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OBJECTIVE: Our objective was to analyze a prospective population-based registry including five sites in four low- and middle-income countries to observe characteristics associated with vaginal birth after cesarean versus repeat cesarean birth, as well as maternal and newborn outcomes associated with the mode of birth among women with a history of prior cesarean. HYPOTHESIS: Maternal and perinatal outcomes among vaginal birth after cesarean section will be similar to those among recurrent cesarean birth. METHODS: A prospective population-based study, including home and facility births among women enrolled from 2017 to 2020, was performed in communities in Guatemala, India (Belagavi and Nagpur), Pakistan, and Bangladesh. Women were enrolled during pregnancy, and delivery outcome data were collected within 42 days after birth. RESULTS: We analyzed 8267 women with a history of prior cesarean birth; 1389 (16.8%) experienced vaginal birth after cesarean, and 6878 (83.2%) delivered by a repeat cesarean birth. Having a repeat cesarean birth was negatively associated with a need for curettage (ARR 0.12 [0.06, 0.25]) but was positively associated with having a blood transfusion (ARR 3.74 [2.48, 5.63]). Having a repeat cesarean birth was negatively associated with stillbirth (ARR 0.24 [0.15, 0.49]) and, breast-feeding within an hour of birth (ARR 0.39 [0.30, 0.50]), but positively associated with use of antibiotics (ARR 1.51 [1.20, 1.91]). CONCLUSIONS: In select South Asian and Latin American low- and middle-income sites, women with a history of prior cesarean birth were 5 times more likely to deliver by cesarean birth in the hospital setting. Those who delivered vaginally had less complicated pregnancy and labor courses compared to those who delivered by repeat cesarean birth, but they had an increased risk of stillbirth. More large scale studies are needed in Low Income Country settings to give stronger recommendations. TRIAL REGISTRATION: NCT01073475, Registered February 21, 2010, https://clinicaltrials.gov/ct2/show/record/NCT01073475 .
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BACKGROUND: Poor growth in early childhood has been associated with increased risk of mortality and morbidity, as well as long-term deficits in cognitive development and economic productivity. OBJECTIVES: Data from the MAL-ED cohort study were used to identify factors in the first 2 y of life that are associated with height-for-age, weight-for-age, and body mass index z-scores (HAZ, WAZ, BMIZ) at 5 y of age. METHODS: A total of 1017 children were followed from near birth until 5 y of age at sites in Bangladesh, Brazil, India, Nepal, Peru, South Africa, and Tanzania. Data were collected on their growth, environmental enteric dysfunction (EED), micronutrient status, enteric pathogen burden, illness prevalence, dietary intake, and various other socio-economic and environmental factors. RESULTS: EED biomarkers were related to size at 5 y. Mean lactulose:mannitol z-scores during the first 2 y of life were negatively associated with all of the growth measures (HAZ: -0.11 [95% CI: -0.19, -0.03]; WAZ: -0.16 [95% CI: -0.26, -0.06]; BMIZ: -0.11 [95% CI: -0.23, 0.0]). Myeloperoxidase was negatively associated with weight (WAZ: -0.52 [95% CI: -0.78, -0.26] and BMIZ: -0.56 [95% CI: -0.86, -0.26]); whereas α-1-antitrypsin had a negative association with HAZ (-0.28 [95% CI: -0.52, -0.04]). Transferrin receptor was positively related to HAZ (0.18 [95% CI: 0.06, 0.30]) and WAZ (0.21 [95% CI: 0.07, 0.35]). Hemoglobin was positively related to HAZ (0.06 [95% CI: 0.00, 0.12]), and ferritin was negatively related to HAZ (-0.08 [95% CI: -0.12, -0.04]). Bacterial density in stool was negatively associated with HAZ (-0.04 [95% CI: -0.08, 0.00]), but illness symptoms did not have any effect on size at 5 y. CONCLUSIONS: EED markers, bacterial density, and iron markers are associated with growth at 5 y of age. Interventions to reduce bacterial burden and EED may improve long-term growth in low-income settings.
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Tamaño Corporal/fisiología , Trastornos del Crecimiento/epidemiología , Enfermedades Intestinales/fisiopatología , Bangladesh/epidemiología , Biomarcadores/orina , Estatura , Índice de Masa Corporal , Peso Corporal , Brasil/epidemiología , Preescolar , Estudios de Cohortes , Heces/química , Heces/microbiología , Femenino , Estudios de Seguimiento , Humanos , India/epidemiología , Lactante , Recién Nacido , Enfermedades Intestinales/microbiología , Lactulosa/orina , Masculino , Manitol/orina , Micronutrientes/sangre , Nepal/epidemiología , Perú/epidemiología , Sudáfrica/epidemiología , Tanzanía/epidemiologíaRESUMEN
Background: Cryptosporidium species are enteric protozoa that cause significant morbidity and mortality in children worldwide. We characterized the epidemiology of Cryptosporidium in children from 8 resource-limited sites in Africa, Asia, and South America. Methods: Children were enrolled within 17 days of birth and followed twice weekly for 24 months. Diarrheal and monthly surveillance stool samples were tested for Cryptosporidium by enzyme-linked immunosorbent assay. Socioeconomic data were collected by survey, and anthropometry was measured monthly. Results: Sixty-five percent (962/1486) of children had a Cryptosporidium infection and 54% (802/1486) had at least 1 Cryptosporidium-associated diarrheal episode. Cryptosporidium diarrhea was more likely to be associated with dehydration (16.5% vs 8.3%, P < .01). Rates of Cryptosporidium diarrhea were highest in the Peru (10.9%) and Pakistan (9.2%) sites. In multivariable regression analysis, overcrowding at home was a significant risk factor for infection in the Bangladesh site (odds ratio, 2.3 [95% confidence interval {CI}, 1.2-4.6]). Multiple linear regression demonstrated a decreased length-for-age z score at 24 months in Cryptosporidium-positive children in the India (ß = -.26 [95% CI, -.51 to -.01]) and Bangladesh (ß = -.20 [95% CI, -.44 to .05]) sites. Conclusions: This multicountry cohort study confirmed the association of Cryptosporidium infection with stunting in 2 South Asian sites, highlighting the significance of cryptosporidiosis as a risk factor for poor growth. We observed that the rate, age of onset, and number of repeat infections varied per site; future interventions should be targeted per region to maximize success.
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Criptosporidiosis/epidemiología , Diarrea/epidemiología , Áreas de Pobreza , África/epidemiología , Asia/epidemiología , Preescolar , Estudios de Cohortes , Aglomeración , Cryptosporidium/aislamiento & purificación , Diarrea/parasitología , Heces/parasitología , Femenino , Trastornos del Crecimiento/parasitología , Humanos , Lactante , Recién Nacido , Masculino , Desnutrición/parasitología , Análisis de Regresión , Factores de Riesgo , Factores Socioeconómicos , América del Sur/epidemiología , Encuestas y CuestionariosRESUMEN
Critical to the design and assessment of interventions for enteropathy and its developmental consequences in children living in impoverished conditions are non-invasive biomarkers that can detect intestinal damage and predict its effects on growth and development. We therefore assessed fecal, urinary and systemic biomarkers of enteropathy and growth predictors in 375 6-26 month-old children with varying degrees of malnutrition (stunting or wasting) in Northeast Brazil. 301 of these children returned for followup anthropometry after 2-6m. Biomarkers that correlated with stunting included plasma IgA anti-LPS and anti-FliC, zonulin (if >12m old), and intestinal FABP (I-FABP, suggesting prior barrier disruption); and with citrulline, tryptophan and with lower serum amyloid A (SAA) (suggesting impaired defenses). In contrast, subsequent growth was predicted in those with higher fecal MPO or A1AT and also by higher L/M, plasma LPS, I-FABP and SAA (showing intestinal barrier disruption and inflammation). Better growth was predicted in girls with higher plasma citrulline and in boys with higher plasma tryptophan. Interactions were also seen with fecal MPO and neopterin in predicting subsequent growth impairment. Biomarkers clustered into markers of 1) functional intestinal barrier disruption and translocation, 2) structural intestinal barrier disruption and inflammation and 3) systemic inflammation. Principle components pathway analyses also showed that L/M with %L, I-FABP and MPO associate with impaired growth, while also (like MPO) associating with a systemic inflammation cluster of kynurenine, LBP, sCD14, SAA and K/T. Systemic evidence of LPS translocation associated with stunting, while markers of barrier disruption or repair (A1AT and Reg1 with low zonulin) associated with fecal MPO and neopterin. We conclude that key noninvasive biomarkers of intestinal barrier disruption, LPS translocation and of intestinal and systemic inflammation can help elucidate how we recognize, understand, and assess effective interventions for enteropathy and its growth and developmental consequences in children in impoverished settings.
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Individuals in the developing world live in conditions of intense exposure to enteric pathogens due to suboptimal water and sanitation. These environmental conditions lead to alterations in intestinal structure, function, and local and systemic immune activation that are collectively referred to as environmental enteropathy (EE). This condition, although poorly defined, is likely to be exacerbated by undernutrition as well as being responsible for permanent growth deficits acquired in early childhood, vaccine failure, and loss of human potential. This article addresses the underlying theoretical and analytical frameworks informing the methodology proposed by the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) cohort study to define and quantify the burden of disease caused by EE within a multisite cohort. Additionally, we will discuss efforts to improve, standardize, and harmonize laboratory practices within the MAL-ED Network. These efforts will address current limitations in the understanding of EE and its burden on children in the developing world.
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Enfermedades Transmisibles , Medicina Ambiental , Diseño de Investigaciones Epidemiológicas , Enfermedades Intestinales , Desnutrición , Preescolar , Costo de Enfermedad , Humanos , Lactante , Recién Nacido , Estudios LongitudinalesRESUMEN
Haitian children were monitored longitudinally in a filariasis study. Included were stool samples examined for Giardia intestinalis and Entamoeba histolytica cysts, and serum specimens analyzed for immunoglobulin G (IgG) responses to eight recombinant antigens from G. intestinalis (variant-specific surface protein [VSP1-VSP5]), E. histolytica (lectin adhesion molecule [LecA]), and Cryptosporidium parvum (17- and 27-kDa) using a multiplex bead assay. The IgG responses to VSP antigens peaked at 2 years of age and then diminished and were significantly lower (P < 0.002) in children > 4.5 years than in children < 4.5 years. The IgG responses to Cryptosporidium tended to increase with age. The IgG responses to LecA and VSP antigens and the prevalence of stools positive for cysts were significantly higher (P < 0.037 and P < 0.035, respectively) in the rainy season than in the dry season. The multiplex bead assay provides a powerful tool for analyzing serologic responses to multiple pathogens.
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Anticuerpos Antiprotozoarios/inmunología , Cryptosporidium parvum/inmunología , Entamoeba histolytica/inmunología , Heces/parasitología , Giardia lamblia/inmunología , Inmunoglobulina G/inmunología , Infecciones por Protozoos/epidemiología , Niño , Preescolar , Criptosporidiosis/epidemiología , Entamoeba histolytica/aislamiento & purificación , Entamebiasis/epidemiología , Giardia lamblia/aislamiento & purificación , Giardiasis/epidemiología , Haití/epidemiología , Humanos , Lactante , Recién Nacido , Estudios Longitudinales , Recuento de Huevos de Parásitos , Pruebas SerológicasRESUMEN
BACKGROUND: Undernutrition remains a significant problem worldwide, with environmental enteropathy implicated as a contributing factor. An understanding of the pathogenesis and identification of children at risk are critical to the design of more-effective interventions. OBJECTIVE: The stool regenerating gene 1ß (REG1B) protein, which is a putative measure of intestinal injury and repair, was tested as a noninvasive biomarker of future childhood stunting. DESIGN: A total of 222 children from Bangladesh and 97 children from Peru, who were from impoverished communities, were followed from birth through 24 mo of age with anthropometric measures obtained every 3 mo. Stool REG1B protein concentrations were obtained by using an REG1B polyclonal-polyclonal ELISA at 3 mo of age. We tested for the ability of REG1B to forecast future anthropometric shortfalls, independent of known predictors of undernutrition of family income and baseline height and weight. RESULTS: In the Bangladesh cohort of 222 children, higher REG1B concentrations at month 3 were significantly and independently associated with a growth shortfall in a linear regression analysis at months 9, 12, 18, 21, and 24 and, in the Peru cohort, at months 12, 15, 18, 21, and 24. With the use of a mixed model for repeated measurements, higher stool REG1B concentrations at 3 mo were also independently predictive of a lower future length-for-age z score through 24 mo of age (Bangladesh P = 0.006; Peru P = 0.058). CONCLUSION: The ability of fecal REG1B to predict growth shortfall in independent cohorts of impoverished children from the developing world offers promise as a malnutrition biomarker and supports a role for environmental enteropathy in the pathogenesis of growth shortfall.
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Trastornos del Crecimiento/epidemiología , Trastornos del Crecimiento/genética , Litostatina/genética , Desnutrición/epidemiología , Bangladesh/epidemiología , Estatura , Peso Corporal , Preescolar , Estudios de Cohortes , Ensayo de Inmunoadsorción Enzimática , Femenino , Trastornos del Crecimiento/etiología , Humanos , Modelos Lineales , Litostatina/metabolismo , Masculino , Desnutrición/complicaciones , Estado Nutricional , Perú/epidemiología , Prevalencia , ARN Mensajero/genética , ARN Mensajero/metabolismo , Factores de Riesgo , Factores SocioeconómicosRESUMEN
We tested a prototype stool enzyme-linked immunosorbent assay (ELISA) (TRI-COMBO) that is simultaneously diagnostic for Giardia lamblia, Cryptosporidium parvum, and Entamoeba histolytica in a rural pediatric clinic in Guatemala. We compared its results to those of three individual ELISAs for these parasites, assessed the prevalence of these parasites, and compared our findings to those found by stool microscopy. We tested 620 non-diarrheal stools. The TRI-COMBO diagnosed 57 positive samples and 52 (91%) had a correlating positive result in an individual assay, giving a kappa coefficient of 0.90. Giardia spp., E. histolytica, and Cryptosporidium spp. were detected in 52 (8.4%), 2 (0.3%), and 3 (0.5%) samples, respectively. Twenty-three (40%) samples positive by ELISA for Giardia spp. were identified by microscopy. This study is the first to test the TRI-COMBO in this setting and, to our knowledge, represents the first assessment of these parasites in Guatemala by stool ELISA.
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Criptosporidiosis/diagnóstico , Entamebiasis/diagnóstico , Ensayo de Inmunoadsorción Enzimática/métodos , Giardiasis/diagnóstico , Criptosporidiosis/complicaciones , Entamebiasis/complicaciones , Giardiasis/complicaciones , Guatemala , HumanosRESUMEN
The Gal/GalNAc lectin of Entamoeba histolytica trophozoites plays an important role in adhesion. The distribution and final destiny of the lectin during the interaction with host cells are poorly understood. Using monoclonal and polyclonal antibodies against the lectin we studied by immunocytochemistry the in vitro and in vivo interaction of E. histolytica trophozoites with human and hamster hepatocytes. We also analyzed the presence and distribution of the lectin in a mouse model of intestinal amoebiasis. In all cases, trophozoites were highly labeled by anti-lectin antibodies. Cultured human and hamster hepatocytes in contact with, or localized at the vicinity of parasites were also labeled by anti-lectin antibodies. Most of the labeled hepatocytes showed variable degrees of cell damage. Hepatocytes distantly localized from the parasites were also stained with the anti-lectin antibodies. Immunolabeling of tissue sections from different stages of the development of experimental amoebic liver abscess in hamsters showed inflammatory foci containing lectin-labeled trophozoites, hepatocytes, and sinusoidal and inflammatory cells. Lectin-containing hepatocytes had vacuolated cytoplasm with some nuclei with a condensed appearance. Damaged intestinal epithelium also was labeled with anti-lectin antibodies in a mouse model of intestinal amoebiasis. Electron microscopy of axenically cultured trophozoites using gold-labeled monoclonal and polyclonal anti-lectin antibody showed that plasma membrane, vacuole membranes and areas of cell cytosol were labeled. Higher deposits of gold particles in plasma membrane suggestive of cell secretion were observed. Our results demonstrated that Gal/GalNAc lectin was bound and captured by different target cells, and that host cells containing the lectin showed signs of cell damage. The contribution of lectin transfer to host cells in adherence and cell injury remains to be determined.