Retinol binding protein as a surrogate measure for serum retinol: studies in vitamin A-deficient children from the Republic of the Marshall Islands.

BACKGROUND: Serum retinol is transported by retinol binding protein (RBP), which has one high-affinity binding site for retinol; consequently, the molar ratio of retinol to RBP in the circulation is approximately 1 to 1. In vitamin A deficiency (VAD), both serum retinol and RBP decline. However, the retinol-RBP relation has not been well studied in populations with a high incidence of severe VAD. OBJECTIVE: The purpose of this study was to determine whether RBP is a good surrogate for serum retinol at the very low retinol concentrations encountered in VAD. DESIGN: The stoichiometric relation between retinol and RBP was studied in 239 Marshallese children: 65 with severe VAD (< or = 0.35 micromol retinol/L), 94 with moderate VAD (0.36-0.70 micromol retinol/L), and 80 with vitamin A sufficiency (> 0.70 micromol retinol/L). RESULTS: Excellent correlation between retinol and RBP (r = 0.94) was observed across all retinol concentrations. Severe VAD was predicted with 96% sensitivity and 91% specificity on the basis of an RBP cutoff of < or = 0.48 micromol/L, whereas moderate VAD was predicted with 87% sensitivity and 98% specificity on the basis of an RBP cutoff of < or = 0.70 micromol/L. CONCLUSIONS: The use of RBP results in the classification of essentially the same children with VAD as does retinol, and RBP is an excellent surrogate for serum retinol. Considering the relative ease of measuring RBP with immunodiagnostic kits compared with that of serum retinol by HPLC, the use of RBP concentrations to assess VAD may be particularly advantageous in field settings. Consequently, measuring RBP concentrations may be a practical alternative to measuring serum retinol in population surveys assessing the prevalence of VAD.

Seroepidemiological characterization of a syphilis epidemic in the Republic of the Marshall Islands, formerly a yaws endemic area.

The annual numbers of reported cases of syphilis in the Republic of the Marshall Islands (RMI) increased from none in 1983 to more than 600 in 1989, suggesting a large outbreak of syphilis. Much of the increase resulted from expanded serological screening. The apparent outbreak of syphilis, therefore, may have been partly the result of increased surveillance or, since the RMI was formerly a yaws endemic area, possibly due to a resurgence of yaws. To address this problem and better characterize the epidemic, we analysed results from a 1989/90 Ministry of Health Services mass serological screening on Majuro Atoll, the main population centre. Serum specimens from 9160 people (86% of residents aged 15-44 years) on Majuro were screened with the rapid plasma reagin (RPR) card test; we repeated the RPR and performed a confirmatory microhaemagglutination assay for Treponema pallidum-specific antibodies (MHA-TP) on a sample of serum specimens. To estimate the seroprevalence of syphilis, we also tested a sample of RPR nonreactive specimens by MHA-TP. Among people less than 45 years of age, total (11.5%) and high-titre (5.2%) seropositivity rates were highest in the 20-24 year age group, as was MHA-TP seroprevalence (15.9%). These results suggested that a large outbreak of syphilis was responsible for the observed seroreactivity. Cumulative incidence modelling and comparisons with the results of a previous serosurvey conducted in 1985 suggested that the duration of the syphilis epidemic was approximately 10 years and that incidence had not increased appreciably since 1985.

Relationship of vitamin A deficiency, iron deficiency, and inflammation to anemia among preschool children in the Republic of the Marshall Islands.

INTRODUCTION: Although vitamin A deficiency, iron deficiency, and inflammation may contribute to anemia, their relative contribution to anemia has not been well characterized in preschool children in developing countries. OBJECTIVE: To characterize the contributions of vitamin A and iron deficiencies and inflammation to anemia among preschool children in the Republic of the Marshall Islands. SUBJECTS AND METHODS: A community-based survey, the Republic of the Marshall Islands Vitamin A Deficiency Study, was conducted among 919 preschool children. The relationship of vitamin A and iron status and markers of inflammation, tumor necrosis factor-alpha, alpha1-acid glycoprotein, and interleukin-10, to anemia were studied in a subsample of 367 children. RESULTS: Among the 367 children, the prevalence of anemia was 42.5%. The prevalence of severe vitamin A deficiency (serum vitamin A < 0.35 micromol/l) and iron deficiency (serum ferritin < 12 microg/dl) were 10.9 and 51.7%, respectively. The respective prevalence of iron deficiency anemia (hemoglobin < 110 g/l and iron deficiency), anemia with inflammation (anemia with TNF-alpha > 2 pg/ml and/or AGP > 1000 mg/l), and severe vitamin A deficiency combined with anemia was 26.7, 35.6, and 7.6%. In multivariate linear regression models that adjusted for age, sex, and inflammation, both iron deficiency (odds ratio (OR) 1.74, 95% confidence interval (CI) 1.08-2.83, P = 0.023) and severe vitamin A deficiency (OR 4.85, 95% CI 2.14-10.9, P < 0.0001) were significantly associated with anemia. CONCLUSIONS: Both iron and vitamin A deficiencies were independent risk factors for anemia, but inflammation was not a significant risk factor for anemia among these preschool children.

Formative research to inform intervention development for diabetes prevention in the Republic of the Marshall Islands.

Formative research was conducted in the Republic of the Marshall Islands to help develop a diabetes prevention intervention. Methods included in-depth interviews, semistructured interviews, and direct observation of household behaviors in urban and remote settings. Foods were classified into two main conceptual spheres: foods from the islands/Marshallese foods and imported/American foods. Diabetes (nanimij in tonal) is a highly salient illness and is believed to be caused by foods high in fat and sugar, consumption of imported/American foods, family background, and the atomic bomb testing. Physical activity and eating a traditional diet were viewed as important for preventing diabetes. The traditional belief system links a large body with health, and a thin body with illness; however, perceptions are changing with increased acculturation and education about the health risks of obesity. These findings were used to develop a diabetes prevention home visit intervention currently being implemented and evaluated in Marshallese households.

Review of the clinical use of intravenous mannitol with ciguatera fish poisoning from 1988 to 1992.

Intravenous mannitol was introduced as an effective treatment for ciguatera in 1988. Clinicians have used intravenous mannitol with success in several geographic areas. However, there remains a general skepticism and reluctance to use mannitol to treat ciguatera amongst clinicians. The possible reasons for the clinician's reluctance to use intravenous mannitol to treat ciguatera are reviewed.

Cancer-related disparities: weathering the perfect storm through comprehensive cancer control approaches.

During the last two decades extraordinary progress in developing and using effective cancer prevention strategies, early detection interventions, and cancer treatments has been made. This progress has resulted in an overall decline in mortality rates for all cancers combined. Nonetheless, cancer is the second most common cause of death in the United States. Although cancer is a diagnosis that many survive, cancer experiences across populations may vary considerably. These differences in cancer experiences have created an unequal disease burden that presents distinct professional and moral challenges to our nation. Many cancer control plans suggest specific strategies that prioritize eliminating cancer-related disparities. This article describes certain cancer-related disparities in the United States and gives several examples of how communities and disenfranchised populations are using comprehensive cancer control (CCC) approaches to eliminate these disparities. One or two interventions are highlighted in each example.

Quantifying tobacco related health care expenditures in the Republic of the Marshall Islands: a case study in determining health costs in a developing US associated island nation.

OBJECTIVES: This case study examines the advantages, disadvantages, and utility of three research methods to measure the medical costs of tobacco use in the Republic of the Marshall Islands (RMI). METHODS: The authors used the morbidity-based models, models based on the difference in utilization of medical facilities between smokers and non-smokers, and models of inter-country comparisons. FINDINGS: In the RMI, morbidity models would have a propensity to grossly under-estimate the medical costs of tobacco use. Models that measure the difference in medical service utilization between smokers and non-smokers can be confounded by cultural factors and by the level of health care that is provided. The RMI population structure affected the sampling methods. The external validity of the survey instrument may be increased through measuring more parameters with greater precision. Inter-country comparisons may be used to approximate and set upper and lower limits of costs for past medical costs, and may be the only method to determine future health care costs from tobacco use. CONCLUSIONS: Determining medical costs of tobacco use in an US Associated island nation with an under-developed health care infrastructure has not been previously attempted. There were significant methodological challenges that were encountered. Health, economic, cultural, and research environments in the RMI are unique and require innovative methods to determine medical costs associated with tobacco use. Direct application of the methodologies utilized in the United States to determine medical costs of tobacco use may grossly under-estimate the medical cost of tobacco use in the RMI. The research challenges can be addressed.

Cultural competence: a proposal for physicians reaching out to Native Hawaiian patients.

Many physicians of Native Hawaiian ancestry, as well as others, have noted a cultural gap between themselves and their Native Hawaiian patients. This cultural gap could potentially lead to discordance in the physician-patient relationship, and in turn, result in less than adequate therapeutic outcomes. Native Hawaiian physicians and those who treat Native Hawaiian patients are seeking ways to improve therapeutic relationships. Developing cultural competency in Native Hawaiian physicians and those who treat Native Hawaiian patients may be expected to improve therapeutic relationships. Principles of cultural competency, including increasing awareness of self and others, enhancing one's cultural knowledge base, and developing skills to communicate effectively, could be applied to physician-patient encounters with Native Hawaiian patients. The principles and skills of cultural competency could be learned during the formal and continuing medical education process. Developing an educational system that promotes cultural competency in physicians is necessary to address the health needs of Native Hawaiians and other diverse populations in Hawai'i.

Chronic phase lipids in sera of chronic fatigue syndrome (CFS), chronic ciguatera fish poisoning (CCFP), hepatitis B, and cancer with antigenic epitope resembling ciguatoxin, as assessed with MAb-CTX.

Clinical reports and descriptions of chronic fatigue syndrome (CFS) and chronic ciguatera fish poisoning (CCFP) show great similarities in clinical symptomology. These similarities in the literature suggested the exploration of lipids in sera of CFS, CCFP, and other diseases with the membrane immunobead assay (MIA), which is typically used for screening ciguateric ocean fish. Sera from patients with other diseases, including hepatitis B, cancer, and diabetes, were included to assess the degree of specificity involved. Sera were treated with acetone in a ratio of 1 part serum to 4 parts acetone. The suspension was centrifuged, and the acetone layer was evaporated. The residue was weighed and redissolved in 1.0 mL methanol and tested by the MIA, undiluted and titered to 1:160. The undiluted acetone fraction of the 37 normal showed +/- activity to +activity with 16 no titer, 15 with 1:5 titer and two with 1:10 titer, and four with > or =1:40 titers. One hundred fifteen CFS sera showed 1 with 1+ and 114 with 2+ activity in the undiluted samples, 1 with 1:10 titer, 3 with 1:20 titer, 31 with 1:40 titer, 50 with 1:80 titer, and 30 with 160 titer. Thus 95.6% of the samples had > or =1:40 titer. Eight hepatitis B sera samples had > or =1:40 titers. Four CCFP samples had > or =1:40 titers. Three of 16 cancer samples had 1:40 titer. These data are summarized in Fig. 1. As shown in Table 1, a significant increase (P<0.001) in the chronic phase lipids (CPLs) was shown relative to the normal group. A preliminary chemical study in C18 octadecylsilyl columns showed all fractions (100% chloroform, 9:1 chloroform : methanol, 1:1 chloroform : methanol, and 100% methanol) to contain lipids reactive to MAb-CTX with different intensities. Prostaglandins were shown in 100% methanol fraction. Competitive MIA with crude fish ciguatoxin and CFS with synthetic JKLM ciguatoxin epitope suggested similarities in structure with ciguatoxin. This was compatible with the neuroblastoma assay demonstrated in the C(18) column fractions 9:1 and 1:1, chloroform : methanol solvents.

Successful treatment of ciguatera fish poisoning with intravenous mannitol.

Twenty-four patients with acute ciguatera fish poisoning were treated with intravenous mannitol, and each patient's condition improved dramatically. All exhibited marked lessening of neurologic and muscular dysfunction within minutes of the administration of mannitol. Gastrointestinal symptoms disappeared more slowly. Two patients in coma and one in shock responded within minutes, with full recovery after infusion. Although these observations were empiric and uncontrolled and the mechanism of action of mannitol in this disease is unclear, mannitol should be considered for initial use in patients with significant illness and morbidity from ciguatera fish poisoning.