Rural child malnutrition and unsuccessful outcome of food basket programme: does ethnicity matter?

Objectives: The objectives of this study were to determine the prevalence of malnutrition among five-year-olds and factors associated with unsuccessful outcome of a Food Basket Programme (FBP) in a rural district of Kelantan, Malaysia.Design: Administrative health records from selected health clinics were reviewed. Study sample includes indigenous population or Orang Asli of Malaysia. Unsuccessful outcome was defined according to failure to complete the programme according to growth gain and on-time. Multiple logistics regression was used to assess the associated factors of unsuccessful outcome of FBP.Results: This study showed that the prevalence rates of malnutrition among children below five years old were 34.2% underweight, 16.4% thinness, 32.5% stunting and 3.0% overweight, with Orang Asli children faring the worse. Orang Asli children were also five times more likely to be unsuccessful in the FBP (p < .001).Conclusion: Malnutrition is still prevalent among children below five years old in this rural setting and Orang Asli children are vulnerable to have an unsuccessful outcome from the Food Basket Programme. Further research is necessary to further explain this association to inform policy, specifically for Orang Asli children.

Study on dosage range evaluation opioid analgesic for breakthrough pain in cancer patients: a retrospective study.

BACKGROUND: Breakthrough pain is an exacerbation of pain occurring in patients with chronic pain who receive opioid therapy every day. Breakthrough pain has not been routinely recognized, evaluated and treated. This study aimed to analyze the utilization of opiates analgesics, including dose regimentation, frequency of use, and the actual adverse effects in cancer patients with breakthrough pain. METHODS: Data were collected by the retrospective method in the period from January to December 2017. Patients involved received opioids around the clock for treating background pain and rescue medication for treating breakthrough pain. The percentage of the rescue medication dose was calculated based on the total daily opioid dose to treat background pain. Descriptive analysis was used. RESULTS: From 335 visits, there were 334 of patient visit where the patient received immediate-release morphine as a rescue medication with a dose percentage between 6.67-60%, and 1 visit where the patient received codeine with a dose percentage of 16.67%. Of 335 visits, 233 patient visits received the right proportion of opioid rescue medication doses, while 102 patient visits received a greater dose proportion than the recommended dose of 5-20%. CONCLUSIONS: Immediate-release morphine is the most commonly prescribed analgesic to treat breakthrough pain and used at 6.67-60% of daily dose with the frequency of use between 2 to 6 times a day. There were 189 (56.42%) patient visits when the patient experienced the adverse effects of the opioid. The identified actual adverse effects are constipation, nausea, and vomiting.

pRotective vEntilation with veno-venouS lung assisT in respiratory failure: A protocol for a multicentre randomised controlled trial of extracorporeal carbon dioxide removal in patients with acute hypoxaemic respiratory failure.

One of the few interventions to demonstrate improved outcomes for acute hypoxaemic respiratory failure is reducing tidal volumes when using mechanical ventilation, often termed lung protective ventilation. Veno-venous extracorporeal carbon dioxide removal (vv-ECCO2R) can facilitate reducing tidal volumes. pRotective vEntilation with veno-venouS lung assisT (REST) is a randomised, allocation concealed, controlled, open, multicentre pragmatic trial to determine the clinical and cost-effectiveness of lower tidal volume mechanical ventilation facilitated by vv-ECCO2R in patients with acute hypoxaemic respiratory failure. Patients requiring intubation and mechanical ventilation for acute hypoxaemic respiratory failure will be randomly allocated to receive either vv-ECCO2R and lower tidal volume mechanical ventilation or standard care with stratification by recruitment centre. There is a need for a large randomised controlled trial to establish whether vv-ECCO2R in acute hypoxaemic respiratory failure can allow the use of a more protective lung ventilation strategy and is associated with improved patient outcomes.

Simvastatin for patients with acute respiratory distress syndrome: long-term outcomes and cost-effectiveness from a randomised controlled trial.

BACKGROUND: Simvastatin therapy for patients with acute respiratory distress syndrome (ARDS) has been shown to be safe and associated with minimal adverse effects, but it does not improve clinical outcomes. The aim of this research was to report on mortality and cost-effectiveness of simvastatin in patients with ARDS at 12 months. METHODS: This was a cost-utility analysis alongside a multicentre, double-blind, randomised controlled trial carried out in the UK and Ireland. Five hundred and forty intubated and mechanically ventilated patients with ARDS were randomly assigned (1:1) to receive once-daily simvastatin (at a dose of 80 mg) or identical placebo tablets enterally for up to 28 days. RESULTS: Mortality was lower in the simvastatin group (31.8%, 95% confidence interval (CI) 26.1-37.5) compared to the placebo group (37.3%, 95% CI 31.6-43.0) at 12 months, although this was not significant. Simvastatin was associated with statistically significant quality-adjusted life year (QALY) gain (incremental QALYs 0.064, 95% CI 0.002-0.127) compared to placebo. Simvastatin was also less costly (incremental total costs -£3601, 95% CI -8061 to 859). At a willingness-to-pay threshold of £20,000 per QALY, the probability of simvastatin being cost-effective was 99%. Sensitivity analyses indicated that the results were robust to changes in methodological assumptions with the probability of cost-effectiveness never dropping below 90%. CONCLUSION: Simvastatin was found to be cost-effective for the treatment of ARDS, being associated with both a significant QALY gain and a cost saving. There was no significant reduction in mortality at 12 months, TRIAL REGISTRATION: ISRCTN, 88244364. Registered 26 November 2010.

The cost-effectiveness of cardiac computed tomography for patients with stable chest pain.

OBJECTIVE: To assess the cost-effectiveness of cardiac CT compared with exercise stress testing (EST) in improving the health-related quality of life of patients with stable chest pain. METHODS: A cost-utility analysis alongside a single-centre randomised controlled trial carried out in Northern Ireland. Patients with stable chest pain were randomised to undergo either cardiac CT assessment or EST (standard care). The main outcome measure was cost per quality adjusted life year (QALY) gained at 1 year. RESULTS: Of the 500 patients recruited, 250 were randomised to cardiac CT and 250 were randomised to EST. Cardiac CT was the dominant strategy as it was both less costly (incremental total costs -£50.45; 95% CI -£672.26 to £571.36) and more effective (incremental QALYs 0.02; 95% CI -0.02 to 0.05) than EST. At a willingness-to-pay threshold of £20 000 per QALY the probability of cardiac CT being cost-effective was 83%. Subgroup analyses indicated that cardiac CT appears to be most cost-effective in patients with a likelihood of coronary artery disease (CAD) of <30%, followed by 30%-60% and then >60%. CONCLUSIONS: Cardiac CT is cost-effective compared with EST and cost-effectiveness was observed to vary with likelihood of CAD. This finding could have major implications for how patients with chest pain in the UK are assessed, however it would need to be validated in other healthcare systems. TRIAL REGISTRATION NUMBER: (ISRCTN52480460); results.

A comparison of cardiac computerized tomography and exercise stress electrocardiogram test for the investigation of stable chest pain: the clinical results of the CAPP randomized prospective trial.

AIMS: To determine the symptomatic and prognostic differences resulting from a novel diagnostic pathway based on cardiac computerized tomography (CT) compared with the traditional exercise stress electrocardiography test (EST) in stable chest pain patients. METHODS AND RESULTS: A prospective randomized controlled trial compared selected patient outcomes in EST and cardiac CT coronary angiography groups. Five hundred patients with troponin-negative stable chest pain and without known coronary artery disease were recruited. Patients completed the Seattle Angina Questionnaires (SAQ) at baseline, 3, and 12 months to assess angina symptoms. Patients were also followed for management strategies and clinical events. Over the year 12 patients withdrew, resulting in 245 in the EST cohort and 243 in the CT cohort. There was no significant difference in baseline demographics. The CT arm had a statistical difference in angina stability and quality-of-life domains of the SAQ at 3 and12 months, suggesting less angina compared with the EST arm. In the CT arm, there was more significant disease identified and more revascularizations. Significantly, more inconclusive results were seen in the EST arm with a higher number of additional investigations ordered. There was also a longer mean time to management. There were no differences in major adverse cardiac events between the cohorts. At 1 year in the EST arm, there were more Accident and Emergency (A&E) attendances and cardiac admission. CONCLUSION: Cardiac CT as an index investigation for stable chest pain improved angina symptoms and resulted in fewer investigations and re-hospitalizations compared with EST. CLINICAL TRIAL REGISTRATION: http://www.controlled-trials.com/ISRCTN52480460.

Description and predictors of hospital costs of oesophageal cancer during the first year following diagnosis in Northern Ireland.

The cost-effectiveness of novel interventions in the treatment of cancer is well researched; however, relatively little attention is paid to the cost of many aspects of routine care. Oesophageal cancer is the ninth most common cancer in the UK and sixth most common cause of cancer death. It usually presents late and has a poor prognosis. The hospital costs incurred by oesophageal cancer patients diagnosed in Northern Ireland in 2005 (n = 198) were determined by review of medical records. The average cost of hospital care per patient in the 12 months from presentation was £7847. Variations in total hospital costs by age at diagnosis, gender, cancer stage, histological type, mortality at 1 year, co-morbidity count and socio-economic status were analysed using multiple regression analyses. Higher costs were associated with earlier stages of cancer and cancer stage remained a significant predictor of costs after controlling for cancer type, patient age and mortality at 1 year. Thus, although early detection of cancer usually improves survival, this would mean increased costs in the first year. Deprivation achieved borderline significance with those from more deprived areas having lower resource consumption relative to the more affluent.

A randomized, placebo-controlled, double-blind trial of the effect of combined therapy with deferoxamine and deferiprone on myocardial iron in thalassemia major using cardiovascular magnetic resonance.

BACKGROUND: Cardiac complications secondary to iron overload are the leading cause of death in beta-thalassemia major. Approximately two thirds of patients maintained on the parenteral iron chelator deferoxamine have myocardial iron loading. The oral iron chelator deferiprone has been demonstrated to remove myocardial iron, and it has been proposed that in combination with deferoxamine it may have additional effect. METHODS AND RESULTS: Myocardial iron loading was assessed with the use of myocardial T2* cardiovascular magnetic resonance in 167 patients with thalassemia major receiving standard maintenance chelation monotherapy with subcutaneous deferoxamine. Of these patients, 65 with mild to moderate myocardial iron loading (T2* 8 to 20 ms) entered the trial with continuation of subcutaneous deferoxamine and were randomized to receive additional oral placebo (deferoxamine group) or oral deferiprone 75 mg/kg per day (combined group). The primary end point was the change in myocardial T2* over 12 months. Secondary end points of endothelial function (flow-mediated dilatation of the brachial artery) and cardiac function were also measured with cardiovascular magnetic resonance. There were significant improvements in the combined treatment group compared with the deferoxamine group in myocardial T2* (ratio of change in geometric means 1.50 versus 1.24; P=0.02), absolute left ventricular ejection fraction (2.6% versus 0.6%; P=0.05), and absolute endothelial function (8.8% versus 3.3%; P=0.02). There was also a significantly greater improvement in serum ferritin in the combined group (-976 versus -233 microg/L; P<0.001). CONCLUSIONS: In comparison to the standard chelation monotherapy of deferoxamine, combination treatment with additional deferiprone reduced myocardial iron and improved the ejection fraction and endothelial function in thalassemia major patients with mild to moderate cardiac iron loading.

Occurrence of fumonisins (B1, B 2, B 3) in maize-based food and feed samples from Indonesia.

A survey to evaluate the contamination level of total fumonisins in maize-based foodstuffs, maize and feed from Indonesia is described. The analyses were carried out by enzyme-linked immunosorbent assay (ELISA). Samples were collected from local retail stores around Yogyakarta, Indonesia between February and May 2001. The 101 samples were classified into six categories, i.e. industrially-produced food (n=24), products of small food manufacturers (n=17), maize flour (n=4), maize for food (n=9), maize for feed (n17), and formulated feed (n30). Control of the method showed that the detection limit was 8.7 µg/kg and repeatability is shown by relative standard deviation (RSD) of analyses of contaminated maize (n=5) of 10 %. Results of analyses indicate that 80 samples analysed were contaminated over a large range from 10.0-3307 pg/kg, and the concentration of fumonisins depended on the type of sample. Of four samples of maize flour, none were contaminated (below detection limit). Of 24 samples of industrially produced food, 14 were contaminated in the range 22.8 - 105 µg/kg and 18 of 19 food samples from small manufacturers were contaminated ranging from 12.9 to 234 µg/kg. The highest contamination was observed in maize samples: six of ten samples of maize for food were contaminated between 68.0 - 2471 µg/kg and 16 of 17 samples for feed contained fumonisins over a large range from 17.6 to 3306 µg/kg.

A survey of aflatoxin B1 and total aflatoxin contamination in baby food, peanut and corn products sold at retail in Indonesia analysed by ELISA and HPLC.

Aflatoxin contamination has been well known as a world-wide health-threatening problem in tropical countries including Indonesia. This research was undertaken to determine the degree of aflatoxin contamination in different Indonesian foodstuffs. A preliminary survey was carried out to evaluate the level of total aflatoxin (AfT) and aflatoxin B1 (AfB1) contamination of baby foods, peanut products, and corn products, which were purchased from traditional markets and supermarkets in Indonesia during the year 2001-2002. Eighty two peanut products, 12 baby foods products, and 11 corn products from different brands were analysed for AfT and AfB1 using the Enzyme-Linked Immunosorbent Assay (ELISA) method. The results indicate that, of the brands analysed, 35% of the peanut products were contaminated with aflatoxins at various levels (range 5 to 870 µg/kg). Peanut-chilli sauces had the highest percentage of AfT contamination 9/12 (75%), which was followed by traditional snacks 5/11 (45%), peanut butter 4/11 (40%), flour egg coated peanut 6/16 (37%), and peanut cake 3/10 (30%). Fried peanuts and roasted peanut were found to contain aflatoxin at relatively lower percentages of 9% and 8%, respectively. From the 12 analysed baby food samples, on the other hand, no sample was found to be contaminated with aflatoxins. Two of 11 samples (18%) of corn based products were contaminated with AfT, ranging between 5.8 and 12.4 µg/kg. Additionally, 30 selected samples in different concentration ranges were further analysed to verify the correlation between ELISA and HPLC techniques and results were compared.

A survey of fumonisins (B1, B2, B3) in Indonesian corn-based food and feed samples.

In this paper a survey is described for determination of contamination level of fumonisins (B(1), B(2), B(3)) in Indonesian cornbased feed and food samples. The survey was conducted from February to May 2001. Foodstuffs, which are consumed directly such as snacks and other products, were investigated for fumonisin contamination. Of 105 food and feed samples purchased from local retail stores and local poultry shops around Yogyakarta, Java, Indonesia were analyzed using ELISA. Results indicate that 74.3% of samples analyzed were contaminated in a large range of 10.0 - 3307 µg/kg, and the concentration of fumonisins depends on the type of samples. Detection limit of the method used was 9 µg/kg.From eight food samples of maize flour, and corn-based beverages and cereals, none was contaminated (below detection limit). For food samples of industrial products (19 samples), 13 were contaminated in the range of 22.8 - 105 µg/kg and 19 of 20 samples from home made products were contaminated between 12.9 - 234 µg/kg. The food samples contaminated in highest level occurred in corn. Of ten samples, 6 were contaminated from 68.0 - 2471 µg/kg. For feed samples, 17 corn samples were evaluated. Of those samples, 16 contained in a large range of 17.6 - 3306 µg/kg.

Natural occurrence of aflatoxin B1 in some Indonesian food and feed products in Yogyakarta in year 1998-1999.

A survey was conducted between 1998-1999 to evaluate the level of aflatoxin B1 (AfB1) contamination in some selected Indonesian food products, mainly peanuts and peanut products for sale in supermarkets or traditional markets in Yogyakarta, Indonesia. Quantitative analysis was carried out on 118 samples using the ELISA (Enzyme-Linked Immunosorbent Assay) technique. The results indicate that (61.1%) samples were contaminated with AfB1 at range 2.0 to 249.0 µg/kg. Approximately 50% of the baby food products analysed were contaminated with AfB1 and the maximum level found was 7.0 µg/kg. In corn products and fermented products, AfB1 was detected in 66.7 and 50.0% of samples, respectively. A level as high as 5.6 µg/kg of AfB1 was found in the corn and 6.0 µg/kg in fermented product. AfB1 was also detected in all rice products, feed products, and other processed products at levels of up to 7.0, 27.0, and 26.0 µg/kg, respectively.

Psychiatric severity and treatment response in a comprehensive methadone maintenance treatment program.

The purpose of this study was to investigate the influence of the severity of concomitant psychiatric symptomatology on some selected measures of methadone maintenance treatment efficacy in a comprehensive methadone maintenance treatment program (MMTP). The cohort studied included 267 patients who entered a maintenance program in the years 1991-92. Two groups of patients differing in the severity of psychiatric symptomatology were obtained on the bases of the referral to the psychiatrist and the ascertainment of a current disorder. These two groups were compared for retention in treatment, urine tests positive for morphine while in treatment and methadone dose during an observation period of 2 years. The outcome of the study suggests that on these outcome parameters, patients on MMTP who are more psychiatrically ill can perform as well as the other patients.

Substrate and Solvent Influence on the Photochemical C-H Bond Activation Reactivity of (HBPz'(3))Rh(CO)(2) (Pz' = 3,5-Dimethylpyrazolyl).

The photochemically-induced intermolecular C-H bond activation reaction of (HBPz'(3))Rh(CO)(2) (Pz' = 3,5-dimethylpyrazolyl) has been investigated in various hydrocarbon solutions at 293 K following excitation at 366 and 458 nm. UV-visible and FTIR spectra recorded throughout photolysis illustrate that the dicarbonyl complex can be converted readily to the corresponding (HBPz'(3))Rh(CO)(R)H derivatives at each of the excitation wavelengths. The photochemistry proceeds without interference from secondary photoprocesses or thermal reactions and the reactivity has been measured quantitatively with the determination of absolute quantum efficiencies for intermolecular C-H bond activation (phi(CH)). These measurements indicate that the C-H activation reaction proceeds very efficiently (phi(CH) = 0.13-0.32) on excitation at 366 nm but is much less effective (phi(CH) = 0.0059-0.011) on photolysis at 458 nm for each of the hydrocarbon substrates. The observed dependence of phi(CH) on irradiation wavelength is consistent with different reactivities from two rapidly dissociating low-energy ligand field (LF) excited states and the generation of monocarbonyl (HBPz'(3))Rh(CO) and ligand-dechelated (eta(2)-HBPz'(3))Rh(CO)(2) intermediates upon UV and visible excitation, respectively. The former species is attributed to be responsible for the unusually efficient C-H bond activation, whereas it is suggested that the latter complex effectively lowers the quantum efficiency by undergoing a facile eta(2)-->eta(3) ligand rechelation process. Significantly, the photoefficiencies are found to be unaffected on increasing the dissolved CO concentration, illustrating that the monocarbonyl reaction intermediate is extremely short-lived and is solvated before CO is able to coordinate. Additionally, the lack of a [CO] dependence on phi(CH) indicates that this solvated intermediate is not subject to a competitive back-reaction with CO prior to the C-H activation step, illustrating that the quantum efficiencies in (HBPz'(3))Rh(CO)(2) appear to be solely determined by the branching ratio between the dissociative and nondissociative routes. At any particular excitation wavelength the photoefficiencies are observed to be similar across the series of alkanes but are significantly reduced for the aromatic solvents, even though the aryl hydrido photoproducts are found to be more thermodynamically stable. These phi(CH) differences are also rationalized in terms of photophysical effects on the upper LF level and are related to variations in the nonradiative relaxation rates for the excited (HBPz'(3))Rh(CO)(2) complex in the hydrocarbon solutions.