Vitamin D Deficiency in Medical Patients at a Central Hospital in Malawi: A Comparison with TB Patients from a Previous Study

Objectives

To determine the prevalence of vitamin D deficiency (VDD) in adult medical, non-tuberculous (non-TB) patients. To investigate associations with VDD. To compare the results with a similar study in TB patients at the same hospital.

Design

Cross-sectional sample.

Setting

Central hospital in Malawi.

Participants

Adult non-TB patients (n = 157), inpatients and outpatients.

Outcome Measures

The primary outcome was the prevalence of VDD. Potentially causal associations sought included nutritional status, in/outpatient status, HIV status, anti-retroviral therapy (ART) and, by comparison with a previous study, a diagnosis of tuberculosis (TB).

Results

Hypovitaminosis D (≤75 nmol/L) occurred in 47.8% (75/157) of patients, 16.6% (26/157) of whom had VDD (≤50 nmol/L). None had severe VDD (≤25 nmol/L). VDD was found in 22.8% (23/101) of in-patients and 5.4% (3/56) of out-patients. In univariable analysis in-patient status, ART use and low dietary vitamin D were significant predictors of VDD. VDD was less prevalent than in previously studied TB patients in the same hospital (68/161 = 42%). In multivariate analysis of the combined data set from both studies, having TB (OR 3.61, 95%CI 2.02–6.43) and being an in-patient (OR 2.70, 95%CI 1.46–5.01) were significant independent predictors of VDD.

Conclusions

About half of adult medical patients without TB have suboptimal vitamin D status, which is more common in in-patients. VDD is much more common in TB patients than non-TB patients, even when other variables are controlled for, suggesting that vitamin D deficiency is associated with TB.     

A Cost-Effectiveness Analysis of a Program to Control Rheumatic Fever and Rheumatic Heart Disease in Pinar del Rio,Cuba

Background

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) persist in many low- and middle-income countries. To date, the cost-effectiveness of population-based, combined primary and secondary prevention strategies has not been assessed. In the Pinar del Rio province of Cuba, a comprehensive ARF/RHD control program was undertaken over 1986 – 1996. The present study analyzes the cost-effectiveness of this Cuban program.

Methods and Findings

We developed a decision tree model based on the natural history of ARF/RHD, comparing the costs and effectiveness of the 10-year Cuban program to a “do nothing” approach. Our population of interest was the cohort of children aged 5 – 24 years resident in Pinar del Rio in 1986. We assessed costs and health outcomes over a lifetime horizon, and we took the healthcare system perspective on costs but did not apply a discount rate. We used epidemiologic, clinical, and direct medical cost inputs that were previously collected for publications on the Cuban program. We estimated health gains as disability-adjusted life years (DALYs) averted using standard approaches developed for the Global Burden of Disease studies. Cost-effectiveness acceptability thresholds were defined by one and three times per capita gross domestic product per DALY averted. We also conducted an uncertainty analysis using Monte Carlo simulations and several scenario analyses exploring the impact of alternative assumptions about the program’s effects and costs. We found that, compared to doing nothing, the Cuban program averted 5051 DALYs (1844 per 100,000 school-aged children) and saved $7,848,590 (2010 USD) despite a total program cost of $202,890 over 10 years. In the scenario analyses, the program remained cost saving when a lower level of effectiveness and a reduction in averted years of life lost were assumed. In a worst-case scenario including 20-fold higher costs, the program still had a 100% of being cost-effective and an 85% chance of being cost saving.

Conclusions

A 10-year program to control ARF/RHD in Pinar del Rio, Cuba dramatically reduced morbidity and premature mortality in children and young adults and was cost saving. The results of our analysis were robust to higher program costs and more conservative assumptions about the program’s effectiveness. It is possible that the program’s effectiveness resulted from synergies between primary and secondary prevention strategies. The findings of this study have implications for non-communicable disease policymaking in other resource-limited settings.     

Boosting the globalization of plant proteomics through INPPO: current developments and future prospects

The International Plant Proteomics Organization (INPPO) is a non-profit-organization consisting of people who are involved or interested in plant proteomics. INPPO is constantly growing in volume and activity, which is mostly due to the realization among plant proteomics researchers worldwide for the need of such a global platform. Their active participation resulted in the rapid growth within the first year of INPPO's official launch in 2011 via its website (www.inppo.com) and publication of the 'Viewpoint paper' in a special issue of PROTEOMICS (May 2011). Here, we will be highlighting the progress achieved in the year 2011 and the future targets for the year 2012 and onwards. INPPO has achieved a successful administrative structure, the Core Committee (CC; composed of President, Vice-President, and General Secretaries), Executive Council (EC), and General Body (GB) to achieve INPPO objectives. Various committees and subcommittees are in the process of being functionalized via discussion amongst scientists around the globe. INPPO's primary aim to popularize the plant proteomics research in biological sciences has also been recognized by PROTEOMICS where a section dedicated to plant proteomics has been introduced starting January 2012, following the very first issue of this journal devoted to plant proteomics in May 2011. To disseminate organizational activities to the scientific community, INPPO has launched a biannual (in January and July) newsletter entitled 'INPPO Express: News & Views' with the first issue published in January 2012. INPPO is also planning to have several activities in 2012, including programs within the Education Outreach committee in different countries, and the development of research ideas and proposals with priority on crop and horticultural plants, while keeping tight interactions with proteomics programs on model plants such as Arabidopsis thaliana, rice, and Medicago truncatula. Altogether, the INPPO progress and upcoming activities are because of immense support, dedication, and hard work of all members of the INPPO community, and also due to the wide encouragement and support from the communities (scientific and non-scientific).     

Antibiotics for the primary prevention of acute rheumatic fever: a meta-analysis

Background

Despite heavy recent emphasis on blood pressure (BP) control, many patients fail to meet widely accepted goals. While access and adherence to therapy certainly play a role, another potential explanation is poor quality of essential care processes (QC). Yet little is known about the relationship between QC and BP control.

Methods

We assessed QC in 12 U.S. communities by reviewing the medical records of a randomly selected group of patients for the two years preceding our study. We included patients with either a diagnosis of hypertension or two visits with BPs of ≥140/90 in their medical records. We used 28 process indicators based on explicit evidence to assess QC. The indicators covered a broad spectrum of care and were developed through a modified Delphi method. We considered patients who received all indicated care to have optimal QC. We defined control of hypertension as BP < 140/90 in the most recent reading.

Results

Of 1,953 hypertensive patients, only 57% received optimal care and 42% had controlled hypertension. Patients who had received optimal care were more likely to have their BP under control at the end of the study (45% vs. 35%, p = .0006). Patients were more likely to receive optimal care if they were over age 50 (76% vs. 63%, p < .0001), had diabetes (77% vs. 71%, p = .0038), coronary artery disease (87% vs. 69%, p < .0001), or hyperlipidemia (80% vs. 68%, p < .0001), and did not smoke (73% vs. 66%, p = .0005).

Conclusions

Higher QC for hypertensive patients is associated with better BP control. Younger patients without cardiac risk factors are at greatest risk for poor care. Quality measurement systems like the one presented in this study can guide future quality improvement efforts.     

Nutrient Budget in the Seasonal Wetland of the Okavango Delta, Botswana

The nutrient (P and N species) and chloride budgets were investigated in a representative floodplain in the seasonal wetlands of the Okavango Delta, Botswana. A variety of sources of nutrients in the surface water were considered, namely ion species coming with the floodwater, those generated from dry floodplain soils and those from water-soluble dust deposition (both local and long-range sources). Concentrations of total-nitrogen and chloride in surface water were below 1 mg l⁻¹. Total-phosphorus concentrations were 0.05 mg l⁻¹, reflecting the oligotrophic character of the system. Dust deposition rates were highest for chloride at 2.44 g m⁻² year⁻¹ followed by 0.79 g m⁻² year⁻¹ for total-N, 0.40 g m⁻² year⁻¹ for ammonia and only 0.02 g m⁻² year⁻¹ for total-P, respectively. Chloride was derived primarily from long-range transport, while N and P species were of more local origin. Dissolution rates for these ions combined were calculated to be 3.9 g m⁻² for the flooded area in the 1999 season and thus all dry deposits must be re-dissolved. The accumulation of dust deposits on dry surfaces and their subsequent dissolution causes 2–5 times higher concentrations of nitrogen, phosphorus and chloride with the onset of the flood, thus boosting the nutrient stock in the crucial phase of the onset of flooding. Chloride dissolved from dry soil surfaces and dust contributed approximately 40% to the overall floodplain budget. Although contributions from the soil surface and dust to the nitrogen and phosphorus pools of the floodplain are less prominent (with 10% of total), they nonetheless represent a significant source of nutrients in the entire system. Extrapolation to annually flooded swamps (10,000 km²) indicates a maximum contribution of 40% for total-nitrogen and 60% for total-phosphorus from dust deposition on wet or dry surfaces to the nutrient pool of the water body.