Surgical training programmes in the South Pacific, Papua New Guinea and Timor Leste.

BACKGROUND: There is a surgical workforce shortage in Papua New Guinea (PNG), the Pacific and Timor Leste. Previously, Pacific Island specialists who trained overseas tended to migrate. METHODS: A narrative review was undertaken of the training programmes delivered through the University of Papua New Guinea and Fiji National University's Fiji School of Medicine, and support provided through Australian Aid and the Royal Australasian College of Surgeons (RACS), including scholarships and visiting medical teams. RESULTS: The Fiji School of Medicine MMed programme, which commenced in 1998, has 39 surgical graduates. Sixteen of 22 Fijians, nine of ten Solomon Islanders and four of five in Vanuatu currently reside and/or work in-country. Surgical training in PNG began in 1975, and now has 104 general surgical graduates, 11 of whom originate from the Pacific Islands or Timor Leste. The PNG retention rate of local graduates is 97 per cent, with 80 per cent working in the public sector. Twenty-two surgeons have also undertaken subspecialty training. Timor Leste has trained eight surgical specialists in PNG, Fiji, Indonesia or Malaysia. All have returned to work in-country. The RACS has managed Australian Aid programmes, providing pro bono visiting medical teams to support service delivery and, increasingly, capacity building in the region. The RACS has funded scholarships and international travel grants to further train or sustain the surgical specialists. CONCLUSION: The local MMed programmes have been highly successful in retaining specialists in the region. Partnerships with Australian Aid and RACS have been effective in ensuring localization of the faculty and ongoing professional development.

Greatly reduced risk of EBV reactivation in rituximab-experienced recipients of alemtuzumab-conditioned allogeneic HSCT.

EBV-associated post-transplant lymphoproliferative disease (PTLD) remains an important complication of allogeneic haematopoietic stem cell transplantation (allo-HSCT). We retrospectively analysed the incidence and risk factors for EBV reactivation in 186 adult patients undergoing consecutive allo-HSCT with alemtuzumab T-cell depletion at a single centre. The cumulative incidence of EBV reactivation was 48% (confidence interval (CI) 41-55%) by 1 year, with an incidence of high-level EBV reactivation of 18% (CI 13-24%); 8 patients were concurrently diagnosed with PTLD. Amongst patients with high-level reactivation 31/38 (82%) developed this within only 2 weeks of first EBV qPCR positivity. In univariate analysis age⩾50 years was associated with significantly increased risk of EBV reactivation (hazard ratio (HR) 1.54, CI 1.02-2.31; P=0.039). Furthermore, a diagnosis of non-Hodgkin lymphoma (NHL) was associated with greatly reduced risk of reactivation (HR 0.10, CI 0.03-0.33; P=0.0001) and this was confirmed in multivariate testing. Importantly, rituximab therapy within 6 months prior to allo-HSCT was also highly predictive for lack of EBV reactivation (HR 0.18, CI 0.07-0.48; P=0.001) although confounding with NHL was apparent. Our data emphasise the risk of PTLD associated with alemtuzumab. Furthermore, we report the clinically important observation that rituximab, administered in the peri-transplant period, may provide effective prophylaxis for PTLD.

Impact of pre-transplant co-morbidities on outcome after alemtuzumab-based reduced intensity conditioning allo-SCT in elderly patients: a British Society of Blood and Marrow Transplantation study.

The advent of reduced intensity conditioning (RIC) regimens has permitted the extension of allo-SCT to selected patients into their eighth decade but GVHD remains a major cause of morbidity and mortality. Alemtuzumab is increasingly used to reduce the risk of severe GVHD, but there are concerns that T-cell depletion may compromise outcome particularly in older patients. We therefore studied the impact of pre-transplant factors on the outcome of 187 patients with a haematological malignancy over the age of 60 transplanted using an alemtuzumab-based RIC regimen of whom co-morbidity scoring was possible in 169. Of the patients, 120 had a haematopoietic cell transplantation co-morbidity index (HCT-CI) of 0 or 1 and 49 had a score of 2 or more. The 5-year OS was 33%. In multivariable analysis, OS was determined by co-morbidity score (P=0.001) and disease status at transplant (P=0.004) but not by patient age. Non-relapse mortality was determined by co-morbidity score (P=0.001). Two-year OS for patients with a HCT-CI of 0-1 was 59 versus 6% for patients with a higher score. Alemtuzumab-based RIC allografts can be delivered safely in patients aged over 60 but co-morbidity scoring is mandatory to identify patients who will benefit.

Post-transplant T cell chimerism predicts graft versus host disease but not disease relapse in patients undergoing an alemtuzumab based reduced intensity conditioned allogeneic transplant.

In this multicentre retrospective study we have studied the impact of T cell chimerism on the outcome of 133 patients undergoing an alemtuzumab based reduced intensity conditioning allograft (RIC). The median age of the patients was 50 years (range 42-55 years). 77 patients were transplanted using an HLA identical sibling donor while 56 patients received a fully matched volunteer unrelated donor graft. 64 patients had a lymphoid malignancy and 69 were transplanted for a myeloid malignancy. 38 patients (29%) relapsed with no significant difference in risk of relapse between patients developing full donor and mixed donor chimerism in the T-cell compartment on D+90 and D+180 post transplant. Day 90 full donor T cell chimerism correlated with an increased incidence of acute GVHD according to NIH criteria (p=0.0004) and the subsequent development of chronic GVHD. Consistent with previous observations, our results confirmed a correlation between the establishment of T cell full donor chimerism and acute GVHD in T deplete RIC allografts. However our study failed to identify any correlation between T cell chimerism and relapse risk and challenge the use of pre-emptive donor lymphocyte infusions (DLI) in patients with mixed T cell chimerism transplanted using an alemtuzumab based RIC regimen.

Cryopreservation of allogeneic PBSC from related and unrelated donors is associated with delayed platelet engraftment but has no impact on survival.

Cryopreservation of PBSC for allo-SCT offers potential advantages; however, its impact on engraftment and outcomes remains unclear. A total of 76 allo-SCT performed using cryopreserved PBSC from HLA identical related (n=57) and unrelated donors (n=19) were compared with 123 fresh PBSC allo-SCT. Median neutrophil engraftment was on day 12 for both cryopreserved and fresh PBSC; in multivariate analysis, there was a slight but significant delay in neutrophil engraftment after the median date (hazard ratio (HR)=1.44, P=0.003). Platelet engraftment was significantly delayed in cryopreserved PBSC recipients (median time 19 vs 14 days). In multivariate analysis cryopreservation (HR=1.85, P<0.001), earlier date of transplant and lower CD34+ cell dose were associated with delayed platelet engraftment. Two-year OS and relapse and 1-year TRM rates did not differ significantly. Acute GVHD incidence was comparable, and extensive chronic GVHD at 1 year was higher in cryopreserved PBSC recipients (40.3 vs. 28.3%), but not significantly so (P=0.13). Cryopreservation of related and unrelated donor allogeneic PBSC is safe and effective where its benefits outweigh the risks of delayed platelet engraftment; its impact on chronic GVHD incidence requires further assessment.

The clinical features and outcome of 2009 H1N1 influenza infection in allo-SCT patients: a British Society of Blood and Marrow Transplantation study.

The clinical course of 2009 H1N1 influenza in Allo-SCT patients is unknown. Data were collected in the UK from October 2009 to April 2010 on laboratory-confirmed cases of H1N1 influenza in Allo-SCT recipients. H1N1 infection was diagnosed in 60 patients, median age 42 years, at a median of 10 months post-SCT. Twenty-one patients (35%) developed pneumonia and nine (15%) required admission to intensive care units. Actuarial mortality was 7% at 28 days and 19% 4 months post-diagnosis of 2009 H1N1 influenza. Increasing age and pre-existing lung disease were risk factors for pneumonia (P=0.006 and 0.037, respectively); older age was a risk factor for death (P=0.012). Morbidity and mortality from 2009 H1N1 influenza in SCT patients exceeds that of immunocompetent patients, but parallels that in other critically ill hospitalised cohorts; the elderly and those with chronic pulmonary disease are at greatest risk.

Role of HCT-comorbidity index, age and disease status at transplantation in predicting survival and non-relapse mortality in patients with myelodysplasia and leukemia undergoing reduced-intensity-conditioning hemopoeitic progenitor cell transplantation.

Reduced-intensity-conditioning (RIC) regimens have allowed older patients to have allogeneic hemopoietic progenitor cell transplantation (HCT). This retrospective study was done to assess the impact of the HCT-comorbidity index (HCT-CI) in addition to other pre-transplant factors on the outcome of RIC transplants. In all 121 such patients were transplanted between 2002 and 2008 at two centers using fludarabine, melphalan and alumtuzumab conditioning. The OS and non-relapse mortality (NRM) were 56% and 30% at 2 years, respectively. The NRM of patients with HCT-CI ≥ 3 was not significantly different from the NRM of those with HCT-CI 0-2 (P value 0.24). Age and disease status at transplantation were significant factors affecting OS (P value 0.07 and 0.008, respectively), with no impact on NRM (P value 0.14 and 0.24, respectively). Although HCT-CI on its own did not independently predict NRM or survival, taken together with age and disease status at transplantation, it can be utilized to further delineate RIC allograft recipients into groups with different outcomes. Patients with none or one of these three adverse factors (age ≥ 60 years, leukemia in second CR or PR/high-risk myelodysplasia (MDS) and HCT-CI ≥ 3) had a 2-year NRM and survival of 18% and 80%, respectively, which was significantly better than those of patients with two or more of these adverse factors with 2-year NRM and survival of 46% (P value 0.03) and 40% (P value 0.02), respectively. None of the patients with all three adverse factors (age ≥ 60 years, leukemia in second CR or PR/high-risk MDS and HCT-CI ≥ 3) had survived for 2 years (median survival 12 months). This information can be used to guide patient selection for RIC transplants and to appropriately counsel patients of the risks and benefits of this treatment.

Left-sided congenital abdominal wall defect and intestinal malformation--a rare case.

A case report of a female newborn with a rare congenital abdominal wall defect associated with intestinal malformation. To our knowledge, only a few case reports of left sided congenital abdominal wall defect with this type of anomalies have been reported in the world literatures and this is the first in Fiji. This case brought numerous challenges to the team in terms of defining the pathology, role of undertaking surgery, providing supportive and nutritional therapy to a neonate and the ethical dilemma with the management in a developing country.

Application of 2-factorial design on the enhanced production of calcium gluconate by a mutant strain of Aspergillus niger.

Sixty-eight isolates of the filamentous fungus Aspergillus niger were examined for calcium gluconate production under submerged culture conditions in 500-ml Erlenmeyer flasks. The isolate Chem-15 was selected for improvement through ultraviolet (UV) light-induced mutagenesis. Among viable mutants, strain 32 exhibited the best gluconate productivity, and it was subjected to N-methyl N-nitro N-nitroso guanidine (NG) treatment. Mutant strain NG-7 gave the highest gluconate production (86.48g/L) which varied significantly (p0.05) from that of the wild type. The mutant was cultured overnight and plated on 5-fluorocytosine-PDA medium. Gluconate productivity was increased by 35% when the process parameters, incubation period (72h), initial pH (6.5), glucose as carbon source (15%), inoculum size (1.875x10(6)CFU/ml) and corn steep liquor (CSL) as nitrogen source (0.5%) were optimized using a 2-factorial Plackett-Burman design. Maximal glucose oxidase activity (28U/ml/min) was achieved at the optimal fermentation conditions with 26.5g/L DCM. The model terms were highly significant thus suggesting the potential commercial utility of the mutant (HS, df=3 approximately 0.0182).

In vivo (rat assay) assessment of nutritional improvement of peas (Pisum sativum L.).

This study was conducted to determine the nutritional value of peas (Pisum sativum L.) in raw and cooked form and when supplemented with chicken, mutton or beef. Peas had 3.0% lysine, which decreased to 0.6% on cooking. Protein efficiency ratio (PER) of the raw pea diet improved significantly on cooking (P < 0.05). True digestibility (TD) and net protein utilization (NPU) also showed significant improvement (P < 0.05). Supplementation of cooked peas with 15% poultry meat, mutton or beef improved PER significantly (P < 0.05). Higher PER, TD and NPU values were observed in diets supplemented with 15%-20% mutton or beef.

In vivo [rat assay] assessment of nutritional improvement of peas [Pisum sativum L.]

This study was conducted to determine the nutritional value of peas [Pisum sativum L.] in raw and cooked form and when supplemented with chicken, mutton or beef. Peas had 3.0% lysine, which decreased to 0.6% on cooking. Protein efficiency ratio [PER] of the raw pea diet improved significantly on cooking [P < 0.05]. True digestibility [TD] and net protein utilization [NPU] also showed significant improvement [P < 0.05]. Supplementation of cooked peas with 15% poultry meat, mutton or beef improved PER significantly [P < 0.05]. Higher PER, TD and NPU values were observed in diets supplemented with 15%-20% mutton or beef

Nutritional improvement of Lobia (Phaseolus vulgaris) by supplementation with poultry, mutton and beef meat.

The study was conducted to determine the nutritional value of Lobia (Phaseolus vulgaris) in raw and cooked forms and as effected by supplementation with different kinds of meat, i.e. poultry, mutton and beef at 10, 15 and 20% levels. Nutritional assessment of all the Lobia-containing diets (without or with supplementation) was made by chemical analysis as well as through rat assay. Lobia contained 20.43% of protein. Cooking resulted in minor changes in nutrients. It had 0.54% lysine which was reduced to 0.29% on cooking. All other amino acids also showed losses during cooking. Protein efficiency ratio (PER) of diets containing raw Lobia was 1.05 and significantly (P < 0.05) improved to 1.47 on cooking. True digestibility (TD) and net protein utilization (NPU) also showed a significant (P < 0.05) improvement in the case of cooked Lobia. Supplementation of Lobia with 20% of mutton or beef meat improved the PER significantly (P < 0.05) over unsupplemented diet containing cooked Lobia only. TD was improved from 74.9% in cooked to 84.3% in diets containing 20% mutton. Similarly NPU improved as a result of meat supplementation, from 40.7% in cooked to 53.4%. Higher PER, TD and NPU values were observed in diets containing Lobia supplemented with 20% level of mutton or beef.

Effect of cooking and supplementation with different kinds of meats on the nutritional value of mash (Vigna mungo).

The study was conducted to determine the nutritional value of mash (Vigna mungo) in raw and cooked forms and as effected by supplementation with different kind of meat, i.e. poultry, mutton and beef at 10, 15 and 20% levels. Nutritional assessment of all mash-containing diets (without or with supplementation) was made by chemical analysis as well as through rat assay. Mash contained 23.83% protein. Cooking resulted in minor changes in nutrients. Mash had 1.79% lysine which was reduced by 35% on cooking. All other amino acids also showed losses during cooking. Protein efficiency ratio (PER) of diet containing raw mash was 1.9% and cooking improved it to 2.8%. True digestibility (TD) also showed a significant improvement. Supplementation of mash with different kinds of meat did not improve the PER significantly over unsupplemented diet containing cooked mash only. TD, however, was improved from 74.89% in cooked to 75.58-87.06% in supplemented diets. Similarly net protein utilization (NPU), as a result of meat supplementation, improved from 43.54% in cooked to 42.88%-51.96%. Higher PER, TD and NPU values were observed in diets containing mash supplemented with 20% level of different meats.

Nutritional value of mung bean (Vigna radiata) as effected by cooking and supplementation.

The study was conducted to improve the nutritional value of Mung (Vigna radiata) by supplementation with different kinds of meat. Diets were prepared using raw and cooked Mung and then cooked Mung was supplemented with poultry, mutton and beef at 10, 15, and 20 percent levels. Nutritional value of Mung was determined by chemical analysis as well as by rat assay. Mung had 25 percent protein and minor losses were observed during cooking. It had 1.21 percent lysine which was reduced by 43 percent on cooking. Other amino acids also showed losses during cooking. The Protein Efficiency Ratio (PER) of diet containing Mung was significantly reduced on cooking (1.86 vs 1.40). On the contrary cooking resulted in some improvement of Net Protein utilization (NPU) and True Digestibility (TD) of the Mung based diets. Twenty percent level of different meats showed better results in terms of PER, NPU and TD.

Longitudinal study in biochemical composition of human milk during first year of lactation.

The composition (total solids, total protein, casein, coagulable proteins, lactose, fat, and ash) and mineral content (calcium, phosphorus, sodium, potassium, magnesium, zinc, and copper) of human milk was estimated longitudinally for the first year of lactation. Concentration of various nutrients, except zinc and copper, remained nearly constant throughout the first year of lactation and did not show any specific trend of variation. Zinc and copper decreased linearly in the first 6 months. Milk composition was found identical to the data reported from developed countries.

Body weight of Pakistani infants reared on different feeding regimes.

A longitudinal study during the first year of life was conducted in Pakistani infants, to investigate the effect of feeding regimes on body weight. On an average, breast-fed infants showed better weight gain in the first six months. In the last six months of their first year, however, bottle-fed infants grew better. Breast-fed infants doubled their birth weight earlier than bottle- or combined-fed infants.

PIP: 916 randomly selected infants born in various hospitals in Faisalabad, Pakistan with no congenital abnormalities, were followed with weight monitoring and maternal interviews on feeding regimens, from 24 hours after birth to 12 months at 30 day intervals. Exclusively breast fed infants gained significantly more weight for the 1st 6 months of age (p0.01). Breast-fed infants also doubled their birth weight earlier, 4.5 months, than did bottle fed infants, 6-7 months for males and 5-6 months for females. Bottle-fed infants gained weight more rapidly than exclusively breast-fed infants for the 2nd 6 months of life. Children fed by breast and bottle gained weight at a rate intermediate between breast and bottle feeding. Average weight gains for the whole series was consistently inferior to the Harvard standards, as well as local standards at all time points. Mothers here typically give diluted milk by bottle until about age 6 months, then whole milk with solid food supplementation.

Energy utilization of supplemented cereal diets in human volunteers.

Energy utilization was studied in human volunteers using different diets containing wheat flour supplemented by groundnut (Arachis hypogaea), "masur" (Lens culinaris), mung (Phaseolus aureus) and gram (Cicer arietinum) flour. Digestible and metabolizable energies were determined for all the experimental diets. An improved energy digestibility was observed when wheat flour was supplemented with groundnut flour, and groundnut flour plus gram flour, i.e. 93.35 and 89.48%, respectively. Percent digestibility of energy for the other two experimental diets was 81.07% when wheat flour was supplemented with groundnut and "masur" flour. It was further depressed to 77.87% when wheat flour was supplemented with groundnut and mung flour.