The Effect of Zinc Biofortified Wheat Produced via Foliar Application on Zinc Status: A Randomized, Controlled Trial in Indian Children.

BACKGROUND: Agronomic zinc biofortification of wheat by foliar application increases wheat zinc content and total zinc absorption in humans. OBJECTIVES: To assess the effect of agronomically biofortified whole wheat flour (BFW) on plasma zinc (PZC) compared with a postharvest fortified wheat (PHFW) and unfortified control wheat (CW) when integrated in a midday school meal scheme. METHODS: We conducted a 20-wk double-blind intervention trial in children (4-12 y, n = 273) individually randomly assigned to 3 groups to receive a daily school lunch consisting of 3 chapattis prepared with the 3 different wheat flour types. Measurements of anthropometry, blood biochemistry, and leukocyte DNA strand breaks were conducted. We applied sparse serial sampling to monitor PZC over time, and analysis was performed using linear mixed-effects models. RESULTS: Mean zinc content in BFW, PHFW, and CW were 48.0, 45.1, and 21.2 ppm, respectively (P < 0.001). Mean (standard deviation) daily zinc intakes in the study intervention in BFW, PHFW, and CW groups were 4.4 (1.6), 5.9 (1.9) and 2.6 (0.6) mg Zn/d, respectively, with intake in groups PHFW and BFW differing from CW (P < 0.001) but no difference between BFW and PHFW. There were no time effect, group difference, or group × time interaction in PZC. Prevalence of zinc deficiency decreased in the BFW (from 14.1%-11.2%), PHFW (from 8.9%-2.3%), and CW (9.8%-8.8%) groups, but there was no time × treatment interaction in the prevalence of zinc deficiency (P = 0.191). Compliance with consuming the study school meals was associated with PZC (P = 0.006). DNA strand breaks were not significantly associated with PZC (n = 51; r = 0.004, P = 0.945). CONCLUSIONS: Consumption of either PHFW or BFW provided an additional ∼1.8 to 3.3 mg Zn/d, but it did not affect PZC or zinc deficiency, growth, or DNA strand breaks. This trial was registered on clinicaltrials.gov as NCT02241330 and ctri.nic.in as CTRI/2015/06/005913.

Modulating the microenvironment during FVIII uptake influences the nature of FVIII-peptides presented by antigen-presenting cells.

Background and aims: Hemophilia A is a severe bleeding disorder caused by the deficiency of functionally active coagulation factor VIII (FVIII). The induction of neutralizing anti-drug antibodies is a major complication in the treatment of hemophilia A patients with FVIII replacement therapies. Why some patients develop neutralizing antibodies (FVIII inhibitors) while others do not is not well understood. Previous studies indicated that the induction of FVIII inhibitors requires cognate interactions between FVIII-specific B cells and FVIII-specific CD4+ T cells in germinal center reactions. In this study, we investigated the FVIII peptide repertoire presented by antigen-presenting cells (APCs) under different microenvironment conditions that are expected to alter the uptake of FVIII by APCs. The aim of this study was to better understand the association between different microenvironment conditions during FVIII uptake and the FVIII peptide patterns presented by APCs. Methods: We used a FVIII-specific CD4+ T cell hybridoma library derived from humanized HLA-DRB1*1501 (human MHC class II) hemophilic mice that were treated with human FVIII. APCs obtained from the same mouse strain were preincubated with FVIII under different conditions which are expected to alter the uptake of FVIII by APCs. Subsequently, these preincubated APCs were used to stimulate the FVIII-specific CD4+ T cell hybridoma library. Stimulation of peptide-specific CD4+ T-cell hybridoma clones was assessed by analyzing the IL-2 release into cell culture supernatants. Results: The results of this study indicate that the specific microenvironment conditions during FVIII uptake by APCs determine the peptide specificities of subsequently activated FVIII-specific CD4+ T cell hybridoma clones. Incubation of APCs with FVIII complexed with von Willebrand Factor, FVIII activated by thrombin or FVIII combined with a blockade of receptors on APCs previously associated with FVIII uptake and clearance, resulted in distinct peptide repertoires of subsequently activated hybridoma clones. Conclusion: Based on our data we conclude that the specific microenvironment during FVIII uptake by APCs determines the FVIII peptide repertoire presented on MHC class II expressed by APCs and the peptide specificity of subsequently activated FVIII-specific CD4+ T cell hybridoma clones.

Management of two-level proximal femoral fractures.

We present the case of an 82-year-old female, who experienced a ground-level fall on the trochanter of the right femur. X-rays showed a proximal femoral fracture (PFF) with an unclear and unusual fracture pattern. Three-dimensional CT images were obtained and showed a displaced femoral neck fracture and ipsilateral fracture of the greater trochanter. Our patient underwent unipolar hemiarthroplasty and fixation of the greater trochanter with a hook plate and cable grip. At 11 months, functional outcomes, patient satisfaction and quality of life were excellent. Primary osteoporosis was diagnosed and treatment with bisphosphonates was initiated.Two-level PFFs are rare and complex. Due to ageing and a subsequent increase in osteoporosis, numbers of PFFs with complex fracture patterns might increase in the future. Adequate treatment and early prevention of osteoporosis are key to reduce this risk and lower the overall burden. Surgical treatment should be patient-tailored and focus on minimising the risk of complications and reinterventions.

Metabolome and microbiome alterations related to short-term feeding of a micronutrient-fortified, high-quality legume protein-based food product to stunted school age children: A randomized controlled pilot trial.

BACKGROUND & AIMS: Stunting in children is a comorbid condition in undernutrition that may be ameliorated by the provision of high-quality foods that provide protein and micronutrients. Addressing this problem in lower social economic environments requires, in part, affordable and scalable food-based solutions with efficacious food products. Towards this end, biochemical/metabolic indicators for fast-throughput screening of foods and their components are desired. A highly acceptable and economical micronutrient-fortified food product with different levels of legume protein was provided to stunted Indian children for one month, to determine change in their linear growth and explore associated biochemical, metabolomic and microbiome indicators. METHODS: A randomized controlled pilot trial was conducted with 100 stunted children (6-10 years of age) to elucidate metabolic and microbiome-based biomarkers associated with linear growth. They were randomized into 4 groups receiving 6, 8, 10 or 12 g of legume-based protein for one month. Anthropometry, blood biochemistry, aminoacidomics, acylcarnitomics and fecal microbiome were measured before and after feeding. RESULTS: No significant differences were observed between groups in height, height-for-age Z-score (HAZ) or BMI-for-age Z-score (BAZ); however, 38 serum metabolites were altered significantly (Bonferroni adjusted P < 0.1) in response to the interventions. IGF-1 (Insulin like Growth Factor-1) was positively (ρ > 0.2, P = 0.02), while serine and ornithine (ρ < -0.2, P = 0.08) were negatively associated with change in height. Leucine, isoleucine and valine positively correlated (P = 0.011, 0.023 and 0.007 respectively) with change in BAZ. Three Operational Taxonomic Units belonging to Bacteroidetes and Firmicutes (VIP score > 1.5) were significantly correlated with change in height. CONCLUSIONS: In this pilot trial, a number of fasting serum metabolomic and fecal microbiome signatures were associated with linear growth after a short-term dietary intervention. The alterations of these markers should be validated in long-term dietary intervention trials as potential screening indicators towards the development of food products that favor growth. This trial was registered at www.ctri.nic.in as CTRI/2016/12/007564.

Effect of ascorbic acid rich, micro-nutrient fortified supplement on the iron bioavailability of ferric pyrophosphate from a milk based beverage in Indian school children.

BACKGROUND AND OBJECTIVES: Nutritional anemia is a significant public health issue with 50-80% prevalence in Indian children. Fortification of food, specifically milk, with iron is a potential approach to increase dietary iron intake. Ferric pyrophosphate [Fe4(P2O7)3] is organoleptically neutral and is less soluble in acid medium and, further, has low bioavailability in milk. However, since ascorbic acid is a potent enhancer of iron absorption, the coadministration of ascorbic acid with Fe4(P2O7)3 might enhance the absorption of iron. We evaluated the effect of ascorbic acid on iron absorption from a Fe4(P2O7)3 and an ascorbic acid fortified milk beverage with respect to milk fortified with Fe4(P2O7)3 alone. METHODS AND STUDY DESIGN: A double-blind, two-way crossover, randomized study was conducted in 25 mildly anemic children. The test group received milk fortified with beverage powder containing 7 mg isotopically labeled iron (57Fe/58Fe) as Fe4(P2O7)3, equimolar proportions of ascorbic acid and 200 mg of calcium whereas control group received milk fortified with energy, calcium and iron equivalent beverage powder. Fractional iron absorption was measured by erythrocyte incorporation of stable isotopes of iron (57Fe/58Fe) in both the groups. RESULTS: The fractional iron absorption from the control drink was 0.80% (95% CI: 0.57, 1.12). Fortifying the milk with an equimolar amount of ascorbic acid increased the fractional iron absorption almost 2-fold to 1.58% (95% CI: 1.13, 2.22). CONCLUSIONS: The presence of ascorbic acid in an equimolar ratio with that of iron from Fe4(P2O7)3 salt in milk as a fortificant enhanced iron absorption when compared to milk fortified with only Fe4(P2O7)3.

Differences in T-cell infiltrates and survival between HPV+ and HPV- oropharyngeal squamous cell carcinoma.

Recent studies have suggested that immune cells as part of tumor's microenvironment could partly explain the better outcome in HPV-associated oropharyngeal carcinoma. We performed a systematic review of the literature focused on differences in immune-infiltrate in HPV+ versus HPV- oropharyngeal cancers. This comprehensive search yielded 4308 original papers, of which 20 satisfied our eligibility criteria. Increase in both circulating and tumor infiltrating CD8+ lymphocytes is mainly seen in HPV+ oropharyngeal carcinoma. Interestingly, the survival benefit associated with increase in immune cells is equal both in HPV+ and HPV- oropharyngeal cancer. Based on these results, our review underscores the role of the immune system in the biological and clinical behavior of oropharyngeal squamous cell carcinomas (OPSCC) and might open doors to further investigate immune modulatory treatment options in OPSCC patients.

Poor prognosis in human papillomavirus-positive oropharyngeal squamous cell carcinomas that overexpress hypoxia inducible factor-1α.

BACKGROUND: Hypoxia induces stabilization of the transcription factor HIF-1alpha (HIF-1α), associated with (chemo-)radiotherapy resistance in oropharyngeal squamous cell carcinoma (SCC). We investigated the effect of HIF-1α expression on survival in relation to human papillomavirus (HPV) status in oropharyngeal SCC. METHODS: We conducted an immunohistochemical analysis of HIF-1α protein expression and downstream targets carbonic anhydrase-IX (CA-IX) and glucose transporter-1 (GLUT-1) in 274 patients with oropharyngeal SCC. Overall survival (OS) was analyzed in total and stratified for HPV status and treatment. RESULTS: In HPV-positive tumors (n = 44), HIF-1α overexpression predicted worse OS (hazard ratio [HR] = 6.23; p = .012), whereas TNM classification or treatment modality did not. In HPV-negative tumors (n = 218), advanced T and N classification and HIF-1α overexpression all independently predicted worse OS. However, the effect of HIF-1α overexpression on OS was lower in HPV-negative (HR = 1.50; p = .024) than in HPV-positive tumors. CONCLUSION: HIF-1α overexpression is associated with worse OS and characterized a subgroup of patients with HPV-positive oropharyngeal SCC with poor prognosis. Possibly, patients with HIF-1α overexpressing HPV-positive tumors should not be eligible for treatment dose deescalation. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1338-1346, 2016.

The effects of regular consumption of a multiple micronutrient fortified milk beverage on the micronutrient status of school children and on their mental and physical performance.

Multiple micronutrient deficiencies exist in school going children in India and bridging the gap between nutrient intake and requirements is an effective way to combat the deficiencies. This study aimed to test the effect of a multi-micronutrient fortified malt and cocoa based milk beverage on the micronutrient status, cognition, physical performance and nutritional deficiencies of 7-10 years old south Indian children. A randomized, double blind placebo controlled study design was used with normal healthy children from low to middle income families, aged 7-10 years randomly assigned to receive either a multi-micronutrient fortified or an unfortified milk based control drink. The drinks were provided 6 days/week for 5 months. Assessments included anthropometry, blood biochemistry, physical performance and cognition at baseline and endline. The baseline characteristics of the study groups were similar. The changes in body weight and height were similar between the groups at the end of the study. Levels of vitamin B12, red cell folate and vitamin B2 significantly improved in the intervention group, while vitamin D, selenium and body iron showed no difference. The Hemoglobin (Hb) and serum ferritin levels of the control group decreased at endline, while those in the intervention group maintained their levels. The serum transferrin receptor levels increased in both the groups. The prevalence of iron deficiency and Vitamin B2 deficiency were significantly lower in the intervention group at endline. Overall improvement in cognitive and physical performance was seen in both the groups at endline, with no significant differences between the groups. The micronutrient fortified milk based drink was efficacious in improving the micronutrient status of Vitamin B2, Vitamin B12 and red cell folate and in preventing a decline in Hb level compared to an unfortified milk based drink. It also reduced anemia and the risk of deficiencies of iron, and B12, in apparently healthy children. ClinicalTrials.gov IdentifierNCT01415557. Clinical Trial RegistryIndia - REF/2012/12/004332.

Associations between body weight perception and weight control behaviour in South Indian children: a cross-sectional study.

OBJECTIVE: To examine the patterns of weight loss behaviour and the association between weight loss attempts with actual weight status and children's and parental perceptions of weight status. DESIGN: A cross-sectional study. SETTING: Karnataka, South India. PARTICIPANTS: 1874 girls and boys aged 8-14 years from seven schools in Karnataka, South India. MAIN OUTCOME MEASURES: The association between weight loss attempts and sociodemographic factors, weight status and the child's or the parent's perception of weight status. RESULTS: Approximately 73% of overweight and obese, 35% of normal weight and 22% of underweight children attempted to lose weight. Children of lower socioeconomic groups studying in schools in the local vernacular and overweight/obese children were more likely to attempt to lose weight (adjusted OR ie, AOR=1.57, 95% CI 1.11 to 2.25; AOR=4.38, 95% CI 2.64 to 7.28, respectively). Perception of weight status was associated with weight loss attempts. Thus, children who were of normal weight but perceived themselves to be overweight/obese were three times more likely to attempt weight loss compared with those who accurately perceived themselves as being of normal weight, while the odds of attempting weight loss were the highest for those who were overweight and perceived themselves to be so (AOR∼18). CONCLUSIONS: Children are likely to attempt weight loss in India irrespective of their weight status, age and gender. Children who were actually overweight as well as those who were perceived by themselves or by their parents to be overweight or obese were highly likely to try to lose weight. It is necessary to understand body weight perceptions in communities with a dual burden of being overweight and undernourished, if intervention programmes for either are to be successful.

Body weight perception is associated with socio-economic status and current body weight in selected urban and rural South Indian school-going children.

OBJECTIVE: To evaluate the current and ideal body weight perceptions of schoolchildren in relation to their actual body weight and socio-economic status (SES). DESIGN: Baseline evaluation of schoolchildren from January 2008 to April 2008 as part of a 3-year longitudinal study. SETTING: City and non-city locations, Karnataka State, South India. SUBJECTS: Schoolchildren (n 1877) aged between 8 and 14 years. RESULTS: Girls, children of more educated parents and city dwellers were more likely to be overweight (P < 0.001). Younger children aged <10 years and those of lower SES were more likely to perceive themselves as underweight (adjusted OR = 1.63, 95 % CI 1.25, 2.11 and adjusted OR = 1.87, 95 % CI 1.32, 2.65). Underweight children were ten times more likely to overestimate their current weight status, while overweight children were four times more likely to underestimate it. The odds of children of lower SES underestimating their weight, as well as desiring a higher weight, were higher than those of higher-SES children. CONCLUSIONS: SES is associated with body weight perception. Underweight children are more likely to overestimate their weight status and overweight children more likely to underestimate it.

Micronutrient supplementation improves physical performance measures in Asian Indian school-age children.

Micronutrients are important in physical work capacity and therefore performance. The impact of a multi-micronutrient-fortified nutritional beverage on physical performance measures among clinically healthy school-age children was assessed in a double-blind (for test and placebo groups), placebo-controlled, randomized trial in children aged between 7 and 10.5 y (n = 300). The participants with height- and weight-for-age Z-scores between 0 and ≥ -3 were randomized to 1 of 3 study arms: fortified choco-malt beverage powder (F), matched energy equivalent unfortified placebo (U), and untreated control (C). Participants in the F and C groups were given 40 g fortified (19 key vitamins and minerals) and unfortified choco-malt beverage, respectively, daily for 120 d. Primary efficacy outcomes included endurance and aerobic capacity using a 20-m shuttle test and step test. Other physical performance measures included speed (40-m sprint), visual reaction time, maximal hand grip, and forearm static endurance. Micronutrient status included thiamin, riboflavin, folate, niacin, iron, pyridoxal phosphate, and vitamins B-12 and C. All measurements were made at baseline and the end of the intervention. There was a within-subject increase in aerobic capacity and whole body endurance (P < 0.05) accompanied by a significant improvement in the status of iron thiamin, riboflavin, pyridoxal phosphate, folate, and vitamins C and B-12 in the F group compared to the within-subject changes in the other 2 groups (P < 0.05). The study suggests that multiple micronutrient supplementation in similar populations may be beneficial in improving micronutrient status and enhancing aerobic capacity and endurance in children.