Effect of maternal nutritional education and counselling on children's stunting prevalence in urban informal settlements in Nairobi, Kenya.

OBJECTIVE: To determine whether the prevalence of stunting differed between an intervention group and a control group and to identify factors associated with the children's linear growth. DESIGN: This was a follow-up study of mother-child pairs who participated in a 2012-2015 cluster randomised controlled trial. Linear mixed effects models were performed to model the children's linear growth and identify the determinants of child linear growth. SETTING: The study was conducted in two slums in Nairobi. The intervention group received monthly nutrition education and counselling (NEC) during pregnancy and infancy period. PARTICIPANTS: A birth cohort of 1004 was followed up every 3 months after delivery to the 13th month. However, as a result of dropouts, a total of 438 mother-child pairs participated during the 55-month follow-up. The loss to follow-up baseline characteristics did not differ from those included for analysis. RESULTS: Length-for-age z-scores decreased from birth to the 13th month, mean -1·42 (sd 2·04), with the control group (33·5 %) reporting a significantly higher prevalence of stunting than the intervention group (28·6 %). Conversely, the scores increased in the 55th month, mean -0·89 (sd 1·04), with significantly more males (16·5 %) stunted in the control group than in the intervention group (8·3 %). Being in the control group, being a male child, often vomiting/regurgitating food, mother's stature of <154 cm and early weaning were negatively associated with children's linear growth. CONCLUSIONS: Home-based maternal NEC reduced stunting among under five years; however, the long-term benefits of this intervention on children's health need to be elucidated.

Measurement error for ultrasound fetal biometry performed by paramedics in rural Bangladesh.

OBJECTIVES: To document the accuracy and precision of sonographic fetal biometry performed by nine paramedics from rural Bangladesh. METHODS: Paramedics underwent intensive training (6 weeks) including hands-on practice then underwent a series of standardization exercises. Measurements of each fetus were taken by a highly-trained medical doctor (study supervisor) and the nine paramedics. Crown-rump length (CRL) in fetuses of less than 10 weeks' gestation, and biparietal diameter (BPD), occipitofrontal diameter, head and abdominal circumference (AC) and femur diaphysis length (FL) were measured twice using standard procedures by each paramedic and the medical doctor for each fetus, with at least 20 min between them. Precision was quantified using variance components analysis; the intraobserver error for each of the paramedics was calculated by comparing repeat measurements taken on the same participant, and the measurements obtained by each individual paramedic were also compared with those taken by the others (interobserver error). Accuracy was estimated by comparing the mean of the two measures taken by each paramedic to those taken by the study supervisor using paired t-tests. Bland-Altman plots were used to visually assess the relationship between precision of repeat measurements (intraobserver error) and fetal size. RESULTS: A total of 180 women, at 7 to 31 weeks' gestation, participated in the study. Intraobserver error of the measurements obtained by the paramedics, expressed as the mean SD, ranged from 0.97 mm for BPD in the first trimester to 7.25 mm for AC in the third trimester, and was larger than the interobserver error (i.e. accounting for a greater proportion of total variance) for most measurements. Interobserver error ranged from 0.00 mm for FL to 3.36 mm for AC, both in the third trimester. For all measurements except CRL, intraobserver error increased with increasing fetal size. The measurements obtained by the paramedics did show some statistically significant differences from those obtained by the study supervisor, but these were relatively small in magnitude. CONCLUSIONS: Both inter- and intraobserver measurement errors were within the range reported in the literature for studies conducted by technical staff and medical doctors. With intense training, paramedics with no prior exposure to ultrasonography can provide accurate and precise measures of fetal biometry.

Early-life nutritional and environmental determinants of thymic size in infants born in rural Bangladesh.

AIM: The aim was to assess the impact of nutritional status and environmental exposures on infant thymic development in the rural Matlab region of Bangladesh. METHODS: In a cohort of N(max) 2094 infants born during a randomized study of combined interventions to improve maternal and infant health, thymic volume (thymic index, TI) was assessed by ultrasonography at birth and at 8, 24 and 52 weeks of age. Data on birth weight, infant anthropometry and feeding status were also collected. RESULTS: At all ages, TI was positively associated with infant weight and strongly associated with the month of measurement. Longer duration of exclusive breastfeeding resulted in a larger TI at 52 weeks. TI at birth and at 8 weeks correlated positively with birth weight, but by 24 and 52 weeks and when adjusted for infant weight this effect was no longer present. Thymic size was not affected by pre-natal maternal supplementation or by socioeconomic status but was correlated to arsenic exposure during pregnancy. CONCLUSION: In this population of rural Bangladeshi infants, thymic development is influenced by both nutritional and environmental exposures early in life. The long-term functional implications of these findings warrant further investigation.

Effects of intrauterine growth restriction and postnatal nutrition on pediatric asthma in Bangladesh.

Numerous studies have investigated the risk of developing asthma due to early-life experiences and environmental exposures. However, the influence of intrauterine growth restriction and postnatal undernutrition on childhood wheezing/asthma remains unclear. Thus, we examined the effects of both small for gestational age (SGA) and postnatal stunted growth on ever asthma among children in the rural areas in Bangladesh.Multiple follow-up studies were conducted in a cohort of randomized clinical trial of nutrition interventions during pregnancy (the MINIMat trial). Overall, 1208 and 1697 children were followed-up for asthma at 4.5 and 10 years, respectively. Anthropometric measurements were obtained at various intervals from birth to 10 years of age. Ever asthma was identified using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire.Results showed that SGA was significantly associated with increased risk of ever asthma at 4.5 and 10 years after adjusting for sex, body mass index, socioeconomic status, family history of asthma, gestational age at birth, mother's parity, mother's age at birth and intervention trial arm [odds ratio (OR)=1.97 (95% confidence interval (CI): 1.34-2.90) and 1.86 (95% CI: 1.18-2.72)]. For the postnatal effect of undernutrition, stunting at 1 and 2 years was significantly associated with ever asthma at 4.5 and 10 years [1 year: OR=1.77 (95% CI: 1.22-2.57) and OR=1.72 (95% CI: 1.16-2.56), 2 years: OR=1.49 (95% CI: 1.06-2.10) and OR=1.41 (95% CI: 1.02-1.96)].In conclusion, SGA and undernutrition during infancy has an influence on childhood asthma among children in Bangladesh, indicating the need for nutritional interventions early in life.

Determinants of low birth weight in the context of maternal nutrition education in urban informal settlements, Kenya.

Inadequate knowledge in maternal nutrition is one of the determinants of low birth weight. However, little evidence is available on whether maternal nutrition counselling alone can influence birth weight among women from low socioeconomic households. This study assessed the effect of prenatal maternal nutritional counselling on birth weight and examined the related risk factors. A cluster randomized controlled trial was conducted to assess the effectiveness of home-based maternal nutritional counselling on nutritional outcomes, morbidity, breastfeeding, and infant feeding practices by the African Population and Health Research Center in two urban informal settlements of Nairobi. The intervention group received monthly antenatal and nutritional counselling from trained community health volunteers; meanwhile, the control group received routine antenatal care. A total of 1001 participants were included for analysis. Logistic regression was applied to determine associations between low birth weight and maternal characteristics. A higher prevalence of low birth weight was observed in the control group (6.7%) than in the intervention group (2.5%; P<0.001). Logistic regression identified significant associations between birth weight and intervention group (adjusted odds ratio (AOR)=0.26; 95% confidence interval (CI), 0.10-0.64); maternal height <154.5 cm (AOR=3.33; 95% CI, 1.01-10.96); last antenatal care visits at 1st or 2nd trimesters (AOR=9.48; 95% CI, 3.72-24.15); pre-term delivery (AOR=3.93; 95% CI, 1.93-7.98); maternal mid-upper arm circumference <23 cm (AOR=2.57; 95% CI, 1.15-5.78); and cesarean delivery (AOR=2.27; 95% CI, 1.04-4.94). Nutrition counselling during pregnancy reduced low birth weight and preterm births, which was determined by women of short stature, early stoppage of antenatal visit, and cesarean delivery.

Birth weight influences the kidney size and function of Bangladeshi children.

Early-life conditions influence organ growth patterns and their functions, as well as subsequent risk for non-communicable chronic diseases in later life. A limited number of studies have determined that in Bangladesh, kidney size relates to its function among children as a consequence of the maternal and postnatal conditions. The present study objectives were to determine early-life conditions in relation to childhood kidney size and to compare their influences on kidney function. The study was embedded in a population-based prospective cohort of 1067 full-term singleton live births followed from fetal life onward. Kidney volume was measured by ultrasound in children at the age of 4.5 years (range 45-64 months), and the estimated glomerular filtration rate (eGFR) was assessed at the age of 9 years (range 96-116 months). The mean (s.d.) kidney volume of children at 4.5 years was 64.2 (11.3) cm3, with a significant mean difference observed between low birth weight and normal birth weight children (P<0.001). The multivariable model showed, changes in status from low birth weight to normal birth weight children, with kidney volume increases of 2.92 cm3/m2, after adjusting for the child's age, sex, maternal age and early pregnancy body mass index, and socio-economic index variables. One-unit change in kidney volume (cm3/m2) improved the eGFR to 0.18 ml/min/1.73 m2. The eGFR in low birth weight children was 5.44 ml/min/1.73 m2 less than that in normal birth weight children after adjustments. Low birth weight leads to adverse effects on kidney size and function in children.

Association between the MB system and asthma in the Japanese.

Twenty-three unrelated Japanese patients with asthma who showed a high total serum IgE level, a strong skin test response to Dermatophagoides farinae, and a high score on a radioallergosorbent test (RAST) using Dermatophagoides farinae were typed for HLA-A locus, -B locus, and -D region antigens. No significant difference in the frequencies of HLA-A, -B, and -DR antigens were observed between the asthma patients and the healthy controls. A significant difference in the frequency of MB3', however, was found between the asthma patients and the healthy controls (corrected p = 0.04, relative risk = 18.5).

Urinary schistosomiasis in southern Ghana: a logistic regression approach to data from a community-based integrated control program.

The data for this analysis are based on the schistosomiasis control project of the Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana, designed to study the feasibility and effectiveness of an integrated schistosomiasis control program. It embraced chemotherapy and health education for community motivation. The study was carried out from 1993 to 1997. This paper presents observations made 24 months after intervention. Eight communities in southern Ghana were grouped into three areas. Individuals in all the areas received praziquantel after the baseline data collection in 1992-1993. Area 1 had passive while Area 3 received active health education. Area 2 received no education. Prevalence of schistosomiasis was the response variable of interest while age, sex, and area were considered as possible influencing variables. The model for the baseline data indicated no significant difference in prevalence among the three areas. The model 24 months after intervention indicated a significant difference among the three areas, suggesting a possible influence of the health education that motivated community participation in the provision of facilities for the control of schistosomiasis.

Predicting the timing of second praziquantel treatment and its effect on reduction of egg counts in southern Ghana.

Schistosoma haematobium infection could be associated with morbidity. Generally, the cost of schistosomiasis control is high and it becomes a burden for governments or non-governmental organisations to repeat control programs so as to reduce morbidity. There is therefore, the need to optimise the available meagre resources for its control. From 1993 to 1997 the Noguchi Memorial Institute for Medical Research of the University of Ghana carried out a schistosomiasis control program in southern Ghana. Using the generated data, an attempt is made to determine the timing of the second praziquantel treatment and the period needed after the second chemotherapy to have egg counts reduced to low levels in southern Ghana. It was revealed that the second praziquantel treatment in areas 1, 2, and 3 should be administered latest at 13.8, 11.8 and 13.2 months, respectively after the first one. Most importantly, it takes 24.4 months to bring egg counts to zero in area 3 while in area 1, it takes about 29 months after the second praziquantel treatment. Egg counts were not reduced to zero in area 2 after the second chemotherapy. At least passive health education and continuous safe water supply should support the chemotherapy in addition to weed removal at the water contact sites.

Alpha-fetoprotein producing Barrett's esophageal adenocarcinoma: a case report.

A 59-year-old man was admitted to our hospital with upper abdominal pain. His serum alpha-fetoprotein (AFP) level was very high, 1500 ng/ml. Upper gastrointestinal endoscopy revealed depressed lesion at 36 cm from the upper incisors, with columnar epithelium lining the esophagus circumferentially to the oral side of the lesion. Histological examination of biopsy specimens revealed a tubular adenocarcinoma as well as the presence of gastric columnar epithelium with intestinal metaplasia. Immunohistochemistry demonstrated AFP in the tumor cells. From these results, a diagnosis of AFP-producing esophageal adenocarcinoma occurring in Barrett's esophagus, a condition which is extremely rare in Japan, was established. Computed tomography (CT) showed multiple metastasis on the liver and wide-ranging lymph node metastasis. Chemotherapy was not effective and the patient died about 2 months after the start of treatment. The AFP-producing esophageal adenocarcinoma presented here had biological characteristics similar to those of AFP-producing gastric cancer.

Magnetic resonance imaging of heterotopic gray matter.

Heterotopic gray matter was detected by means of magnetic resonance imaging in a 3-year-old girl with left hemiparesis and atonic seizures. In the inversion recovery sequence, a large area of decreased signal intensity was noted in the right centrum semiovale and differentiation of the right basal ganglia was not clear. We speculated that the brain malformation in our patient occurred at ten weeks conceptional age.

Urinary schistosomiasis in southern Ghana: 1. Prevalence and morbidity assessment in three (defined) rural areas drained by the Densu river.

Epidemiological studies on urinary schistosomiasis were carried out in eight villages in the Ga and Akuapem South districts in Ghana. Single urine samples were collected from individuals aged 5 years and above between 10.00 and 14.00 h. The samples were examined for the presence of Schistosoma haematobium eggs using a filtration technique. Indirect morbidity was determined as the presence of microhaematuria and proteinuria using reagent strips, and macrohaematuria was recorded with the naked eye. Out of the study population of 3912 subjects, 2562 (65.5%) submitted urine samples. The prevalence of a Schistosoma haematobium infection ranged between 54.8 and 60.0%. Infection rates increased by age with a peak in the 10-19 years category, and decreased with increasing age. Disease prevalence was higher in males aged 15 years and above in Areas 2 (Ntoaso and Sansami Amanfro) and 3 (Dom Faase, Papase, Chento and Gidi Kope), whereas it was higher among males aged 10 years and above in Area 1 (Ayikai Doblo and Akramaman). The intensity of infection was highest among children aged 10-14 years in most of the villages. More than half of egg-positive children in this age group had a heavy infection (100 eggs and above in 10 ml of urine). Although both egg-positive and egg-negative individuals manifested variable degrees of macro- or micro-haematuria, microhaematuria was more prevalent among egg-positives (chi(2)=918.5, d.f.=1, P<0.01). The degree of microhaematuria and proteinuria were significantly associated with the intensity of the infection. These results indicate a high transmission of disease in the study area.

Study on endoscopic esophageal mucosal resection with ligating device. I--Clinical study.

BACKGROUND/AIMS: EEMRL (endoscopic esophageal mucosal resection with a ligating device) has become increasingly popular. In this article, we review 13 clinical cases of EEMRL. METHODOLOGY: Since 1993, we have performed EEMRL to treat 15 lesions in 13 patients. Twelve squamous cell carcinomas (mucosal cancer in 10 and submucosal cancer in 2) were included among the 15 lesions. RESULTS: EEMRL failed to achieve complete resection of the 2 submucosal lesions (3.0 and 2.8 cm in maximum diameter). However, esophageal lesions could be removed successfully when 2.5 cm or less in maximum diameter. The procedure was not associated with any complication. CONCLUSIONS: Our clinical study showed that this technique may be indicated for esophageal cancer with a maximum diameter < or = 2.5 cm and confined to the mucosa. EEMRL is a technically easy and minimally invasive therapy which could be useful for the treatment of early esophageal cancer.

Study on endoscopic esophageal mucosal resection with ligating device. II--Experimental study.

BACKGROUND/AIMS: This study reports on animal experiments regarding the safety of endoscopic esophageal mucosal resection with a ligating device (EEMRL), as well as the amount of mucosa which can be removed by this technique, the depth of resection and the feasibility of piecemeal resection. METHODOLOGY: Three experiments were performed in six mongrel dogs under general anesthesia. RESULTS: When EEMRL was done without submucosal injection of saline, resection reached the muscular layer and caused esophageal perforation. The average dimensions of the mucosal pieces resected using 8-, 10-, and 12-mm devices was 13 x 10 mm, 18 x 15 mm, and 22 x 18 mm, respectively. Resection reached the mid-plane of the submucosa and the depth was almost uniform. After piecemeal resection, there was no macroscopically visible mucosa at the resection site and each mucosal piece was resected along the mid-plane of the submucosa. CONCLUSIONS: The experimental study indicated that submucosal injection of saline is essential to prevent esophageal perforation. It also showed that EEMRL allows resection up to the mid-plane of the submucosa, that the 12-mm device allows en bloc resection of lesions < or = 15 mm in diameter and that EEMRL is suitable for piecemeal resection.

Health education and community participation in the control of urinary schistosomiasis in Ghana.

OBJECTIVE: To study the role of health education and community participation for the provision of facilities necessary for the control of urinary schistosomiasis in southern Ghana. HYPOTHESIS: Health education facilitates community participation in the provision of facilities for the control of bilharzia. STUDY AREA: Three rural communities drained by the Densu river in southern Ghana. PARTICIPANTS: Individuals aged 14 years and above formed groups of 10-12 persons by age, sex, ethnic and educational background; 15-16 groups were formed. INTERVENTIONS: Based on existing structures, one community received active, another passive health education and the third had no education. All three communities received chemotherapy. DESIGN: Study was carried out in three phases: pre-intervention phase--during which baseline data on residents' knowledge, attitude, beliefs and perception about bilharzia were collected using focus group discussions (FGD) prior to the second phase, intervention. Another FGD was held after 18 months to evaluate the intervention--third phase. RESULTS: This study suggests that most community members were aware of schistosomiasis but not as a disease. Before the health education, some residents believed bilharzia was a sign of manhood while others attributed the red colour of the urine to the red colour of a variety of sugar cane eaten in the area. After the health education, residents in the three areas constructed hand-dug wells. In addition, those who received active health education constructed two toilets for the schools and weeded the banks of the rivers. Residents also associated the disease with the water snail. CONCLUSION: Health education was useful in changing community perception on bilharzia.

PIP: This paper examines the role of health education and community participation in the control of urinary schistosomiasis in Ghana. The study population included individuals 14 years old and above living in three rural communities drained by the Densu river. Focus group discussions were employed in the pre-intervention and evaluation phases of the study. Meanwhile, interventions include passive and active health education on schistosomiasis and chemotherapeutic treatment with praziquantel. One of the communities served as a control where no health education was employed. The investigation found out that most community members were aware of schistosomiasis, not as a disease but simply as a sign of manhood. Still others associate the condition with eating red sugar cane, sexual intercourse with infected partner and so on. The health education program gave the communities the opportunity to enrich their knowledge on urinary schistosomiasis, its causes, treatment, and prevention. As evidence, hand-dug wells and toilets were constructed and the residents in the communities cleaned riverbanks. Health education also made the people realize that Bilharzia is a curable and preventable public health problem.

The knowledge and practice on malaria among community members in Zimbabwe.

OBJECTIVES: To assess the knowledge of the cause, preventive measures and symptoms of malaria, treatment seeking behaviour on malaria and source of information about malaria among community members for the planning of effective malaria intervention. DESIGN: A cross sectional study was carried out using a questionnaire, which was administered by health workers from rural health centres. SETTING: Households in rural areas from five districts namely Uzumba Maramba Pfungwe (UMP), Hurungwe, Mount Darwin, Bulilimamangwe and Chipinge in Zimbabwe. SUBJECTS: 2,531 community members who were in charge of households sampled systematically in the area. MAIN OUTCOME MEASURES: Percentage of knowledge of transmission, signs and symptoms, prevention methods such as residual house spraying and personal protection, and treatment seeking practice on malaria. RESULTS: Knowledge of malaria transmission was generally high ranging from 57.9% to 95.9%, although there were some misconceptions such as drinking dirty water and poor hygiene. Knowledge of malaria preventive methods was varied among districts ranging from 19.4% to 93.0% about residual house spraying, and low (0.2% to 22.7%), (8.1% to 24.5%) about mosquito nets and repellents, respectively. Knowledge of malaria signs was generally high although this also varied among districts. Treatment seeking practice on malaria shows that the majority of respondents (85.4%) visit the clinic first when seeking treatment although there are other options such as shops and traditional healers. Other sources of information about malaria mentioned were, health workers (72.9%), radio (44.0%), television (37.5%), teachers (25.0%) and village community workers (10.0%). CONCLUSION: Despite widespread knowledge about the cause of malaria and symptoms, and the fairly extensive sources of health information, understanding of the preventive measures was relatively low. Appropriate health education is essential to stimulate changes in both knowledge and behaviour in malaria control activities. Schools can be effective health education tools as well as health facilities.

Highly symptom-aware children were heavily infected with urinary schistosomiasis in southern Ghana.

OBJECTIVES: To assess the relationship between the infection status of children and their knowledge, attitudes, beliefs, and practices (KABP) related to urinary schistosomiasis. DESIGN: Questionnaire survey. SETTING: Nine schools in eight rural communities (total population: 4,636) in Ga and South Akuapem Districts, Ghana. SUBJECTS: Four hundred and six children attending primary and secondary schools. MAIN OUTCOME MEASURE: Schistosoma haematobium infection status of children and their KABP. RESULTS: Of 354 children who responded and also submitted their urine samples, 297 (83.9%) tested positive for S. haematobium and the intensity of infection was 90 (95% CI: 74 to 110) eggs per 10 ml urine. General knowledge variables such as the knowledge of symptoms (p < 0.001), and knowledge of swimming or bathing in the river as a transmission route (p < 0.001) showed significant association for higher prevalence and intensity of infection. Treatment-seeking behaviour was not associated with the lower prevalence or intensity of infection. Practice variables such as washing clothes in the stream (p < 0.001) and fishing in the stream (p < 0.01) were significantly associated with both higher prevalence and higher intensity of infection. Children who knew of contact with river water as a transmission route reported more water contact activities (p < 0.001). CONCLUSION: This study showed that highly symptom-aware people were heavily infected, and people frequently exposed to infested water were heavily infected. Moreover, highly symptom-aware people never constituted a group whose exposure was slight. Why was awareness of disease symptoms and general knowledge of the disease not linked to low infectivity? Why didn't awareness result in avoidance of infested water sources? This report highlights the urgent need to address these important questions in future research.

[Clinical evaluation of biapenem (L-627) in children].

Biapenem (L-627) was evaluated for its efficacy and safety. The following results were obtained. L-627 was given to 9 patients with infections: 3 with pneumonia, 1 with acute bronchopneumonia, 1 with acute bronchitis, 1 with bacteremia, 1 with tonsillitis, 2 with exceptional case. Therapeutic responses were excellent in 3, good in 4, with an efficacy rate of 100%. Adverse reactions were noted. No abnormalities were shown in laboratory data. It has been concluded that L-627 is a useful drug for the treatment of bacterial infections in children.

[Clinical evaluation of meropenem in children].

Meropenem (MEPM) was evaluated for its efficacy and safety. The following results were obtained. MEPM was given to 12 patients with infections: 5 with pneumonia, 1 with bacterial meningitis, 2 with pharyngitis, 4 with skin and soft tissue infections. Therapeutic responses were "excellent" in 5, "good" in 4 and "fair" in 3, with an efficacy rate of 75%. Adverse reactions were not noted. No abnormalities were shown in laboratory data. It has been concluded that MEPM is a useful drug for the treatment of bacterial infections in children.