Mandibulotomy access to tumour sites: fewer complications for postoperative compared with preoperative radiotherapy.

The purpose of this study was to compare complication rates at the mandibulotomy site between patients receiving preoperative radiotherapy (RT) and those receiving postoperative RT during treatment for oral and oropharyngeal cancer where the surgical procedure required a mandibular osteotomy to gain access to the tumour. Sixty-four consecutive patients treated during the period 2000-2015 were available for analysis. Their medical records were reviewed retrospectively. All patients were followed for at least 1year postoperatively. A subgroup of patients received RT on several occasions or long before the mandibulotomy, therefore the statistical comparisons focused on the two groups of patients receiving RT on one occasion and within 6 months prior to or following surgery. Seventeen patients presented a total of 29 complications, yielding an overall complication rate of 27%. Orocutaneous fistula was the most common complication. Patients who received RT preoperatively presented a higher complication rate (9/15; 60%) when compared to those who received RT postoperatively (2/31; 6.5%) (odds ratio 21.8, P<0.001). This study demonstrated fewer complications in the mandibulotomy area exposed to postoperative RT compared with preoperative RT. It is therefore suggested that, when possible, RT should be given postoperatively if combination treatment with RT and surgery, including a mandibulotomy, is planned.

Urinary iodine and thyroid volume in a Swedish population.

OBJECTIVE: To evaluate the present efficacy of an iodine supplementation programme working in Sweden since 1936 by studying the iodine excretion in urine and determining the thyroid volume in a population in a semi-rural community. DESIGN: A cross-sectional population screening comprising three age groups with randomly selected individuals: group 1 (children): 7-9 years, n = 61 (invited 70); group 2 (teenagers): 15-17 years, n = 61 (invited 63), and group 3 (adults): 60-65 years; n = 57 (invited 73). MAIN MEASUREMENTS: Urinary iodine was measured spectrophotometrically; thyroid volume by ultrasonography. RESULTS: The median values for urinary iodine concentration in the three age groups were 194 microg L(-1), 246 microg L(-1) and 190 microg L(-1), respectively, indicating an adequate iodine intake. In the 7-9 year olds, the median value of the thyroid volume was 4.7 mL, which coincides with the recently established upper limit of normal children of that age, 4.0-4.8 mL (ICCIDD, International Council for control iodine deficiency disorders). One eight-year-old boy had a pronounced goiter. Four teenagers and one adult were found to have an enlarged thyroid gland according to earlier established reference volumes (15 years >16 mL; adults > 25 mL). CONCLUSION: We conclude that the iodine intake in our region is sufficient in age groups ranging from young children to pre-retirement adults.

Growth under privileged conditions of healthy Swedish infants exclusively breastfed from birth to 4-6 months: a longitudinal prospective study based on daily records of feeding.

AIM: In most studies the methodology used to study growth in relation to breastfeeding patterns cannot ensure that exclusive breastfeeding has in fact occurred since birth. The aim of this study was to investigate the growth of healthy infants in Sweden in whom exclusive breastfeeding for the first 4-6 mo was ascertained through daily feeding records and to compare the results with the World Health Organization (WHO) "12-month breastfed pooled data set" and the Euro-Growth references for exclusively breastfed infants, as well as with the National Center for Health Statistics (NCHS)/WHO reference. METHODS: 147 exclusively breastfed infants and 325 non-exclusively breastfed Swedish infants, with a birthweight of > or = 3 kg, were included. The mothers had previous breastfed at least one infant for at least 4 mo. Weight was recorded fortnightly and length monthly. RESULTS: Infants exclusively breastfed since birth showed similar growth in weight and height to that of the non-exclusively breastfed infants. During the first 6 mo of life the growth of exclusively breastfed infants was also similar to that of the infants regularly receiving formula at 12-16 wk of age, mostly in addition to breast milk. The monthly growth increments were fairly similar to those of the "WHO pooled breastfed data set" and the Euro-Growth references for exclusively breastfed infants. CONCLUSION: In an affluent society truly exclusively breastfed infants seem to have the same growth during the first half year of life as non-exclusively breastfed infants with a high breastfeeding rate.

Thyroid function in the newborn in relation to maternal thyroid status during labour in a mild iodine deficiency endemic area in Sudan.

OBJECTIVES: Data on neonatal and maternal thyroid function during labour in a mild iodine deficiency endemic area are lacking. The current study focuses on elucidating the thyroid function during labour, in a group of pregnant women who live in an area of mild iodine deficiency in Sudan compared to that observed in their corresponding newborns. MEASUREMENTS: Serum concentrations of TSH, thyroglobulin (Tg), triiodothyronine (T3) and free thyroxine (FT4) were investigated during labour in a group of mothers and their neonates residing in an area with mild iodine deficiency in Sudan (n = 76 mother-newborn pairs). DESIGN: Maternal blood samples were taken on two occasions: first, during the third trimester of pregnancy (weeks 32-39); and, second, just before delivery. Cord blood samples were obtained by a doctor or a trained midwife during delivery. RESULTS: The median concentrations (and interquartile ranges) of neonatal TSH, Tg, T3 and FT4 were 6.8 (4.7-12.4) mU/l, 61 (40.2-98.2) microg/l, 0.9 (0.8-1.2) nmol/l and 14.2 (13.4-15.9) pmol/l, respectively. The corresponding levels for the mothers during labour were 2.3 (1.9-3.2) mU/l, 33 (15.0-56.8) microg/l, 2.6 (2.0-2.9) nmol/l and 11.4 (10.3-13.3) pmol/l, respectively. The median neonatal serum concentrations of TSH, Tg and FT4 were significantly higher than the corresponding maternal levels (P < 0.0001, P < 0.0001, P < 0.0001, respectively). In contrast, the median maternal serum concentration of T3 was significantly higher than that of the neonates (P < 0.0001). When the different neonatal thyroid parameters were compared with each other, significant correlations were observed between TSH and FT4 (r = 0.4, P = 0.001); Tg and T3 (r = -0.3, P = 0.04) and Tg and FT4 (r = 0.5, P = 0.0001). Women with Tg concentrations above 20 microg/l showed a higher median TSH concentration and lower median FT4 concentration than those with Tg concentrations below 20 microg/l (P < 0.001, P < 0.001, respectively). Nevertheless, the thyroid function of neonates born of mothers with elevated Tg was similar to that of neonates born of mothers with low Tg levels. No significant changes had occurred in the thyroid function parameters between the third trimester of pregnancy and during the time of labour. The thyroid function indicators of the babies born by vaginal delivery did not differ significantly from those of the babies born by Caesarian section. CONCLUSIONS: The study suggests that, in areas with mild iodine deficiency, neonates may be at the limit of decompensation as evidenced by their enhanced TSH and Tg levels as well as increased T4 compared to their mothers. This finding must not create a false sense of well-being and points rather to the urgency of iodine supplementation of mothers even in areas with mild iodine deficiency, as in this part of Sudan. The mode of delivery, whether by spontaneous vaginal delivery or Caesarian section, did not seem to affect the thyroid function of the newborn.

Information and socioeconomic factors associated with early breastfeeding practices in rural and urban Morogoro, Tanzania.

UNLABELLED: A cross-sectional study was undertaken in a rural and an urban area in Tanzania with the aim of identifying factors related to early infant feeding practices. The study included 320 mothers from each area with infants below 7 mo of age. A significant proportion of both rural and urban mothers had erroneous beliefs about infant feeding practices. None of the socioeconomic, demographic or biological variables studied were associated with feeding practices. Urban residence was positively associated with the duration of exclusive but not predominant breastfeeding. Better knowledge about specific breastfeeding issues was positively associated with the duration of both exclusive and predominant breastfeeding. Ownership of a radio was positively associated with both exclusive and predominant breastfeeding in the rural area. Although both rural and urban mothers had a high antenatal clinic attendance rate, 65% of the rural and 14% of the urban mothers delivered at home. Urban mothers informed about breastfeeding at the antenatal clinic had better feeding practices. CONCLUSION: We hypothesize that exclusive breastfeeding is not a traditionally recognized practice and thus its duration is mainly associated with information and knowledge about breastfeeding. This suggests that information programmes to provide knowledge, beginning at antenatal visits, may reduce premature complementation, though additional support may also be required.

Supplementing lactating women with puréed papaya and grated carrots improved vitamin A status in a placebo-controlled trial.

Doubts have been raised about the effectiveness of carotene-containing foods in improving the vitamin A status of populations at risk. We investigated the effect of papaya and carrots on the vitamin A status of lactating women with 2- to 12-mo-old infants in ZIMBABWE: The women were randomly assigned to three supplementation groups and a placebo group, and received 6 mg of beta-carotene capsules, 650 g puréed papaya, 100 g grated carrots or a placebo, daily for 60 d. All groups were given a meal containing 10 g of vegetable oil daily. Serum retinol, relative dose response, serum ferritin, hemoglobin and C-reactive protein were measured before and after the supplementation period. Mean serum retinol increased significantly after supplementation in the beta-carotene group (P < 0.001), the papaya group (P < 0.001) and the carrot group (P < 0.001), but not in the placebo group (P > 0.05). The relative dose response decreased significantly (P < 0.05) in the beta-carotene and papaya groups, but not in the carrot or placebo groups (P > 0.05). There was an increase in mean serum ferritin in all groups but the increase did not differ among groups. The hemoglobin increases in the beta-carotene and papaya groups were greater than that in the placebo group. We conclude that puréed papaya and grated carrots can improve the vitamin A and iron nutriture of lactating women. These findings reinforce the importance of plant food-based approaches in the control of vitamin A deficiency in low income countries.

Evidence of grave vitamin A deficiency among lactating women in the semi-arid rural area of Makhaza in Zimbabwe. A population-based study.

OBJECTIVE: To assess the vitamin A and iron status of lactating women. DESIGN: A population-based cross-sectional descriptive study. SETTING: A semi-arid rural area of Makhaza in Zimbabwe. SUBJECTS: Two hundred and seven lactating women with babies aged 2-12 months. METHODS: Serum retinol (SR) was measured by HPLC, serum ferritin (SF) by ELIZA, haemoglobin (Hb) by HemoCue and C-reactive protein (CRP) by a turbo metric method. A seven-day recall of consumption of vitamin A containing foods was recorded. MAIN OUTCOME MEASURES: Relative dose response (RDR), SR, SF, Hb and CRP. RESULTS: Dark green leafy vegetables were the main sources of vitamin A; retinol-containing foods and yellow to red fruits and vegetables were rarely consumed. Five women had elevated CRP and these women had lower SR (P < 0.001) than the rest. Forty percent of the women had vitamin A deficiency (SR < 20 microg/dl), 76% had low liver stores of vitamin A (RDR > 20%) while 15 women had both abnormal SR and abnormal RDR. Forty percent had anaemia (Hb < 12 g/l) while 12% had iron deficiency (SF < 12 microg/dl) and 4% (n = 7) had iron deficiency anaemia. CONCLUSION: Vitamin A and iron deficiencies are problems of public health significance among the lactating women in the Makhaza area.

Growth hormone receptor is expressed in human breast cancer.

Several clinical observations and experimental studies indicate that pituitary hormones, including growth hormone, play a role in the development of human breast cancer. We analyzed 48 human breast carcinomas using reverse transcription polymerase chain reaction, immunohistochemistry, and Western blotting techniques to assess growth hormone receptor expression. In 17 of these cases, adjacent normal breast tissue was similarly analyzed. These analyses revealed that growth hormone receptor (GHR) is expressed in human breast cancer and appears to be up-regulated compared to adjacent normal breast tissue. GHR expression correlated inversely with tumor grade and MIB-1 index. Progesterone receptor expression correlated positively with GHR expression. These findings, along with our observation of GHR expression in breast cancer stromal cells and previous reports of local production of growth hormone in breast carcinoma, suggest that GHR-mediated signaling pathways are involved in the development of human breast cancer, possibly via autocrine or paracrine mechanisms.

Increase in serum beta-carotene following dark green leafy vegetable supplementation in Mebendazole-treated school children in Bangladesh.

OBJECTIVE: To study the effect of consumption of dark green leafy vegetables (DGLV) and sweet pumpkin on serum beta-carotene and retinol concentrations in children treated for Ascaris lumbricoides. DESIGN: Experimental study with a randomised design. SUBJECTS: A total of 110 primary school children aged 8-12 y in northwestern Bangladesh. INTERVENTIONS: All children were de-wormed and 2 weeks later randomly assigned to one of three groups to receive for 6 days per week, for 6 weeks, one complete meal containing either: (1) 4.4 mg beta-carotene from DGLV (n=37, after 18 dropouts); (2) 1.5 mg beta-carotene from sweet pumpkin (n=36, 18 dropouts); or (3) vegetables containing virtually no beta-carotene (control) (n = 37, 18 dropouts). RESULTS: Significant increases (P < 0.001) in mean serum beta-carotene concentrations were seen in all three study groups, with a statistically higher increase (micromol/l) in the DGLV group (0.44; 95% confidence interval (CI) 0.32, 0.55) compared to the control group (0.20; 95% CI 0.14, 0.26; P = 0.002). The increase in serum retinol (micromol/l) was statistically significant (P=0.04) only in the DGLV group (mean 0.066; 95% CI 0.002, 0.13), but this increase was not different from the increase in the control group. CONCLUSION: In children successfully treated for Ascaris lumbricoides, a substantial increase in serum beta-carotene was seen after feeding with a moderately high cumulative dose of DGLV for 6 weeks.

Exclusive breast-feeding is rarely practised in rural and urban Morogoro, Tanzania.

OBJECTIVE: To investigate and compare feeding practices among infants of less than 7 months of age in a rural and an urban area in Tanzania. DESIGN: Cross-sectional, questionnaire-based interview of mothers and focus group discussions with extension workers and community leaders. SETTING: Eleven villages in a rural district and 10 wards in an urban district in the Morogoro region, Tanzania, west of Dar es Salaam. SUBJECTS: Probability samples of mothers with infants of less than 7 months of age from each area). RESULTS: Exclusive breast-feeding was rarely practised in either the rural or urban areas investigated. However, the urban mothers initiated breast-feeding earlier, discarded colostrum less frequently, breast-fed exclusively for a longer period, gave breast milk as the first feed more often and delayed the introduction of solid foods for longer than their rural counterparts. The rural mothers, on the other hand, breast-fed their previous infants slightly longer than the urban mothers. CONCLUSIONS: The better performance of urban mothers could be partly due to sustained breast-feeding support in hospital settings and other campaigns which may not have reached the rural areas. In both the rural and urban areas more efforts are needed to encourage exclusive breast-feeding, to avoid premature complementation and, in the case of the urban areas, to protect extended breast-feeding.

How exclusive is exclusive breastfeeding? A comparison of data since birth with current status data.

BACKGROUND: There is no accepted and widely used indicator for exclusive breastfeeding since birth. Indeed, the difference between 'current status' data on exclusive breastfeeding and data on 'exclusive breastfeeding since birth' is rarely recognized. We used data from a longitudinal study to examine this issue. METHODS: A descriptive longitudinal, prospective study design was used in which 506 mother-infant pairs were included. The mothers completed daily recordings on infant feeding during the first nine months after birth. A research assistant conducted fortnightly home visits with structured interviews. The resulting data on breastfeeding patterns are presented in two different ways: analysis of 'current status' data based on a single 24-hour recording of infant feeding at 2, 4 and 6 months of age, and analysis of data 'since birth', i.e. data on infant feeding for every day, starting from birth until the ages of 2, 4 and 6 months. RESULTS: A wide discrepancy between the results obtained from the two analyses was found. The difference in the exclusive breastfeeding rate was over 40 percentage points at both 2 and 4 months of age (92% versus 51% at 2 months and 73% versus 30% at 4 months) and 9 percentage points at 6 months (11% versus 1.8%). CONCLUSIONS: Current status indicators based on a 24-hour period may be inadequate and even misleading for many purposes. We propose that in many studies an indicator called 'exclusive breastfeeding since birth' could be added.

Prolactin (PRL) receptor gene expression in mouse adipose tissue: increases during lactation and in PRL-transgenic mice.

There are indications that PRL may exert important metabolic actions on adipose tissue in different species. However, with the exception of birds, the receptor has not been identified in white adipose tissue. The present study was designed to examine the possible expression and regulation of the PRL receptor (PRLR) in mouse adipose tissue. The long PRLR messenger RNA (mRNA) splice form (L-PRLR) and two short splice forms (S2- and S3-PRLR) were detected in mouse adipose tissue by RT-PCR. Furthermore, L-PRLR mRNA was detected by ribonuclease protection assay. Immunoreactive PRLR with a relative molecular mass of 95,000 was revealed by immunoblotting. Furthermore, L-PRLR mRNA expression was demonstrated in primary isolated adipocytes. In mouse adipose tissue, the level of L-PRLR mRNA expression increased 2.3-fold during lactation compared with those in virgin and pregnant mice. In contrast, in the liver the expression of L-PRLR increased 3.4-fold during pregnancy compared with those in virgin and lactating mice. When comparing the levels of L-PRLR expression in virgin female and male mice, no difference was detected in adipose tissue. However, in virgin female liver the expression was 4.5-fold higher than that in male liver. As PRL up-regulates its own receptor in some tissues, we analyzed L-PRLR expression in PRL-transgenic female and male mice. In PRL-transgenic mice L-PRLR expression was significantly increased in both adipose tissue (1.4-fold in females and 2.4-fold in males) and liver (1.9-fold in females and 2.7-fold in males) compared with that in control mice. Furthermore, in female PRL-transgenic mice retroperitoneal adipose tissue was decreased in weight compared with that in control mice. However, no difference was detected when comparing the masses of parametrial adipose tissue. Our results suggest a direct role for PRL, mediated by PRLR, in modulating physiological events in adipose tissue.

Female genital mutilation in eastern Ethiopia.

In Ethiopians at large, women and men are caught in a vicious circle of erroneous expectations and a mute consensus that maintains female genital mutilation (FGM). We have shown clear signs of erosion of this practice and the potential for further influence and change.

PIP: This paper examines the incidence of female genital mutilation (FGM) in Harrar, eastern Ethiopia. The researchers studied three ethnic groups (Adere, Oromo and Amhara) using focus group interviews. A total of 24 women were interviewed, 8 from each ethnic group, at two hospitals in Harrar. The predominant types of FGM are clitoridectomy and excision, but infibulation is also practiced by some ethnic groups in the southeast. It is shown that the Adere and the Oromo perform FGM on women aged 4 years to puberty, while the Amhara perform it on the 8th day following birth. Both the Adere and Oromo practice infibulation, and the Amhara practice excision and clitoridectomy. Although the practice of FGM is widespread, signs of change of the practice are evident. However, these signs do not mean that the FGM problem is solved. All efforts must continue until the total global abolition of FGM is achieved.

Dietary cyanide from insufficiently processed cassava and growth retardation in children in the Democratic Republic of Congo (formerly Zaire).

Dietary cyanide exposure from cyanogenic glucosides in insufficiently processed cassava has been advanced as a contributing factor in child growth retardation. Whether cyanide exposure aggravates children's growth retardation was studied by comparing two populations of children from the northern and the southern zones of the Bandundu region, Democratic Republic of Congo (former Zaire), using dietary interviews, anthropometry and urine analyses. Both populations consumed cassava as their staple diet, but whereas in the north the cassava was well processed, in the south it was inadequately processed. The mean urinary thiocyanate was much higher in the south, whereas mean urinary sulphate excretion was equally low in the two areas. However, the mean urinary SCN/SO4 molar ratio was higher in the south (0.20), indicating that 10-20% of sulphur amino-acids were used for cyanide detoxication. No significant differences were found between the two populations in weight-for-height and weight-for-age indices but the height-for-age index was significantly lower in children from the south, indicating more severe growth retardation in children exposed to dietary cyanide. Because of the preferential use of sulphur amino-acids for cyanide detoxification in the human body, dietary cyanide exposure from cassava may be a factor aggravating growth retardation in Bandundu.

Changes in iodine metabolism during late pregnancy and lactation: a longitudinal study among Sudanese women.

OBJECTIVE: To elucidate the persistence, or otherwise, of the pregnancy-related changes in the iodine metabolism and thyroid function in a population residing in an area of mild iodine deficiency in the Sudan. DESIGN: A longitudinal prospective cohort study involving pregnant women who were recruited during their third trimester of pregnancy and were followed up for up to nine months after delivery. SETTING: The study was conducted among Sudanese women residing in the Omdurman area in Khartoum, an area with a total goitre rate of 17.5%. SUBJECTS: Forty-seven pregnant women were recruited during their third trimester of pregnancy. Their mean age and weight were 29+/-4.6 y and 62.4+/-8.7 kg, respectively. Age matched healthy non-pregnant women living in the same area (n=40) served as a control group. METHODS: Serum levels of thyrotropin (TSH), thyroxine (T4), triiodothyronine (T3), thyroglobulin (Tg) and the urinary iodine concentration (UIC) were determined during the third trimester (first occasion), and subsequently at three months (second occasion), six months (third occasion) and nine months after delivery (fourth occasion). Control subjects provided corresponding samples on one occasion. MAIN OUTCOMES MEASURES: UIC, TSH, Tg, FT4 and T3. RESULTS: During the third trimester of pregnancy the median UIC and the free T4 (FT4) were lower than in the control group (P<0. 0001, P<0.0001, respectively), while the median Tg was higher than in the controls (P<0.03). Three months post-partum maximum thyroidal stimulation was evident, with elevated serum levels of TSH and Tg (P<0.0001, P<0.03) and reduced UIC and serum T3 and FT4 (P<0.0004, P<0.0005, P<0.0001), compared with the control group. Nine months post-partum the thyroid function was restored to the pre-pregnancy state, and the median values of TSH, Tg, T3, FT4 and UIC did not differ significantly from those in the control group. CONCLUSIONS: Our study suggests that the reversibility of the pregnancy-induced changes in the iodine status and thyroid function to the pre-pregnancy levels may depend on the iodine status of the mother during and after pregnancy. The thyroidal stress during the first three months of the post-partum period, which is partially due to the iodine loss in the breast milk, justifies further detailed studies to assess the iodine content of the breast milk and the role of breast milk as a vehicle for iodine supply of infants in situations of iodine deficiency. SPONSORSHIP: This study was supported by a grant from the Swedish Agency for Research Co-operation with Developing Countries.

Thyroglobulin in serum as an indicator of iodine status during pregnancy.

Serum thyroglobulin and thyrotropin as well as urinary iodine concentrations were measured in healthy, pregnant Swedish (n=27) and Sudanese (n=21) women and the results compared with those of healthy Swedish (n=14) and Sudanese (n=20) non-pregnant controls. The median thyroglobulin concentrations (and interquartile range) in the Swedish pregnant women for the three trimesters were 15.5 (8-24), 10.5 (7-19) and 18.0 (13-25) microg/L, respectively. The median third trimester concentration was higher than both the first and second trimester concentrations, respectively (p<0.0001, p<0.0001). Compared to the control group, the Swedish pregnant women had a significantly higher median thyroglobulin concentration in the third trimester (p<0.05). Among the Sudanese pregnant women, the median serum thyroglobulin concentrations (and interquartile range) were 27.5 (12-40), 25.0 (15-43) and 30.0 (15-67) microg/L during the first, second and third trimesters, respectively. There were no significant differences between these concentrations. Compared to the control group, the Sudanese pregnant women had a significantly higher median thyroglobulin in the third trimester (p<0.01). The Sudanese pregnant women also showed significantly higher median thyroglobulin concentrations than the Swedish pregnant women in all the three trimesters of pregnancy (p<0.05, p<0.001 and p<0.01, respectively). However, there were no significant differences between the two non-pregnant controls. Among the Swedish pregnant women, 40%, 23% and 30% of the subjects showed serum thyroglobulin concentrations above 20 microg/ L during the first, second and third trimesters of pregnancy, respectively. Corresponding figures for the Sudanese pregnant women were 55%, 61% and 64%, respectively. A significantly negative correlation was shown between serum thyroglobulin and urinary iodine concentrations during the second and third trimesters in the Swedish women (r= -0.8, p=0.01 and r= -0.5, p=0.03, respectively), and in the third trimester in the Sudanese women (r= -0.6, p=0.03). No such correlation was observed between thyrotropin and urinary iodine concentration in either the Swedish or the Sudanese pregnant women. It is concluded that serum thyroglobulin is a more sensitive indicator of iodine deficiency than serum thyrotropin during pregnancy.

Relationships between vitamin A, iron status and helminthiasis in Bangladeshi school children.

OBJECTIVE: To explore the relationships between biochemical indicators of vitamin A and iron status and the intestinal helminths Ascaris lumbricoides and hookworm in primary school children. SETTING: Two rural governmental schools in northwestern Bangladesh. DESIGN: Cross-sectional study. SUBJECTS: The sample consisted of 164 children in grades 3-5. METHODS: Serum retinol and beta-carotene (by high-performance liquid chromatography, HPLC), haemoglobin (HemoCue), ferritin (enzyme-linked immunoadsorbent assay, ELIZA) and height and weight were measured. Dietary intake of vitamin A was assessed using a food frequency questionnaire and faecal analyses were done using Stoll's egg-count technique. RESULTS: The mean serum retinol was 26.8 microg dl(-1) and 20% had a level of < 20 microg dl(-1), the cut-off value for low vitamin A status. There was a strong positive association between serum beta-carotene and serum retinol (r = 0.44, P < 0.001), suggesting those with higher retinol levels had a higher carotene intake. Thirty-one per cent were anaemic (Hb < 11.5 g dl(-1)), 30% had iron deficiency (serum ferritin < 12.0 microg l(-1)) and 14% were suffering from iron deficiency anaemia. Children with a serum retinol level of 20 microg dl(-1) had significantly lower ferritin (14.0 compared to 26.0 microg l(-1), P = 0.005) and Hb levels (11.7 compared to 12.4 g dl(-1), P = 0.005) than those with higher levels. The proportion of iron deficiency anaemia was significantly greater among children with hookworm. Our data suggest that hookworm exerts its impact on iron status independently of the vitamin A status of the host. CONCLUSIONS: Programmes to improve iron status should consider including both vitamin A prevention programmes and deworming.

Low dietary cyanogen exposure from frequent consumption of potentially toxic cassava in Malawi.

In a cassava-growing area in Malawi, where roots are processed by soaking and water is available throughout the year, we interviewed 176 women farmers regarding their preferences for cassava cultivars and frequency of cassava consumption. Dietary cyanogen exposure was estimated from urinary levels of linamarin, the cyanogenic glycoside in cassava, and urinary thiocyanate, the main cyanide metabolite. Protection against unplanned harvest by family members, theft and animal spoilage were stated to be very important reasons for growing bitter cassava cultivars by 91%, 90% and 74% of the women, respectively. The mean (+/- SD) number of cultivars grown by each woman was 4.6 (+/- 2.4). The correlation between mean taste and mean danger scores for the 25 most grown cultivars was strong (r > 0.98). The scoring indicated that cultivars belonged to two distinct groups, eight to a group referred to as 'cool' and 17 to a group termed 'bitter'. The dumpling-like porridge (kondowole) made from cassava flour from bitter roots was eaten twice daily by 51% and at least weekly by 81%. The mean (+/- SEM) urinary linamarin was 14 (+/- 1) mumol/L and thiocyanate was 50 (+/- 4) mumol/L, less than a tenth of levels reported from populations eating insufficiently processed bitter cassava roots, and in the same range as in a non-smoking Swedish reference population. We conclude that cyanogenesis is a preferred characteristic of cassava by the studied farmers because it enhances food security. The availability of water and their knowledge about toxicity and processing enables these women farmers to provide a safe staple food from bitter cassava roots.

Classification of thyroid size by palpation and ultrasonography in field surveys.

BACKGROUND: Goitre surveys are used to assess the degree of iodine deficiency in a population. The change of goitre classification made by WHO in 1994 implied that a smaller thyroid size should be regarded as goitre. Furthermore, the acceptable goitre prevalence was lowered from 10% to 5%, and ultrasonography was recommended as a more precise method for diagnosis of goitre. We studied the effects of the change of palpation system, and compared the precision of the old and new systems with that of ultrasonographic examination. METHODS: We studied 225 schoolchildren (aged 7-14 years) in a highland village in Tanzania. The size of the thyroid was assessed in duplicate by ultrasonography and by WHO's 1960 and 1994 palpation systems. The latter were done by three examiners. Variations within and between examination methods and examiners were assessed, and measurement errors by ultrasonography were assessed from duplicate examinations. The sensitivity and specificity of the two palpation systems were calculated, with diagnosis by ultrasonography as the gold standard. Apparent palpation prevalences were calculated at a "true" 5% prevalence. FINDINGS: The lowered criterion for goitre resulted in an extra 20-33% of children being diagnosed as having goitre by palpation. The variation between repeat examinations was only slightly smaller by ultrasonography (kappa=0.63) than by experienced examiners (kappa=0.57-0.58). The variation between thyroid volume estimation by ultrasonography and the true volume was about 50% due to both measurement error and variation in the shape of thyroid lobes. The new goitre criterion decreased specificity from 76% to 29%, whereas sensitivity rose from 56% to 80%. In contrast, a suggested sharpening of the old criterion increased specificity to 90%. INTERPRETATION: A return to the old (1960) palpation criterion for goitre: "lobes larger than the terminal phalanxes of thumbs" and to an accepted palpation goitre prevalence of 10% can allow affordable monitoring of thyroid size through palpation in field surveys.