Medicine Digest General
Agricultural interventions to improve diets of children in developing countries It is accepted that for agricultural inter- ventions to be fully successful in improv- ing nutrition they should be initiated with that specific aim. Interventions aimed at improving the nutrition of children may include biofortification of crops, home gardening, aquaculture, small-scale fish- eries, poultry development, animal hus- bandry, and dairy development. A sys- tematic review has included 23 studies since 1990 that reported interventions in low- or middle-income countries aimed at improving child nutrition. Overall, the studies provided insuffi- cient evidence about the effectiveness of such interventions. They provided little information about programme partici- pants or participation rates. Fifteen stud- ies were of home gardens. Most studies had methodological flaws. They provid- ed little evidence of an improvement in the diets of poor people and no evidence of increased household income. There was no evidence of increased
iron intake but some evidence of better vitamin A status. There was little evi- dence of an effect on the prevalence of undernutrition: eight studies reported undernutrition rates, one showed a significant reduction in stunting preva- lence, three showed a significant reduc- tion in the prevalence of underweight, and two showed a reduction in wast- ing. Most studies were underpowered to show an effect on undernutrition rates. Studies of interventions aimed at im-
proving child nutrition in low-or middle- income countries have been inadequate to show whether such interventions are effective.
Masset E et al. Effectiveness of agricultural interven- tions that aim to improve nutritional status of chil- dren: systematic review. BMJ 2012; 344 (11Feb): 16 (d8222); Dorward A, Dangour AD. Agriculture and health. Ibid: 8 (d7834) (editorial).
Specific exercises for subacromial impingement syndrome
Researchers in Sweden have shown that a specific exercise strategy may prove beneficial for patients with subacromial impingement syndrome. The study included 102 patients with symptoms for more than 6 months and failure to respond to standard conserva- tive treatment leading to them being put on a waiting list for surgery. Randomisa-
July 2012
tion was to an exercise strategy targeting the rotator cuff and scapula stabilisers or to control exercises, for 12 weeks. The improvement in Constant–Murley shoul- der score by 3 months was significantly greater in the specific exercise group and 69% in that group vs 24% in the control group described themselves as recov- ered or greatly improved. The proportion of patients opting for surgery was 20% (specific exercises) vs 63% (controls). The specific exercise programme gave better results and reduced the number of
operations performed. Holmgren T et al. Effect of specific exercise strategy on need for surgery in patients with subacromial im- pingement syndrome: randomised controlled study. BMJ 2012; 304 (March 3): 15 (e787).
Pasireotide for Cushing’s disease Cushing’s disease is caused by a corti- cotrophin-secreting pituitary adenoma. Transsphenoidal surgery is successful in 65–90% of patients but relapses are frequent. The options after relapse or surgical failure include further surgery, radiotherapy, bilateral adrenalectomy, and medical therapy. Somatostatin re- ceptors (mostly subtype 5) are expressed by corticotroph adenomas and activation of these receptors inhibits corticotrophin secretion. Pasireotide, a somatostatin analogue, targets somatostatin receptor subtype 5 and, to a lesser degree, three of the other four subtypes. A multination- al study of pasireotide in the treatment of Cushing’s disease has been reported. A total of 162 adults with Cushing’s
disease, either persistent or recurrent, or not suitable for pituitary surgery, were randomised to s.c. pasireotide 600μg twice daily or 900μg twice daily. At 3 months, non-responders received an ex- tra 300μg twice daily. The primary end- point (normal urinary free cortisol at 6 months without an increase in dosage) was reached by 12/82 (14.6%) in the 600μg group and 21/80 (26.3%) in the 900μg group. In both groups the median urinary free cortisol level was reduced by about 50% after 2 months and then remained stable. Patients with a baseline urinary free cortisol level more than five times the upper limit of normal were less likely to achieve a normal level. Treat- ment resulted in reductions in serum and salivary levels of cortisol and in plasma levels of corticotrophin. Adverse events related to hyperglycaemia occurred in 73% of patients and 74 patients (46%) needed glucose-lowering medication. Pasireotide shows promise as a sec- ond-line treatment for Cushing’s disease.
Colao A et al. A 12-month phase 3 study of pasire- otide in Cushing’s disease. NEJM 2012; 366: 914–24.
Tropical
Worldwide malaria mortality 1980–2010
In 2011, the secretary general of the United Nations called for the total eradi- cation of malaria by 2015. Since the turn of the century there has been a large in- crease in developmental assistance lead- ing to advances in malaria control. A sys- tematic analysis has collated all available data for malaria mortality for the period 1980–2010. The
estimated annual mortality
from malaria was 995000 (711000 to 1412000) in 1980, rising to 1817000 (143000 to 2366000) in 2004 and then falling
to 1238000 (929000 to
1685000) in 2010. The figure for Africa was 493000 in 1980, 1613000 in 2004, and 1133000 in 2010. Malaria deaths outside Africa fell from 502000 in 1980 to 104000 in 2010. Among people aged 5 years and older malaria deaths in 2010 were greater than previous estimates (435000 in Africa and 89000 elsewhere). The number of deaths from malaria in 2010 was greater than previous esti- mates, especially among older children and adults. Since 2004 malaria deaths in Africa have decreased by 30%. These in-
vestigators call for more donor support. Murray CJL et al. Global malaria mortality between 1980 and 2010: a systematic analysis. Lancet 2012; 379: 413–31; The Lancet. New estimates of malaria deaths: concern and opportunity. Ibid: 385 (editorial).
Azithromycin for yaws in children
Yaws was almost eradicated in the 1970s as a result of a global control programme but in recent years it has reappeared in children in poor rural areas of Africa, Asia, and South America. Unless treated early it can become chronic and relaps- ing causing severe bone deformities. Intramuscular benzathine benzylpenicil- lin is the standard treatment but an oral treatment would have advantages. A trial in Papua New Guinea, has suggested that oral azithromycin might be suitable. A total of 250 children aged 6 months
to 15 years were randomised to single- dose treatment with either oral azithro- mycin, 30mg/kg, or i.m. benzathine benzylpenicillin, 50000 units/kg. The 6-month cure rate was 96% (azithromy- cin) vs 93% (benzathine benzyl penicil- lin), showing non-inferiority of azithro- mycin. Drug-related adverse events were
Africa Health 55
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