Use of serum retinol-binding protein for prediction of vitamin A deficiency: effects of HIV-1 infection, protein malnutrition, and the acute phase response

BACKGROUND: Serum retinol is the most commonly used indicator of vitamin A status. Retinol is transported in a 1-to-1 complex with retinol-binding protein (RBP). RBP is easy and inexpensive to measure, and studies have shown a high correlation between concentrations of RBP and concentrations of retinol. The performance of RBP in the context of infection or protein malnutrition, however, has not been evaluated. OBJECTIVE: Our aim was to determine whether RBP is a good surrogate measure for retinol in the context of HIV-1 infection, protein malnutrition, and the acute phase response. DESIGN: The relation between RBP and retinol was examined in a cross-sectional study of 600 Kenyan women. RESULTS: There was a high correlation between concentrations of RBP and those of retinol (r = 0.88). When equimolar cutoffs were used, RBP predicted marginal vitamin A status (retinol < 1.05 micro mol/L) with 93% sensitivity and 75% specificity and vitamin A deficiency (retinol < 0.70 micro mol/L) with 91% sensitivity and 94% specificity. Similarly high sensitivities and specificities were found among subgroups with HIV-1 infection, a positive acute phase response, and protein malnutrition. Protein malnutrition and a positive acute phase response were common, especially among HIV-1-infected women, and were independently and synergistically associated with lower RBP concentrations. CONCLUSIONS: Equimolar RBP cutoffs predict vitamin A deficiency with high sensitivity and specificity, even in the context of infection and protein malnutrition. Like retinol, RBP may not accurately identify true vitamin A status under all conditions, because the acute phase response and protein malnutrition depress RBP concentrations. However, RBP may be a simple, inexpensive tool for assessment of vitamin A deficiency in population studies.     

Networks for integrated care provision: an economic approach based on opportunism and trust

In this paper, we provide the economic rationale for an important issue in the health care sector, namely the network formation, e.g., in The Netherlands. The presence of such cooperation structures is hard to explain using the basic concept of the economic organization (EO) theory, i.e., the dichotomy of hierarchy versus market. However, acknowledging the aspect of trust renders the clan concept to be a powerful tool in understanding the viability of intra- and inter-organizational cooperation in the health sector. The main reason for this is the manner in which the professionals involved perform, as well as the importance of the tacit knowledge of the actors employed in the various health institutions. First, we address the conversion from supply towards demand orientation and the resulting pressure on multi-professional cooperation between health care providers. Then, relevant EO concepts will be reviewed, while introducing theory on knowledge, learning, and trust. Moreover, we offer conclusions for the health care sector on a concept-by-concept basis. Finally, we propose the notion of interclan, a clan-inspired notion for inter-organizational cooperation, and analyse the observed network formation.     

Endotoxin-induced cytokine production of monocytes of third-trimester pregnant women compared with women in the follicular phase of the menstrual cycle

OBJECTIVE: Little is known about the function of the innate immune response during pregnancy. We therefore investigated monocyte cytokine production, as a measure of monocyte function, in pregnant women compared with nonpregnant women. STUDY DESIGN: Whole blood of women in the follicular phase (day 5-6) and of healthy pregnant women (30 weeks) was collected and stimulated with endotoxin (2 microg/mL). After incubation for 4 hours (37 degrees C, 5% carbon dioxide), red blood cells were lysed and white blood cells were permeabilized, followed by staining with anti-CD14 (fluorescein isothiocyanate labeled) and with phycoerythrin-labeled tumor necrosis factor-alpha, interleukin-1beta, or interleukin-12. The cells were analyzed by flow cytometry after fixation. Results are expressed as a percentage cytokine producing cells after endotoxin stimulation. Statistical analysis was performed with the Mann-Whitney U test (P <.05). RESULTS: Compared with the percentage endotoxin-induced cytokine producing peripheral monocytes in women in the follicular phase, this percentage in pregnancy was decreased for interleukin-12 (mean 6.63 +/- 1.34 vs 3.34 +/- 0.87, P <.05) and tumor necrosis factor-alpha (mean 50.20 +/- 5.80 vs 31.29 +/- 5.57, P >.05). No significant difference was seen in the production of interleukin-1beta (mean 58.22 +/- 11.09 vs 47.18 +/- 7.88, P >.05). CONCLUSION: The percentage of interleukin-12 and tumor necrosis factor-alpha producing monocytes is decreased in pregnant women compared with nonpregnant women, suggesting that pregnancy is a proinflammatory state.     

Potential healing benefit of an osteoperiosteal bone plug from the proximal tibia on a mosaicplasty donor-site defect in the knee

Introduction Autologous osteochondral transplantation is a popular treatment for articular cartilage lesions in the knee joint. The donor defect is commonly left empty and remains a matter of concern.Materials and methods In 20 knees of 10 goats, we created a standardised donor defect in the knee. In the control group the defects were left empty, whereas in two other groups a bone plug from the proximal tibia was press-fitted into the defect with or without a covering periosteal layer.Results Histological evaluation after 8 and 16 weeks showed that relatively rapid osteoclastic resorption of the bone plug occurred. Defects were mainly filled with fibrous tissue, and collapse of the adjacent bone and cartilage was visible, especially when the defects were left empty. Occasionally, some consolidation of the graft to the host bone could be detected, and in some samples periosteal chondrogenesis was present.Conclusion Our findings suggest that transplantation of a tibial bone plug with covering periosteum to the donor defect in a cartilage transplantation procedure does not have any additional value in an attempt to minimise the damage at the donor site. The observed resorption of the bone plug and the collapse of the adjacent joint margin remain a matter of concern with this technique.     

Cell proliferation and apoptosis are altered in mice deficient in the NF-kappaB p50 subunit after treatment with the peroxisome proliferator ciprofibrate.

We previously showed that the peroxisome proliferator ciprofibrate increases hepatic NF-kappaB DNA binding activity in rats, mice, and hepatoma cell lines. Here, we analyzed the response to ciprofibrate in mice that lack the NF-kappaB p50 gene (p50-/-). Wild-type and p50-/- mice were fed a diet with or without 0.01% ciprofibrate for 10 days. NF-kappaB DNA binding activity was present and increased after ciprofibrate treatment in wild-type mice, but was not detected in p50-/- mice. The untreated p50-/- mice had a higher level of hepatic cell proliferation, as measured by BrdU labeling, than did untreated wild-type mice. However, the increase in proliferation was greater in ciprofibrate-fed wild-type mice than in ciprofibrate-fed p50-/- mice. The apoptotic index was low in wild-type mice in the presence or absence of ciprofibrate. Apoptosis was increased in untreated p50-/- mice compared to wild-type mice; apoptosis was reduced in p50-/- mice after ciprofibrate feeding. The c-Jun and JunB mRNA levels were higher in untreated p50-/- mice than in untreated control mice; c-Jun mRNA levels increased, whereas JunB mRNA levels decreased in both groups after ciprofibrate treatment. The c-Jun and JunB protein levels were the same in untreated wild-type and p50-/- mice and increased in both groups after ciprofibrate treatment. Several apoptosis-related mRNAs were higher in untreated p50-/- mice compared to untreated control mice; expression of these genes increased in both groups after ciprofibrate treatment. These data indicate that NF-kappaB contributes to the proliferative and apoptotic changes that occur in the liver in response to ciprofibrate.     

Predictors of long-term adherence to pelvic floor muscle exercise therapy among women with urinary incontinence

This study assessed predictors of long-term adherence to pelvic floor muscle exercise (PFME) therapy including a health education programme among women with urinary incontinence. Sequential multiple regression analyses revealed several significant predictors that predicted 50% of variance in long-term adherence behavior. Short-term adherence significantly predicted long-term adherence. Further, women with frequent weekly wet episodes before and 1 year after therapy were more likely to have high adherence levels 1 year after therapy than women with fewer weekly losses. Thus, women seemed to adapt long-term adherence behavior to their symptoms. Adherence to PFME therapy was very high. The protocol checklist for the PFME therapy developed to standardize treatment among physiotherapists had structured therapy content, which may have optimized adherence behavior in this study. Implementation of this protocol checklist in clinical guidelines is suggested.     

Should I stay or should I go? Waiting lists and cross-border care in the Netherlands

The recent ruling of the European Court of Justice in the case Smits-Peerbooms explicitly mentions undue delay as a legitimisation for cross-border care within the EU. In the Netherlands, waiting times are well above the norm set by several health care parties as well as maximally acceptable waiting times elicited in patients. This might indicate that Dutch patients are often entitled to care in other Member States, in the sense that insurers cannot withhold reimbursement of cross-border care in the present situation. However, experiments clearly demonstrate that few Dutch patients are willing to travel abroad. Patients seem to prefer longer waiting in the Netherlands over shorter waiting by going abroad, even those living in border regions. In addition, mobility of patients within the Netherlands is very modest. Given this inertia in patient mobility, in the short run, cross-border care will probably remain an insignificant phenomenon in terms of quantities of patients travelling abroad and therefore the impact of the Smits-Peerbooms rulings is limited.     

Impact of beta-carotene supplementation through red palm

A 10-month long feeding trial was conducted to assess the impact of beta-carotene supplementation through red palm oil (RPO) with the focus on vitamin A status, morbidity status and acceptability of an RPO-incorporated noon-meal as a dietary supplement among two cohorts of 409 (experimental) and 346 (control) preschool children in two southern districts of rural Tamil Nadu, selected by stratified random sampling. Information was gathered on ocular symptoms of vitamin A deficiency and anthropometry, and blood samples were drawn at baseline and final rounds for estimation of serum beta-carotene, retinol and tocopherol. Data about Socioeconomic Status (SES) were collected once during the study period, while information on attendance, consumption and morbidity was recorded by preschool teachers. The results showed the following. 1. Significant improvement in the vitamin A status of children in terms of disappearance of Bitot's spots (50.0 per cent) in the experimental group vs. 28.0 per cent in the control group. 2. After feeding of RPO, incidence rate of new Bitot's spots cases was low at 2.13 in the experimental children vs. 4.78 in control children. 3. Marked improvement in the serum beta-carotene levels after 10 months of feeding. 4. RPO is acceptable to children as an edible grade oil as there is no perceptible difference in the consumption pattern between experimental and control children.     

The influence of psychological factors on self-reported physiological effects of noise

We examine the possibility that physiological effects of noise may result not only from noise exposure per se, but also from people's beliefs about the noise. Due to widely publicised changes to the runway configuration at Sydney Airport, aircraft noise levels in nearby areas were expected to either increase, decrease or remain the same. As part of the Sydney Airport Health Study, residents in each of these 3 expected-change areas (N=1015) completed a structured interview which included indices of noise reaction (including annoyance) and physical and mental health, prior to the anticipated changes. Concurrent (pre-change) measures of aircraft noise levels were taken. Self-reported physiological/health effects differed across areas with the same aircraft noise level consistently with differences in psychological reaction across these areas. Expected change in noise level added to the level of self-reported physiological symptoms predicted by noise level in regression analyses. Dose-response functions differed across the expected-change areas. These results are consistent with the hypothesis that noise exposure produces physiological symptoms, but that expectations regarding future noise levels also contribute to the physiological impact of noise, which may be reduced by addressing psychosocial factors related to noise reaction.