 16 patients treated with co-trimoxazole who submitted stool specimens compared with 15 (88%) of 17 patients receiving placebo (p < 0.0001). Eradication of the organism was correlated with clinical improvement. There was no evidence of relapse of infection among treated patients followed for an additional 7 days. Treatment with co-trimoxazole for 7 days was effective in curing cyclospora infection among an expatriate population in Nepal.

[The AMBER thoracic imaging system in routine diagnosis]

After installation of an Amber lung x-ray imaging system the range of application of this technique was registered for two months. Additionally the image quality for structures of the lung parenchyma and mediastinum were proved and dose measurements were performed. 50.6% (772) patients from a total of 1525 could be x-rayed by the Amber imaging system. Related to all people able to stand 73.6% from 1049 patients were examined with the Amber system. Most of the imaging figures of merit specified by the German national physician board were accomplished, besides the fact that 1/3 of the p.a. radiographs were cut off at the side because of the small size of the film. The excellent image of pleuro-mediastinal structures was proofed quantitatively by counting the pleuro-mediastinal lines and comparing the results with standard radiographs. Measuring the exposure at entrance point we obtained nearly the same values for the Amber system using a screen-film combination with a speed of 400 and conventional radiographs (40-120 mu Gy; 21 pat.).

Epidemiology of diarrhoeal illness associated with coccidian-like organism among travellers and foreign residents in Nepal

A newly described organism called CLB (coccidian-like or cyanobacterium-like body) has been identified in cases of prolonged diarrhoea. To confirm an association of CLB with disease and identify risk factors for transmission, we conducted a case-control study of travellers and foreign residents at two outpatient clinics in Kathmandu, Nepal. Patients without diarrhoea were matched to CLB cases by clinic and date of visit. For comparison, patients with other causes of diarrhoea were also studied. Stools were examined for enteric pathogens with standard microbiological and molecular genetic techniques. CLB was identified in 108 (11%) of 964 individuals with gastrointestinal symptoms compared with only 1 (1%) of 96 symptom-free controls (p = 0.003). 7% of residents in the US Embassy community acquired the infection. The diarrhoeal illness associated with CLB lasted a median of 7 weeks (interquartile range 4-9) compared with 9 days (4-19) for individuals with other causes of diarrhoea (p < 0.0001). The prevalence of other enteric pathogens was no higher among CLB cases than among symptom-free controls. Patients with CLB infection were more likely than controls to report consumption of untreated water (odds ratio 3.98; 95% CI 1.29-13.14); organisms of the same appearance were identified in an epidemiologically implicated water sample. The significant association of CLB with prolonged diarrhoea, and the low rate of other enteropathogens in CLB cases, strongly supports the hypothesis that CLB is a new pathogen. Epidemiological and environmental data suggest that the organism is waterborne.

Effect of father's death or departure on growth of poor children in Peru

Between 1966 and 1976, heights and weights were determined yearly on all available children from 163 families who had had at least one child successfully treated for malnutrition between 1961 and 1971 and from eight families who had adopted such a child. Between 1959 and 1976, a total of 72 fathers departed from these families: 12 died, 47 deserted, six were jailed, and seven left to look for work elsewhere. Heights and weights as Z scores and the weight age/height age ratios were analyzed, when available, during four periods around the date of the event: 6 to 18 months before (period 1B), 0 to 6 months before (period 2B), 0 to 6 months after (period 3A), and 6 to 18 months after (period 4A). Mean Z scores for all children measured in the period were already low (-0.26 +/- 0.93 and -0.25 +/- 0.95) during period 1B, were higher during period 2B, (-0.15 and 0.04), lower during period 3A (-0.39 and -0.46), and similar to original levels during period 4A (-0.37 and -0.27). Mean weight age/height age was low (0.93 +/- 0.17) only during period 3A for children 2 to 18 years of age. In paired comparisons for children measured during any two periods there were significant increases in Z height and Z weight from periods 1B to 2B and from periods 1B to 4A in children less than 2 years of age and a significant decrease in the weight age/height age ratio from periods 1B to 3A in those 2 to 18 years of age. Loss of father had little or no further impact on the already poor growth of these children.

Later growth of malnourished infants and children. Comparison with 'healthy' siblings and parents

Growth was evaluated in 144 boys and 71 girls hospitalized for malnutrition from 1961 through 1971 at mean ages of 13.1 and 10.7 months, respectively. During the period 1961 through 1966, ex-patients were measured at irregular intervals, while from 1966 through 1976, ex-patients and siblings were measured yearly. Average follow-up was seven years. Female ex-patients were 2.0 cm shorter than boys at 1 year and 7.0 cm taller at 13 years; their better growth was possibly due to earlier hospitalization, more adoptions, and renewed pubertal "catch-up." Ex-patents were compared with siblings at the same age; girls apparently caught up with sisters during puberty and both matched or exceeded maternal heights, while boys lagged behind brothers. Stunting, usually reported after severe infant malnutrition, seems more the result of continued poor environment and diet than of a limited episode of marasmus or kwashiorkor.

Determinants of growth among poor children: effect of expenditure for food on nutrient sources

The effect of increasing expenditure on the nature and the amounts of foods consumed by children from an urban population was estimated by studying the diets of 111 children from 20 typically poor families and those of 12 children from six economically better off families who had a much more satisfactory growth status. Total calories and protein, fat, and carbohydrate calories were expressed as a fraction of each individual's estimated energy requirement, thus adjusting for sex, age, and size. No important sex differences were found. Calorie intake was 87.2 +/- 17.3% and 111.4 +/- 18.1% of requirement for the two groups, respectively. Differences were found between the groups in protein calories which were totally due to milk and meat. Differences in fat calories were due to milk, meat, and separated fats. There was no significant difference between groups in total carbohydrate calories, although there were shifts in its components with increasing expenditure. Regression analysis of calorie adequacies as a function of per capita expenditure for food, both in the poorer group and in the combined population, were performed and yielded highly significant (p less than 0.001) results. These were due to significant gradual increases in the consumption of milk, meat, separated fats, fruits and vegetables on top of an almost constant consumption of the staple cereals, roots and tubers.

Determinants of growth among poor children: nutrient intake-achieved growth relationships

Seven-day individual weighed dietary intakes and anthropometric measurements were determined in 123 children, 2 to 19 yr of age, from 26 poor families in Lima: each included one child who had been malnourished, six were adopting families. Heights and weights were converted to "ages" based on Boston reference data and local data, then to "quotients" as percentages of actual ages. Mineral and vitamin intakes were expressed as amounts per day and per 1000 kcal, calories and protein as percentages of FAO/WHO recommendations for age and height age and of modified recommendations based on size of Peruvian children. Regression analyses identified common sources of nutrients and greater dependence of intakes on body size than on age. Analysis of covariance for sex identified different nutrient-growth correlations. Polynomial regression analysis identified percentage protein from animal sources and percentage fat calories as having significant quadratic as well as linear correlations with achieved growth. In males, multiple regression analysis identified percentage protein from animal sources and beta-carotene intakes as strongly associated with achieved height and weight, and percentage fat calories as strongly associated with weight quotient/height quotient ratios. In females the correlations were not as strong, possibly because a significant percentage had reached the menarche some time before the survey and were probably no longer growing. Nevertheless, calorie intake, as a percentage of the recommendation for height age, was prominent in the regressions for height quotient and percentage fat calories in that for weight quotient. The very strong association of animal protein intake with male height, despite seemingly generous total protein intakes, is difficult to reconcile with current recommendations. The possible role of vitamin A (as beta-carotene) has potentially important implications for food policies.

Determinants of growth among poor children: relation of nutrient intakes to expenditure for food

The growth status and the nutrient intakes of 123 children from 26 urban poor families in Peru were related to per capita expenditure for food. Children from six better off families were taller and heavier (p less than 0.001), with no difference in weight for height. They had significantly higher calorie and total protein intakes (as percentage of recommended) and higher intakes of animal protein, fat, calcium, carotene, riboflavin, and vitamin C. When macronutrient intakes were expressed as percentages of recommended calorie intakes, correcting for age and relative size, all of the increase in total protein intake was due to animal protein, vegetable protein remaining constant. Almost all of the increase in adequacy of total calories was due to increasing fat intakes, relatively much less to carbohydrate, and this only among the poor families. In this population, as more money becomes available to purchase food, there is an increase in animal protein and fat intakes, over an almost constant vegetable protein and carbohydrate intake. There is a simultaneous increase in consumption of fruits and vegetables, accounting for increases in the carotene and vitamin C intakes.

Urban-rural differences in the growth of Peruvian children

The growth characteristics of children from four villages in northern Peru were compared with those of poor urban children in the capital city, in whom short stature but generally satisfactory weight for height relationships after infancy had been demonstrated. Height for age and weight for age fell more rapidly during infancy in the rural than in the urban children of both sexes. Rural girls caught up with the urban girls in height during childhood but did not match them in weight until late adolescence. Their weight to height ratios were consistently lower after 1 year of age, most strikingly between 2 and 5 years of age, and did not approach or match those of the urban girls until adolescence. Rural boys did not catch up with the urban boys in height or weight (differences in height were not statistically significant between 6 and 10 years, however) and their ratios remained consistently lower until late adolescence, most strikingly in early childhood and during puberty. Such urban-rural and sex differences, if typical and current, might well call for very different remedial measures at different ages in each of the populations.

Growth standards for poor urban children in nutrition studies

In order to estimate the importance of a variety of environmental and dietary factors as determinants of growth in a group of 123 poor Peruvian urban children between 2 and 19 years old, we found it necessary to express anthropometric measurements in units that were not age- or sex-dependent. Height quotient and weight quotient for each child were calculated from height and weight ages derived from the 50th percentile of the Boston reference data for the appropriate sex. Only 5% of the children had heights above the Boston 50th percentile (height quotient greater than 100) and 18% had weights above the 50th percentile (weight quotient greater than 100), but 88% had weights that were appropriate or excessive for height (weight/height quotient greater than or equal to 1.00). Some CATch-up" gains in relative height and weight were apparent in preschool children but more impressive gains in both linear and ponderal growth, relative to the Boston data, were evident between 8 and 13.5 years in girls and 10 and 17 years in boys. When the same quotients were calculated for a much larger sample from the same socioceonomic level it seemed likely that this last peak was due to earlier puberty and sexual maturation, and that quotients derived from the Boston data would have different meanings at different ages, making them inappropriate for further statistical analysis. New quotients for the study population, derived from the larger Peruvian group, did not have sex- or age-dependent trends. Racial and regional differences in patterns of growth must be taken into account in the interpretation of anthropometric and nutritional data.