Substantial and sustained reduction in under-5 mortality, diarrhea, and pneumonia in Oshikhandass, Pakistan: evidence from two longitudinal cohort studies 15 years apart.

BACKGROUND: Oshikhandass is a rural village in northern Pakistan where a 1989-1991 verbal autopsy study showed that diarrhea and pneumonia were the top causes of under-5 mortality. Intensive surveillance, active community health education and child health interventions were delivered in 1989-1996; here we assess improvements in under-5 mortality, diarrhea, and pneumonia over this period and 15 years later. METHODS: Two prospective open-cohort studies in Oshikhandass from 1989 to 1996 (Study 1) and 2011-2014 (Study 2) enrolled all children under age 60 months. Study staff trained using WHO guidelines, conducted weekly household surveillance and promoted knowledge on causes and management of diarrhea and pneumonia. Information about household characteristics and socioeconomic status was collected. Hurdle models were constructed to examine putative risk factors for diarrhea and pneumonia. RESULTS: Against a backdrop of considerable change in the socioeconomic status of the community, under-5 mortality, which declined over the course of Study 1 (from 114.3 to 79.5 deaths/1000 live births (LB) between 1989 and 1996), exceeded Sustainable Development Goal 3 by Study 2 (19.8 deaths/ 1000 LB). Reductions in diarrhea prevalence (20.3 to 2.2 days/ Child Year [CY]), incidence (2.1 to 0.5 episodes/ CY), and number of bloody diarrhea episodes (18.6 to 5.2%) seen during Study 1, were sustained in Study 2. Pneumonia incidence was 0.5 episodes /CY in Study 1 and 0.2/CY in Study 2; only 5% of episodes were categorized as severe or very severe in both studies. While no individual factors predicted a statistically significant difference in diarrhea or pneumonia episodes, the combined effect of water, toilet and housing materials was associated with a significant decrease in diarrhea; higher household income was the most protective factor for pneumonia in Study 1. CONCLUSIONS: We report a 4-fold decrease in overall childhood mortality, and a 2-fold decrease in childhood morbidity from diarrhea and pneumonia in a remote rural village in Pakistan between 1989 and 2014. We conclude that significant, sustainable improvements in child health may be achieved through improved socioeconomic status and promoting interactions between locally engaged health workers and the community, but that continued efforts are needed to improve health worker training, supervision, and the rational use of medications. TRIAL REGISTRATION: Not Applicable.

Endotherapy in symptomatic pancreas divisum: a systematic review.

Pancreas divisum (PD) is the most common congenital variant of the pancreas and has been implicated as a cause of pancreatitis; however, endoscopic treatment is controversial. Our objective was to examine patient response to endotherapy for treatment of symptomatic PD in adult patients in a systematic review of the literature. A systematic review of all case series and case-control studies with ten or more patients undergoing endotherapy for treatment of symptomatic PD indicated by acute recurrent pancreatitis (ARP), chronic pancreatitis (CP), or chronic abdominal pain (CAP) was performed. PubMed, Embase, and Web of Science databases were searched from inception through February 2013 using [pancreas divisum] AND [endoscopic retrograde cholangiopancreatography (ERCP)] OR [endotherapy] OR [endoscopy] as search terms. Importantly, the majority of studies were retrospective in nature, significantly limiting analysis capacity. Main outcomes measures included endotherapy response rate in patients with PD and ARP, CP, or CAP. Twenty-two studies were included in the review, with a total of 838 patients. Response to endoscopy was seen in 528 patients, but response rate varied by clinical presentation. Patients with ARP had a response rate ranging from 43% to 100% (median 76%). Reported response rates were lower in the other two groups, ranging from 21% to 80% (median 42%) for patients with CP and 11%-55% (median 33%) for patients with CAP. Complications reported included perforation, post-endoscopic retrograde cholangiopancreatography pancreatitis, bleeding, and clogged stents. Endotherapy appears to offer an effective treatment option for patients with symptomatic PD, with the best results in patients presenting with ARP.

Ischemic Colitis in Association with Sevelamer Crystals.

Sevelamer is an important drug used to lower serum phosphate levels in advanced kidney disease and in patients on dialysis. This drug is generally well tolerated but some patients report mild gastrointestinal distress as a side effect. Although regulatory agencies, such as Food and Drug Administration, list bowel ischemia and necrosis as potential and rare side effects, there are few case reports describing these adverse effects. We present a 35-year-old HIV patient with end-stage renal disease on hemodialysis who developed colonic hemorrhage and perforation. Imaging showed ischemic gangrene of bowel wall. Histopathology was consistent with transmural ischemic necrosis with deposition of fibrin thrombi and sevelamer crystals.

Antigen-targeted liposome-encapsulated methotrexate specifically kills lymphocytes sensitized to the nonapeptide of myelin basic protein.

Antigen targeting of liposome-encapsulated cytotoxic drugs to specific lymphocytes may be a useful approach for antigen-specific immunosuppressive treatment of autoimmune diseases in which a specific antigen is involved. The feasibility of utilizing this approach was investigated using experimental allergic encephalomyelitis as an animal model for an autoimmune response. The encephalitogenic determinant of myelin basic protein for the guinea pig is contained in residues 114-122, the so-called nonapeptide. We have acylated the nonapeptide at its N-terminal to anchor it in the lipid bilayer of liposomes containing the cytotoxic drug methotrexate. The nonapeptide on the surface of the liposomes then allows targeting of the liposomal methotrexate in vitro to anti-nonapeptide T lymphocytes obtained from guinea pigs with experimental allergic encephalomyelitis. Treatment with the nonapeptide-targeted liposomal methotrexate inhibited proliferation of anti-nonapeptide lymphocytes significantly more than that of control lymphocytes. These included non-sensitized lymphocytes, stimulated with phytohemagglutinin, or lymphocytes sensitized to different, unrelated proteins, the purified protein derivative of tuberculin and keyhole limpet hemocyanin, and stimulated with their specific antigens. Furthermore, nonapeptide-targeted liposomes had a greater cytotoxic effect on anti-nonapeptide T cells than untargeted liposomes. The results indicated that specific targeting to and killing of anti-nonapeptide cells was achieved, although improvements of the treatment are necessary before its use can be attempted in vivo.

Immune lysis of lipid vesicles containing myelin basic protein or glycolipid antigens by multiple sclerosis and normal sera.

We have compared the reactivity of sera from 34 multiple sclerosis (MS) patients and 32 normal (N) individuals with lipid vesicles containing myelin basic protein (BP) and several glycolipids reconstituted into a membrane environment. The ability of the sera to cause complement-mediated lysis of lipid vesicles containing these antigens was determined by measuring the release of a water-soluble spin label, tempocholine chloride, from the height of its electron spin resonance spectrum. Only 4 MS sera caused lysis of BP-containing vesicles which was comparable to that produced by specific antibody to BP. A number of both MS and N sera caused significant lysis of vesicles containing GM1 ganglioside or digalactosyldiglyceride. A few MS and N sera also caused significant lysis of vesicles containing GM2, GT1 and GD1a gangliosides. However, in no case was there a statistically significant difference between the mean lysis produced by MS and N sera. There was some overlap between the specific MS and N sera reactive to vesicles containing BP, GM1, GM2, and DGDG while a completely different group of MS and N sera were reactive to GT1 and GD1a gangliosides. This suggested that there was either antigenic cross reactivity between the two groups of glycolipids or two different origins of the immune response to the two groups of antigens. It was concluded that antibody-dependent complement fixation by these particular antigens, in the kind of lipid environment used, is not characteristic of or specific to MS.

Comparison of membrane structure, osmotic fragility, and morphology of multiple sclerosis and normal erythrocytes.

Erythrocyte membranes from multiple sclerosis (MS) patients and normal individuals were studied by electron spin resonance spectroscopy, osmotic fragility tests, scanning electron microscopy (SEM) and fatty acid analysis of membrane lipids. There was no significant difference in the membrane fluidity between MS and normal erythrocytes using fatty acid spin labels with the nitroxide moiety on carbons 5, 12, or 16 from the carboxyl group. Linoleic acid, which has been reported to decrease the absolute electrophoretic mobility of only MS erythrocytes, increased the fluidity of MS and normal erythrocyte membranes to a similar extent. The osmotic fragility of MS erythrocytes obtained from outpatients was similar to normal control cells but the osmotic fragility of erythrocytes obtained from hospitalized MS patients was greater than normal. Scanning electron microscopy of MS erythrocytes revealed no gross abnormalities. Cells incubated with linoleic acid had transformed from discocytes into sphero-echinocytes with prominent membrane surface indentations but MS and normal erythrocytes appeared identical. Of the fatty acid content of the total lipid extract, erythrocytes from most, but not all, MS hospitalized patients and some patients with other demyelinating diseases had relatively less (P less than .001) 18:2 than the normal cells. These results indicate that at least some of the abnormalities reported in MS erythrocytes may only be found in hospitalized patients and may be due to other complications of the disease. They also indicate that the reported abnormal effects of linoleic acid on the electrophoretic mobility of MS erythrocytes may be caused by some other mechanism than an effect on the fluidity of the bilayer.

Immune lysis of reconstituted myelin basic protein--lipid vesicles and myelin vesicles.

Complement-mediated lysis of reconstituted lipid-myelin basic protein (BP) vesicles and myelin vesicles due to antibody raised against BP and isolated myelin is measured by determination of the amount of a water-soluble spin label, tempocholine chloride, released from the vesicles. The response is shown to be antigen-specific, antibody-dependent, and complement mediated. The relative response to different anti-BP antibody samples is similar to that determined by radioimmunoassay procedures. In contrast to immunoassays with BP in aqueous solution, this method measures immune recognition of the protein in either a synthetic or a natural membranous environment. This is important because this protein has been shown to have a different conformation when bound to lipid bilayers than in aqueous solution and its conformation depends on lipid composition. It is also a more rapid method because no separation of spin label still trapped in the vesicles and that released due to immune lysis is required. In synthetic membranes consisting of sphingomyelin, cholesterol, and an acidic lipid, either phosphatidylglycerol, phosphatidic acid, or phosphatidylserine, the response was greatest when the acidic lipid was phosphatidic acid. The response did not depend significantly on the antigen concentration expressed as molar ratio of BP to sphingomyelin, over the range 0.15:600 to 2:600, although it decreased at molar ratios less than 0.15:600. The antigen density required for immune lysis of vesicles containing this protein antigen is similar to that reported elsewhere for lipid antigens, although the time required for maximal lysis was greater. Both anti-BP and anti-myelin antibodies caused a greater specific complement-mediated response with synthetic vesicles than with myelin vesicles, which may be due to the different lipid and/or protein composition of myelin. Response was also obtained with the myelin vesicles, however, indicating that some determinants of BP can be recognized on the surface of the bilayer in isolated myelin by anti-BP.