The food multimix concept: new innovative approach to meeting nutritional challenges in Sub-Saharan Africa

Food insecurity, chronic hunger, starvation and malnutrition continue to affect millions of individuals throughout the developing world, especially Sub-Saharan Africa. Various initiatives by African governments and International Agencies such as the UN, the industrial nations, the International Monetary Fund, the World Bank and the World Trade Organisation to boost economic development, have failed to provide the much-needed solution to these challenges. The impact of these economic shifts and the failures of structural adjustment programmes on the nutritional well-being and health of the most vulnerable members of poor communities cannot be over-emphasised. The use of ad hoc measures as an adjunct to community-based rural integrated projects have provided little success and will be unsustainable unless they are linked to harnessing available local resources. The present paper therefore focuses on exploring alternative ways of harnessing the scant agricultural resources by employing a scientific approach to food-related problem-solving. The food multimix (FMM) concept offers a scientific contribution alongside other attempts currently in use by the World Food Programme, WHO and FAO to meet the food insecurity challenges that confront most of the developing world in the twenty-first century. It is an innovative approach that makes better use of traditional food sources as a tool for meeting community nutritional needs. The FMM concept employs a food-based approach using traditional methods of food preparation and locally-available, cheap and affordable staples (fruits, pulses, vegetables and legumes) in the formulation of nutrient-enriched multimixes. Developed recipes can provide >= 40% of the daily nutritional requirements of vulnerable groups, including patients with HIV/AIDS and children undergoing nutrition rehabilitation. The FMM approach can also be used as a medium- to long-term adjunct to community-based rural integration projects aimed at health improvement and economic empowerment in Sub-Saharan Africa.

Exploring knowledge and skills on HIV in student nurses and midwives

A cross-sectional survey design using a self-administered questionnaire was sent to a sample of 62 final-year student nurses and midwives to describe their knowledge of, skills related to, and attitudes towards, human immunodeficiency virus/acquired immune deficiency syndrome. Out of the 47 respondents who return the questionnaire, only 53% stated that they had received class instruction on the topic and 63.8% claimed to have increased their knowledge mainly from reading professional journals. Although only 32% said that they had cared for a patient or knew of a family member or another person with the disease, 91% indicated that they were willing to care for such patients. Overall, the respondents demonstrated positive attitudes towards this group of patients and a good level of knowledge about the subject, although some gaps were evident. However, a large majority stated that their skills to cater for the physical and psychological needs of this group of patients were deficient and would like further training.

Resting energy expenditure in non-ventilated, non-sedated patients recovering from serious traumatic brain injury: Comparison of prediction equations with indirect calorimetry values

Background & aims: Little is known about energy requirements in brain injured (TBI) patients, despite evidence suggesting adequate nutritional support can improve clinical outcomes. The study aim was to compare predicted energy requirements with measured resting energy expenditure (REE) values, in patients recovering from TBI.

Methods: Indirect calorimetry (IC) was used to measure REE in 45 patients with TBI. Predicted energy requirements were determined using FAO/WHO/UNU and Harris–Benedict (HB) equations. Bland– Altman and regression analysis were used for analysis.

Results: One-hundred and sixty-seven successful measurements were recorded in patients with TBI. At an individual level, both equations predicted REE poorly. The mean of the differences of standardised areas of measured REE and FAO/WHO/UNU was near zero (9 kcal) but the variation in both directions was substantial (range 591 to þ573 kcal). Similarly, the differences of areas of measured REE and HB demonstrated a mean of 1.9 kcal and range 568 to þ571 kcal. Glasgow coma score, patient status, weight and body temperature were signi?cant predictors of measured REE (p < 0.001; R²⁼ 0.47).

Conclusions: Clinical equations are poor predictors of measured REE in patients with TBI. The variability in REE is substantial. Clinicians should be aware of the limitations of prediction equations when estimating energy requirements in TBI patients.

Development of a novel DNA microarray to detect bacterial pathogens in patients with chronic obstructive pulmonary disease (COPD)

A novel microarray was constructed with DNA PCR product probes targeting species specific functional genes of nine clinically significant respiratory pathogens, including the Gram-positive organisms (Streptococcus pneumoniae, Streptococcus pyogenes), the Gram-negative organisms (Chlamydia pneumoniae, Coxiella burnetii Haemophilus spp., Legionella pneumophila, Moraxella catarrhalis, and Pseudomonas aeruginosa), as well as the atypical bacterium, Mycoplasma pneumoniae. In a "proof-of-concept" evaluation of the developed microarray, the microarray was compared with real-time PCR from 14 sputum specimens from COPD patients. All of the samples positive for bacterial species in real-time PCR were also positive for the same bacterial species using the microarray. This study shows that a microarray using PCR probes is a potentially useful method to monitor the populations of bacteria in respiratory specimens and can be tailored to specific clinical needs such as respiratory infections of particular patient populations, including patients with cystic fibrosis and bronchiectasis. (C) 2010 Elsevier B.V. All rights reserved.

Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy

Background: This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 2010.
For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both. The optimal method of enteral feeding for this patient group has yet to be established.

Objectives: To compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications.

Search methods: Our extensive search included the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was 13 February 2012.

Selection criteria:Randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy.

Data collection and analysis:Two authors independently assessed trial quality and extracted data using standardised forms. We contacted study authors for additional information.

Main results: One randomised controlled trial met the criteria for inclusion in this review. No further studies were identified when we updated the searches in 2012.
Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual. A high degree of bias was identified in the study.
Weight loss was greater for the NG group at six weeks post-treatment than for the PEG group (P = 0.001). At six months post-treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded six weeks post-treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG, though this was not found to be significant. There was no difference in the treatment received by the two groups. However, four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of two and six days respectively.
We identified no studies of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review.

Authors' conclusions: There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required.

C5a-mediated neutrophil phagocytic dysfunction is RhoA-dependent and predicts nosocomial infection in critically ill patients.

Critically ill patients are at heightened risk for nosocomial infections. The anaphylatoxin C5a impairs phagocytosis by neutrophils. However, the mechanisms by which this occurs and the relevance for acquisition of nosocomial infection remain undetermined. We aimed to characterize mechanisms by which C5a inhibits phagocytosis in vitro and in critically ill patients, and to define the relationship between C5a-mediated dysfunction and acquisition of nosocomial infection. In healthy human neutrophils, C5a significantly inhibited RhoA activation, preventing actin polymerization and phagocytosis. RhoA inhibition was mediated by PI3Kd. The effects on RhoA, actin, and phagocytosis were fully reversed by GM-CSF. Parallel observations were made in neutrophils from critically ill patients, that is, impaired phagocytosis was associated with inhibition of RhoA and actin polymerization, and reversed by GM-CSF. Among a cohort of 60 critically ill patients, C5a-mediated neutrophil dysfunction (as determined by reduced CD88 expression) was a strong predictor for subsequent acquisition of nosocomial infection (relative risk, 5.8; 95% confidence interval, 1.5-22; P = .0007), and remained independent of time effects as assessed by survival analysis (hazard ratio, 5.0; 95% confidence interval, 1.3-8.3; P = .01). In conclusion, this study provides new insight into the mechanisms underlying immunocompromise in critical illness and suggests novel avenues for therapy and prevention of nosocomial infection.

Llama antibody fragments have good potential for application as HIV-1 topical microbicides

There is an urgent global need for preventative strategies against HIV-1 infections. Llama heavy-chain antibody fragments (VHH) are a class of molecules recently described as potent cross-clade HIV-1 entry inhibitors. We studied the potential of a VHH-based microbicide in an application-oriented fashion. We show that VHH can be inexpensively produced in high amounts in the GRAS organism S. cerevisiae, resulting in very pure, and endotoxin free product. VHH are very stable under conditions they might encounter during transport, storage or use by women. We developed active formulations of VHH in aqueous gel and compressed and lyophilized tablets for controlled release from an intra vaginal device. The release profile of the VHH from e.g. a vaginal ring suggests sufficient bioavailability and protective concentration of the molecule at the mucosal site at the moment of the infection. The ex vivo penetration kinetics through human tissues show that the VHH diffuse into the mucosal layer and open the possibility to create a second defense layer either by blocking the HIV receptor binding sites or by blocking the receptors of immune cells in the mucosa. In conclusion, our data show that VHH have

Characteristics and Treatment of Medical Device Related Infections

Medical device related infections are becoming an increasing prevalent area of infectious disease. They can be attributed to a multitude of factors from an increasing elderly population with reduced immunological status to increasing microbial resistance and evolution. Of greatest significance is the failure of standard antimicrobial regimens to eradicate biomaterial-related infections due to the formation of microbial biofilms consisting of extracellular polymeric substances. Biofilms form and thrive at the abiotic device surface where nutrients are more concentrated and symbiotic colonies can be formed. The formation of a biofilm matrix occurs in a series of steps beginning with reversible attachment of bacteria to the surface of the substrate and terminating in dispersion of mature biofilm microcolonies that aim to colonise fresh surfaces high in nutrients. Mature biofilms can resist 10-1000 times the concentrations of standard antibiotic regimens that are required to kill genetically equivalent planktonic forms. The extent of the infection and the pathogen(s) present can be attributed to both the form and location of the device. It is important that preventative measures and treatment strategies relate to combating the causative microorganisms. Preventative measures include: the use of anti-infective biomaterials that can be coated or incorporated with standard or innovative antimicrobials; modified anti-adhesive medical devices; environmental sterilisation protocols and prophylactic drug therapy. Treatment of established infection may require removal of the device or if deemed possible the device may be salvageable through the initiation of antimicrobial therapy. The increasing spectre of antibiotic resistance and medical device related infections are a large and increasing burden on health care systems and the patient’s quality of life and long term prognosis. As an infectious disease it represents one of the most difficult challenges facing modern science and healthcare.

Sequential antimicrobial therapy: treatment of severe lower respiratory tract infections in children

Although there have been a number of studies in adults, to date there has been little research into sequential antimicrobial therapy (SAT) in paediatric populations. The present study evaluates the impact of a SAT protocol for the treatment of severe lower respiratory tract infection in paediatric patients. The study involved 89 paediatric patients (44 control and 45 SAT). The SAT patients had a shorter length of hospital stay (4.0 versus 8.3 days), shorter duration of inpatient antimicrobial therapy (4.0 versus 7.9 days) with the period of iv therapy being reduced from a mean of 5.6 to 1.7 days. The total healthcare costs were reduced by 52%. The resolution of severe lower respiratory tract infection with a short course of iv antimicrobials, followed by conversion to oral therapy yielded clinical outcomes comparable to those achieved using longer term iv therapy. SAT proved to be an important cost-minimizing tool for realizing substantial healthcare costs savings.

Rising incidence of Pneumocystis jirovecii pneumonia suggests iatrogenic exposure of immune compromised patients may be becoming a significant problem.

Against a background of point-source outbreaks of Pneumocystis pneumonia (PCP) in renal transplant units in Europe, we undertook a retrospective 3 year observational review of PCP in Northern Ireland. This showed an unexpected increase in incidence, with a mortality rate of 30%. Fifty-one cases were confirmed compared to 10 in the preceding 7 years. Where undiagnosed HIV infection had previously been the main risk factor for PCP, this was now equally matched by chemotherapy for haematological and non-haematological malignancy and immune suppression for a range of autoimmune conditions. Congenital immunodeficiency and transplantation were less common pre-disposing factors, but renal grafts also showed a rising incidence. Asymptomatic carriage was uncommon. At presentation both upper and lower respiratory samples were of equal use in establishing the diagnosis and treatment resulted in rapid clearance. The data suggests the need for considering PCP in at risk patients, reviewing its mode of acquisition and whether iatrogenic colonization is a treatable pre-condition. [Epub ahead of print]