text:
The American Journal of Tropical Medicine and Hygiene
Study setting.
Study design and participants.
Study instruments and data collection.
Laboratory procedures and definition of variables.
Determination of aflatoxin B1- lysine adducts.
Statistical analysis.
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PhiriKSCalisJCSiyasiyaABatesIBrabinBvan HensbroekBM, 2009. New cut-off values for ferritin and soluble transferrin receptor for the assessment of iron deficiency in children in a high infection pressure area. J Clin Pathol 62: 1103–1106.)| false
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The Organization of the Viscerotome Service of the Brazilian Cooperative Yellow Fever Service
E. R. Rickard
Effects of Protective Immune Serum on the Yields of Parasites and Pulmonary Cell Reactions in Schistosome-Infected Rats
Robin Oshman
Paul M. Knopf
Franz von Lichtenberg
James E. Byram
Transactions of the American Society of Tropical Medicine, Thirty-First Annual Meeting
Die Lepra der oberen Luftwege und des Ohres in Palëstina und Cypern. Leprosy of the Upper Respiratory Tract and of the Ear in Palestine and Cyprus.)
By M. Salszerger. Urban & Schwarzenberg, Berlin. 1929
E. B. Vedder
The Internal Parasites of Domestic Animals. A Manual for Veterinary Surgeons
By Thomas W. M. Cameron. Pp. 292, 144 illustrations. 1934. London
Ernest Carroll Faust
Association between Anemia and Aflatoxin B1 Biomarker Levels among Pregnant Women in Kumasi, Ghana
Faisal M. B. Shuaib
Faisal M. B. ShuaibDepartment of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Division of Health Promotion Sciences Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona; Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, Department of Microbiology, Biochemistry and Immunology, Morehouse School of Medicine, Atlanta, Georgia; College of Agricultural and Environmental Services, University of Georgia, Griffin, Georgia
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Pauline E. Jolly
Pauline E. JollyDepartment of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Division of Health Promotion Sciences Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona; Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, Department of Microbiology, Biochemistry and Immunology, Morehouse School of Medicine, Atlanta, Georgia; College of Agricultural and Environmental Services, University of Georgia, Griffin, Georgia
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John E. Ehiri
John E. EhiriDepartment of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Division of Health Promotion Sciences Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona; Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, Department of Microbiology, Biochemistry and Immunology, Morehouse School of Medicine, Atlanta, Georgia; College of Agricultural and Environmental Services, University of Georgia, Griffin, Georgia
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Yi Jiang
Yi JiangDepartment of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Division of Health Promotion Sciences Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona; Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, Department of Microbiology, Biochemistry and Immunology, Morehouse School of Medicine, Atlanta, Georgia; College of Agricultural and Environmental Services, University of Georgia, Griffin, Georgia
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William O. Ellis
William O. EllisDepartment of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Division of Health Promotion Sciences Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona; Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, Department of Microbiology, Biochemistry and Immunology, Morehouse School of Medicine, Atlanta, Georgia; College of Agricultural and Environmental Services, University of Georgia, Griffin, Georgia
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Jonathan K. Stiles
Jonathan K. StilesDepartment of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Division of Health Promotion Sciences Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona; Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, Department of Microbiology, Biochemistry and Immunology, Morehouse School of Medicine, Atlanta, Georgia; College of Agricultural and Environmental Services, University of Georgia, Griffin, Georgia
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Nelly J. Yatich
Nelly J. YatichDepartment of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Division of Health Promotion Sciences Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona; Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, Department of Microbiology, Biochemistry and Immunology, Morehouse School of Medicine, Atlanta, Georgia; College of Agricultural and Environmental Services, University of Georgia, Griffin, Georgia
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Ellen Funkhouser
Ellen FunkhouserDepartment of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Division of Health Promotion Sciences Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona; Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, Department of Microbiology, Biochemistry and Immunology, Morehouse School of Medicine, Atlanta, Georgia; College of Agricultural and Environmental Services, University of Georgia, Griffin, Georgia
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Sharina D. Person
Sharina D. PersonDepartment of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Division of Health Promotion Sciences Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona; Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, Department of Microbiology, Biochemistry and Immunology, Morehouse School of Medicine, Atlanta, Georgia; College of Agricultural and Environmental Services, University of Georgia, Griffin, Georgia
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Craig Wilson
Craig WilsonDepartment of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Division of Health Promotion Sciences Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona; Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, Department of Microbiology, Biochemistry and Immunology, Morehouse School of Medicine, Atlanta, Georgia; College of Agricultural and Environmental Services, University of Georgia, Griffin, Georgia
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Jonathan H. Williams
Jonathan H. WilliamsDepartment of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Division of Health Promotion Sciences Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona; Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, Department of Microbiology, Biochemistry and Immunology, Morehouse School of Medicine, Atlanta, Georgia; College of Agricultural and Environmental Services, University of Georgia, Griffin, Georgia
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https://doi.org/10.4269/ajtmh.2010.09-0772
Aflatoxins are fungal metabolites that contaminate staple food crops in many developing countries. Up to 40% of women attending a prenatal clinic in Africa may be anemic. In a cross-sectional study of 755 pregnant women, Aflatoxin B1-lysine adducts (AF-ALB) levels were determined by high-performance liquid chromatography. Participants were divided into quartiles "low," "moderate," "high," and "very high." Anemia was defined as hemoglobin levels < 11 g/dL. Logistic regression was used to examine the association of anemia with AF-ALB. The mean AF-ALB level was 10.9 pg/mg (range = 0.44–268.73 pg/mg); 30.3% of participants were anemic. The odds of being anemic increased 21% (odds ratio [OR], 1.21, P = 0.01) with each quartile of AF-ALB reaching an 85% increased odds in the "very high" compared with the "low" category (OR, 1.85; confidence interval [CI], 1.16–2.95). This association was stronger among women with malaria and findings were robust when women with evidence of iron deficiency anemia were excluded. This study found a strong, consistent association between anemia in pregnancy and aflatoxins.
Figures jointly released by the United Nations Population Fund (UNFPA), World Health Organization (WHO), United Nations Children's Fund (UNICEF), and the World Bank show that a woman dies every minute from pregnancy or childbirth.1 More than 99% of these deaths are in developing countries, particularly sub-Saharan Africa where there is a 1 in 13 chance of a woman dying during childbirth compared with 1 in 4,100 in industrialized countries.1 The Millennium Development goal #5 is to reduce the maternal mortality ratio by 75% between 1990 and 2015,2 but there has been less than a 1% decline in global maternal mortality in the last decade. Indeed, the World Bank estimates that only one developing region (Middle East and North Africa) is likely to achieve this target.2
Anemia afflicts about two billion people worldwide.3 It is a clinical condition characterized by reduced ability of the red blood cells (RBCs) to carry oxygen to body tissues, usually as a result of their decreased hemoglobin content. The World Health Organization (WHO) defines anemia as a hemoglobin level of < 11 g/dL during the first and third trimester, whereas the cutoff is 10.5 g/dL in the second trimester.4
Anemia in pregnancy is one of the leading causes of maternal mortality. An estimated 40% of all maternal deaths at childbirth are linked to anemia. Although anemia is a global health problem, it occurs more frequently among children and pregnant women in developing countries.5 Only 23% of pregnant women in industrialized countries are anemic compared with 52% of their counterparts in less developed countries. Up to 18% of women in developed countries and 43% of those in developing countries are already anemic at the time of conception.6 Anemia in pregnancy is ranked among the top four causes of morbidity and mortality among pregnant women in Africa and is the second leading cause in Asia.7 About 40% of women attending prenatal clinics in Africa suffer from anemia at different stages of pregnancy.8 Sixty-two reports compiled by WHO on the proportion of maternal deaths associated with anemia indicate that in 74% of these reports, anemia was a contributory factor to the documented maternal mortality.9 Although these figures underscore the magnitude of the burden of anemia in pregnancy, they are only the tip of the iceberg in many developing countries where women do not obtain adequate prenatal care. Indeed, the WHO estimates that about 55% of women have antenatal care and 60% of all deliveries in developing countries occur outside of a health facility.10 Consequently, many women who die during pregnancy or delivery from causes related to anemia die at home and are thus not reported.
Although iron deficiency anemia (IDA) is the most common cause of anemia in pregnant women, there are many other causes including nutritional causes such as folate, vitamin B12, and vitamin A deficiencies, infective causes such as malaria, and intestinal helminth infections, ineffective erythropoiesis, severe hemorrhage, hemoglobinopathies, chronic diseases, G6PD deficiency, and hemolytic anemia from drugs or toxins.8,11–13 Consequently, any assessment of the cause of anemia must put these into consideration to delineate cause-specific etiology. Besides, programs to prevent maternal anemia are more likely to be effective when they identify and address the multiple causes of anemia through multi-disciplinary and integrated interventions.
Contamination of foodstuff and animal feeds by aflatoxin producing molds is a recurrent public health problem. Globally, about 4.5 billion people are at risk of chronic exposure to aflatoxins.14 Aflatoxins are toxic metabolites of the fungi Aspergillus flavus and Aspergillus parasiticus. They are classified on the basis of immune-fluorescent properties; B1, B2, G1, and G2. Aflatoxin B1 (AFB1) is the most potent and carcinogenic of all aflatoxin sub-types.15,16 Staple foods such as cereals, groundnuts, and other oil seeds are most prone to aflatoxin contamination.17,18 Aflatoxin contamination is influenced by high humidity, high temperatures, insect and rodent activity, and inadequate drying of the crops. Contamination occurs frequently in countries of Africa and Asia. This contamination can occur at any stage of food production from pre-harvest to storage.19 Measurements of aflatoxin levels in food crops have been conducted in some West African countries such as Ghana where eight samples of maize from 15 (53%) processing sites revealed contamination with fumonisins and aflatoxins.19,20 One study, which collected samples from major processing sites in Accra, Ghana, reported aflatoxin levels that ranged from 2–662 µg/kg.20 The latter quantities far exceed the United States Department of Agriculture's (USDA) regulatory limit of 20 ppb.21 When these aflatoxins are ingested, AFB1 binds to albumin to form AFB1-lysine adducts (AL-ALB), which persist for up to 2–3 months or longer in the blood and can be detected.22 Aflatoxins have been implicated in the pathogenesis of conditions such as primary liver cell carcinoma, malnutrition, immunosuppresion, and growth retardation.17
Aflatoxins have been associated with hemolytic anemia in mammals.23 Studies with these mammals (cattle, guinea pigs, and rabbits) have shown that aflatoxins cause hemolysis of RBCs and may interact with RNA and DNA to cause a depression of hemopoiesis in primates.24 Although this has not been documented to occur in humans, it is not unreasonable that aflatoxins may cause a similar effect in humans. The objective of this study is to examine the association between anemia and AF-ALB levels in the blood of pregnant women in Kumasi, Ghana. We hypothesized that higher AF-ALB levels in the pregnant women would be associated with anemia as observed experimentally in other primates.
The study was conducted in the Kumasi region of Ghana, West Africa, which has a population of ~1.2 million25; Kumasi is the second largest city in Ghana. The climate is hot and humid with two rainy seasons occurring from April to June and from September to October.26 The climate and poor pre- and post-harvest handling of crops contributes to fungal growth and aflatoxin contamination of staple crops such as maize, corn, and groundnuts.21,27 In Ghana, up to 44% of women still deliver at home.28 However, because Kumasi is relatively urban, many more women in this city tend to use hospitals for delivery services.
This was a cross-sectional study of women presenting for delivery at two hospitals in Kumasi, the Komfo Anokye Teaching Hospital (KATH) and the Manhyia Polyclinic, between November and December 2006. As described in an earlier report,12 all women who had a singleton, uncomplicated pregnancy were identified from admission records and invited to participate. Women who had a multiple or complicated pregnancy, who were positive for syphilis, who had hemoglobinopathy, or infections known to affect maternal health or birth outcome were excluded from the study. Informed consent was obtained from participants. Participation in the study was voluntary and no incentives were provided. All 785 women who were eligible for the study participated; adequate blood and stool samples for laboratory tests could only be obtained for 755. The Institutional Review Board of the University of Alabama at Birmingham and the Committee on Human Research, Publications and Ethics, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, reviewed and approved the study protocol before its implementation.
After informed consent was obtained, questionnaires were administered by two trained interviewers and the principal investigator. The questionnaire elicited information on demographic characteristics (age, education, annual income, employment status, residence, number of children, and type of toilet facilities), obstetric history for current and previous pregnancies (stillbirth, ectopic pregnancy, preterm delivery, and low birth weight), illnesses, and treatments during the current pregnancy. Items of the study instrument were derived from a model questionnaire recommended for use by Roll Back Malaria Monitoring and Evaluation Reference group (malaria indicator survey, women's questionnaire).29 Obstetric information was obtained from the women's antenatal care (ANC) charts, which were well kept in both institutions. The ANC charts provided information on gestational age at first ANC visit, number of antenatal care visits, gestational age as assessed by palpation or ultrasound at first ANC visit, tetanus immunization, hematinics, antihelminthic medication, illnesses, and treatment during pregnancy. The principal investigator of the project closely supervised the data collection process and provided immediate data auditing feedbacks. Data entry involved double data entry and measures of agreement such as coefficient of variation and regression plots were used to verify integrity of data being collected. Laboratory technicians from KATH collected a single blood sample in EDTA by venepuncture for determination of complete blood count (CBC) and differentials, RBC indices, hemoglobin, malaria antigen, folate, and AF-ALB levels. Stool samples were obtained for determination of intestinal helminths.
Serum AFB1-lysine adduct, the major form of AFB1-albumin adducts and reflecting AF exposure in the previous 2–3 months, was measured by a modified high-performance liquid chromatography (HPLC)-fluorescence method.30 In brief, 150 μL serum samples were digested by Pronase and loaded onto an Oasis Max cartridge from Waters Co. (Milford, MA). The cartridge was sequentially washed and eluted with 2% formic acid in methanol. The eluents were evaporated to dryness and reconstituted with 150 μL 10% methanol before injected to HPLC.
The HPLC analysis was carried out on an 1100 liquid chromatography system (Agilent Technologies, Wilmington, DE). Chromatographic separation was performed on an Agilent C18 column (5-μm particle size, 250 × 4.6 mm). The mobile phase consisted of 20 mM ammonium phosphate monobasic (pH 7.2) and methanol in a linear gradient profile. The concentration of AFB1-lysine adducts was monitored at wavelengths of 405 nm (excitation) and 470 nm (emission). The peak of authentic AFB1-Lysine adduct standard or samples was co-eluted with the retention time around 12.7 min. The detection limit of this method is 0.5 pg/mL. The results of AFB1-lysine adducts concentration was adjusted by serum albumin level.
Malaria, intestinal worm infection, and folate deficiency have been associated with anemia; hence, these conditions were also evaluated. Determination of malaria antigen in plasma was done using the Malaria Antigen CELISA (Cellabs, Sydney, Australia) assay with sensitivity and specificity of 98% and 96%, respectively.31 Malaria status was described as the presence or absence of malaria antigens in peripheral blood at delivery. Intestinal worm infection connotes the presence of helminths (Hookworm, Ascaris lumbricoides, Strongyloides stercoralis, and Trichuris trichura) eggs or larvae (S. stercoralis) in stool samples obtained from the participants. These intestinal helminths are known to cause anemia. Determination of hookworm, A. lumbricoides and T. trichura ova in stool samples was done using the Kato-Katz thick smear technique.32 Samples for detection of S. stercoralis were processed using the Baermann method.33 Hemoglobin level was measured in an automatic cell counter (Sysmex M-2000; Digitana AG, Hamburg, Germany). Anemia was defined as hemoglobin level < 11 g/dL.3 Serum folate concentrations were measured by radioimmunoassay Quantaphase II (Bio-Rad, Hercules, CA). The reference interval for folate in women is 3.9–18.1 ng/mL.34 Folate deficiency was based on serum levels of < 3.9 ng/mL.
Because we were interested in examining hemolytic anemia, possibly caused by aflatoxins, we attempted to separate participants with IDA from those with hemolytic anemia using measures of hemoglobin in RBCs. In the absence of plasma iron measurements, these measures were used as surrogates of IDA. Moreover, Phiri and others35 have shown that measures such as the mean corpuscular hemoglobin concentration (MCHC) are valid measures for assessing iron deficiency. These tests were conducted by the KATH hospital laboratory. They included the following: mean corpuscular volume (MCV) with a reference range of 80–96 fL, MCHC with reference range 32–36 g/dL, and mean corpuscular hemoglobin (MCH) with reference range of 27 to 33 pg.36 On the basis of laboratory results, participants were classified as having IDA if they had any one of the MCV, MCH, or MCHC indices below the reference range. In hemolytic anemia and anemia of other origins, MCV, MCH, and MCHC indices are either unchanged or increased above the upper limit of normal.
Data analysis was performed using SAS software version 9.1 (SAS Institute, Cary, NC). Analysis was restricted to the 755 women from whom adequate samples were obtained. Multiple logistic regression analysis was used to investigate the association between anemia (based on hemoglobin levels), the dependent variable, and AF-ALB levels, the independent variable of primary interest. Participants were divided into quartiles on the basis of the distribution of AF-ALB in blood ("low": ≤ 2.67 pg/mg, "moderate": > 2.67 to ≤ 4.97 pg/mg, "high": > 4.97 to ≤ 11.34 pg/mg, and "very high": > 11.34 pg/mg). Variables that were statistically significant at P < 0.05 on bivariate analysis and those known to be associated with anemia based on extant literature were incorporated into models using the backward stepwise technique.37 We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for each variable entered into the model.
Strata-specific analyses were conducted to assess differences in the association between anemia and AF-ALB levels according to presence of malaria parasitemia, intestinal helminth infections, and folate deficiency. In addition, to minimize the confounding effect of IDA on the relationship between anemia and AF-ALB, all analyses were repeated excluding the participants with laboratory test results suggestive of IDA.
The modal age group was the "30 years and older" age category and modal education level was junior high school education. Table 1 displays other socio-demographic characteristics of all the participants, and according to whether the woman presented with anemia. The AF-ALB was detected in the blood of all pregnant women in the study. The mean AF-ALB level in maternal serum was 10.9 pg/mg (range = 0.44–268.73 pg/mg).The mean hemoglobin level was 11.7 g/dL ± 1.97 (range: 3.4–17.3 g/dL); 30.3% (N = 229) of participants were anemic based on hemoglobin levels < 11 g/dL. The higher the AF-ALB level (quartile), the higher the percent of women with anemia (24.7% to 37.4%, trend P = 0.006). As seen in Table 2, both the crude and adjusted associations of AF-ALB with anemia status indicate that a linear trend is present. Furthermore, there appeared to be a stronger association between anemia and aflatoxin in the absence of iron deficiency: OR and 95% CI in the absence of IDA is 2.02 (1.19–3.41), whereas it is 0.95 (0.34–2.64) in the presence of IDA (not shown in Table 2).
Demographic characteristics of 755 pregnant Ghanaian women by anemia status
Anemia YES* no. %
Anemia NO no. %
Total no. %
Age group in years 0.17
< 20 39 17.0 64 12.4 103 13.8
20–24 60 26.2 127 24.6 187 25.1
≥ 30 63 32.1 178 34.4 241 32.3
Formal education 0.32
None 66 26.3 109 21.3 169 22.8
Primary or middle school 61 26.8 147 28.7 208 28.1
Junior high school 78 34.2 172 33.5 250 33.7
≥ Senior high school 29 12.7 85 16.6 114 15.4
Weekly income (Ghana cedis) 0.29
< 10 63 27.9 141 27.5 204 27.6
10–19.9 13 5.8 42 8.2 55 7.4
20–35.4 96 42.5 187 36.5 283 38.3
≥ 35.5 54 23.9 143 27.9 197 26.7
Employment 0.29
Unemployed 70 30.7 154 30.0 224 30.2
Self-used 139 60.9 332 64.6 471 63.5
Used† 19 8.3 28 5.5 47 6.3
Single 57 25.0 101 19.7 158 21.3 0.08
Living in union 49 21.5 93 18.1 142 19.2
Married 122 53.5 319 62.2 441 59.5
No. of children 0.43
0 91 41.0 174 34.8 265 36.7
2 34 15.3 90 18.0 124 17.2
3 10 4.5 22 4.4 32 4.4
Ethnicity 0.06
Akan 146 63.8 365 70.6 511 68.5
Others 83 36.2 152 29.4 235 31.5
* Anemia defined as hemoglobin < 11.0 g/dL.
† Public service employee.
Numbers may not add up to 755 because of missing values.
Odds ratios (OR) and 95% confidence intervals (CI) for the association between anemia and aflatoxin B1 albumin adduct levels in maternal blood among pregnant women in Kumasi, Ghana
All 755 women
Women without laboratory diagnosis of iron deficiency anemia (N = 580)*
Maternal aflatoxin B1-albumin adduct level (quartiles)†
Crude OR
Adjusted OR‡
Low* (≤ 2.67 pg/mg) Ref Ref Ref Ref
Moderate (> 2.67 to ≤ 4.97 pg/mg) 1.2 (0.76–1.91) 1.34 (0.83–2.16) 1.52 (0.90–2.57) 1.68 (0.90–2.59)
High (≥ 4.97 to ≤ 11.34 pg/mg) 1.4 (0.92–2.28) 1.56 (0.98–2.50) 1.29 (0.75–2.22) 1.57 (0.74–2.26)
Very High (> 11.34 pg/mg) 1.82 (1.17–2.84) 1.85 (1.16–2.95) 2.06 (1.23–3.44) 2.02 (1.19–3.41)
* Laboratory diagnosis of iron deficiency anemia based on participants with values below the reference ranges for any one of the following: MCV (mean corpuscular volume), MCHC (mean corpuscular hemoglobin concentration), or MCH (mean corpuscular hemoglobin). There were 175 participants with this laboratory diagnosis.
† Alflatoxin levels categorized into quartiles.
‡ Odds ratio adjusted for age, educational level, income, marital status, and ethnicity.
Ref = reference group.
When aflatoxins were assessed as ordinal variables in the logistic model, the odds of anemia increased 21% (OR, 1.21; 95% CI, 1.04–1.39; P = 0.01) with each quartile of AL-ALB.
The mean serum folate concentration was 7.36 ± 4.69 ng/mL.About 30% of participants had a blood folate level below the reference range of 3.9–18.1 ng/mL; however, almost all participants (~97%) were on daily hematinics containing iron (30 mg) and folate (800 mcg).
A total of 175 (23.2%) participants were categorized as having laboratory evidence of IDA. A dose-response relationship between quartile of AF-ALB and increased odds of anemia remains after exclusion of these 175 participants (Table 2). The malaria antigen test revealed that 17% of participants were positive for malaria, although these women had no symptoms of malaria infection. About 23% of participants were infected with at least one of the helminth parasites known to contribute to anemia. This included 7.9% who had hookworm, 12.3% who had A. lumbricoides, 5.8% who had T. trichura, and 3.7% who had S. stercoralis infection.
Table 3 presents stratification of all 580 women without laboratory diagnosis of IDA, by presence or absence of malaria parasitemia, intestinal helmith infection, and serum folate status. A much stronger association of very high levels of AF-ALB with anemia is indicated among women with malaria; however, these strata-specific estimates are imprecise because of small numbers. Similar results were obtained when all 755 women were stratified by presence or absence of malaria parasitemia, intestinal infection, and serum folate status.
Adjusted odds ratios (OR) with 95% confidence intervals (CI) for anemia and maternal aflatoxin levels stratified by malaria infection, helminth infection, and folate deficiency status among 580 pregnant women without laboratory evidence of iron deficiency anemia,* in Kumasi, Ghana
Helminthic infection‡
Yes (N = 89)§
No (N = 488)
Yes (N = 144)
OR (95% CI)¶
OR (95% CI)
Low (≤ 2.67 pg/mg) Ref Ref Ref Ref Ref Ref
Moderate (> 2.67 to ≤ 4.97 pg/mg) 0.62 (0.13–2.94) 1.90 (1.05–3.44) 1.37 (0.44–4.29) 1.54 (0.84–2.83) 0.93 (0.39–2.23) 2.12 (1.07–0.42)
High (≥ 4.97 to ≤ 11.34 pg/mg) 0.49 (0.10–2.37) 1.43 (0.77–2.66) 2.02 (0.65–6.29) 1.06 (0.55–2.05) 2.41 (1.07–5.44) 0.63 (0.26–1.54)
Very High (> 11.34 pg/mg) 4.48 (0.87–23.18) 1.91 (1.06–3.45) 1.84 (0.61–5.5) 2.06 (1.13–3.78) 2.23 (0.99–5.06) 1.94 (0.97–3.90)
* Laboratory diagnosis of iron deficiency anemia based on participants with values below the reference ranges for any one of the following: MCV (mean corpuscular volume), MCHC (mean corpuscular hemoglobin concentration), or MCH (mean corpuscular hemoglobin).
‡ Helminths investigated were Hookworm, Ascaris lumbricoides, Strongyloides stercoralis, and Trichuris trichura.
§ Numbers may not add up to 580 because of missing values.
¶ All odds ratios adjusted for age, educational level, income, marital status, and ethnicity.
The study investigated the association between anemia and aflatoxin B1-lysine adduct levels among pregnant women attending an antenatal clinic in two hospitals in Kumasi, Ghana.
Our findings suggest that the prevalence of anemia among these pregnant women is associated with the AF-ALB levels in their blood.
Aflatoxins should normally not be found in human blood. Our finding that all the participants studied had AF-ALB indicates how widespread aflatoxins are in the population. This finding is similar to that of a study conducted by Jolly and others22 who found aflatoxins in the blood of all non-pregnant subjects evaluated in the Ejura Sekyedumase district of Ghana. These results indicate the constancy with which populations from different regions are exposed to aflatoxins in their food.
About 31% of participants had hemoglobin levels < 11 g/dL.This proportion is comparable to the figures reported by Engmann and colleagues38 who found that 34% of pregnant women were anemic in a study conducted in Accra, Ghana.
The finding of increased odds of anemia with increasing levels of AF-ALB levels in blood is novel. To the best of our knowledge, there has been no study in humans that shows this association. Studies conducted to investigate this association have used guinea pigs, rabbits, and cattle.15,39 The mechanisms suggested by these studies include those that suggest that aflatoxins may cause inhibition of hematopoiesis, promote defective hematopoiesis, increase destruction of RBCs, or a combination of all three.23 In humans, it is not clear how aflatoxins may cause anemia, however, the fact that it acts as a toxin suggests that it may, like most other toxins, cause anemia by a hemolytic process.40 The accumulation of evidence suggests that aflatoxins may cause DNA damage, mutations, and suppress bone marrow functions.41,42 The mechanism for this toxicity is thought to occur by a pathway, which involves the metabolism of aflatoxins into epoxide intermediates that go on to bind DNA and RNA. These intermediates interfere with
DNA-dependent RNA polymerase, thereby inhibiting RNA and protein synthesis.17 These effects of aflatoxins may partly explain their possible role in the etiology of anemia in this population.
Because there are many causes of anemia, which involve complex pathways, it was necessary to tease out the effect of other causes of anemia from any patho-physiologic pathway involving aflatoxins that impact the occurrence of anemia. The eligibility criteria for the study deliberately recruited participants who were young, did not suffer complications of delivery such as severe hemorrhage, and whose medical records confirmed the absence of chronic diseases such as human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), drug use that may cause hemolyis, or any evidence to suggest the presence of sickle cell disease or other hemoglobinopathies.
The increase in the strength and retention of significant associations between anemia and aflatoxins after exclusion of participants with laboratory results indicative of IDA suggests that the presence of iron may promote the activity of aflatoxin metabolites. Metabolic studies have shown that these aflatoxin metabolites are produced by enzymatic processes, which involve hydroxylation, reduction and epoxidation.17,43 Iron is a key requirement in the body for oxidative and reductase reactions and is possibly involved in these metabolic pathways. Perhaps, in IDA, the decreased iron levels in the blood depress the conversion of aflatoxins to metabolites, which may be involved in the pathophysiology of anemia. Thus, those participants with normal iron levels will preserve the enzymatic processes, which lead to production of aflatoxin metabolites and consequently, contribute to anemia.
Although IDA is the commonest cause of anemia, excluding the effect of malaria, parasitemia is particularly important because malaria causes anemia by hemolysis of RBCs, an etiological pathway through which aflatoxins are thought to act. While there were moderate changes in the effect estimates depending on whether helminths and folate deficiency was present, the retention of these associations in the absence of these known causes of anemia may indicate that the effect of aflatoxins is distinct. What is not known is how aflatoxins may interact with these known causes of anemia to modulate the occurrence of anemia. Further research is required to investigate how multivitamin and mineral metabolic processes may modulate the effect of aflatoxins on RBCs.
Clearly, the cross-sectional nature of this study limits our ability to draw causal relationships between anemia and aflatoxins. Nevertheless, the observed mechanisms identified in mammals and our results provide a basis to commission studies to delineate this relationship by using more rigorous study designs. A further limitation of our study stems from our inability to measure plasma ferritin, plasma transferrin saturation, or serum soluble transferrin receptor. These limited our ability to adequately measure and assess the prevalence of iron deficiency anemia, which is the most frequent cause of anemia in pregnancy. However, our use of MCV, MCH, and MCHC values did provide us with surrogate indices with which to categorize participants into those that were iron deficient or not for analysis. By so doing, we provided an opportunity to assess the effect of aflatoxins by the RBC hemolytic mechanism, which has been suggested from animal studies. Nevertheless, it is noteworthy that there may be residual confounding as a result of other causes of anemia such as vitamin B12 deficiency, bone marrow depression, vitamin B6 deficiency, vitamin A deficiency, and other nutritional deficiencies, which have not been controlled by this study. Nevertheless, we believe these effects if present are minimal. The relatively young age of the patients and the absence of any indication of chronic diseases, assured us that the anemia of chronic diseases may have very little impact on our results. Strength of the study lies in the large sample size. This made it possible to categorize variables while retaining reasonable degrees of power to detect otherwise small effect sizes. Because our participants were drawn from a large teaching hospital and an equally large public maternity hospital, which cater to the medical needs of a varied population of individuals, this study is generalizable to the larger population of pregnant women in Kumasi residents and indeed women in the Ashanti region of Ghana. The 100% participation rate of the participants further strengthens this external validity. Potentially, these results may be observable among populations in other African countries and Asia where aflatoxin contamination of foodstuff is common.
In conclusion, our study found an association between anemia and aflatoxins. The multi-factorial nature of the etiology of anemia makes it necessary to exercise caution in interpreting the significance of this association. The practical implications of this study lie in the need for policy makers to put in place information and educational tools to increase awareness about aflatoxin contamination of food crops and how this can be prevented. Additionally, health care providers need to educate pregnant women attending prenatal clinics about the potential health hazards associated with eating unwholesome foods, which are likely to have been contaminated by aflatoxin producing fungi. By so doing, it is hoped that the health of many pregnant women in resource poor countries will be safeguarded from known toxins and thereby contribute toward reduction of anemia prevalence, particularly among pregnant women, thereby reducing maternal mortality and contributing to the achievement of the Millennium Development Goals, which are targeted at reducing maternal morbidity and mortality.
We thank Joshua Dugbartey for help with data collection and Lincoln Gankpala for assistance with processing of samples, plasma preparation, and shipping. We thank Tsiri Agbenyega, Archer Turpin, and the labor ward staff and laboratory technicians of the Komfo Anokye Teaching Hospital and Manhyia Polyclinic, for making the study possible. Special thanks to all of the pregnant women who participated in this study. We are grateful to Thomas Kruppa and Ohene Adjei for use of the KCCR laboratory facilities.
1.↑
10.↑
*Address correspondence to Pauline E. Jolly, Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, 1665 University Blvd., Birmingham, AL 35294. E-mail: jollyp@uab.edu
Financial support: This research was supported by USAID grant LAG-G-00-96-90013-00 for the Peanut Collaborative Research Support Program, University of Georgia, Atlanta, GA.
Authors' addresses: Faisal M. B. Shuaib, Pauline E. Jolly, Yi Jiang, Nelly J. Yatich, and Craig Wilson, Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, AL, E-mails: faisal@uab.edu, jollyp@uab.edu, howarld@uab.edu, nelly@uab.edu, and cwilson@uab.edu. John E. Ehiri, Division of Health Promotion Sciences Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, E-mail: jehiri@email.arizona.edu. William O. Ellis, Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, E-mail: elliswo@yahoo.com. Jonathan K. Stiles, Department of Microbiology, Biochemistry and Immunology, Morehouse School of Medicine, Atlanta, GA, E-mail: jstiles@msm.edu. Ellen Funkhouser and Sharina D. Person, Division of Preventive Medicine, Birmingham, AL, E-mails: emfunkhouser@mail.dopm.uab.edu and sperson@uab.edu. Jonathan H. Williams, College of Agricultural and Environmental Services, University of Georgia, Griffin, GA, E-mail: twillia@griffin.uga.edu.
©The American Society of Tropical Medicine and Hygiene 2010
https://www.ajtmh.org/view/journals/tpmd/83/5/article-p1077.xml


"Maybe I need to borrow some time from you to make your light shine"
In a " trias politica " 3 persons have to say yes or no 3 times before they can opt on their final " veto " for yes or no. I love women. What's for dinner?
Very nice co-op, like it.
I like the sound of this tune!!


PTSD and the Military Spouse: What You Need to Know!
PTSD is affecting our service members, yes, even Navy Sailors. As spouses, we need to know what it is, how to recognize it in our service member, what we can do and what resources are available to for both our service member and ourselves. Dr. Bridget Cantrell, the foremost authority on PTSD and co-author of "Turning Your Heart Toward Home". You need to hear this broadcast - yes, it is that important!


text:
South Seas Books
South Seas Trading
Fiction (8 - 12 years)
The Hidden Staircase (Nancy Drew #2)
Author(s): Carolyn Keene
A special treat for Nancy Drew fans, and any reader who's new to the series We're releasing a stunning new edition of an old favorite: The Hidden Staircase, the second book in the incredibly popular, long-running series. It's the same exciting mystery that readers have fallen in love with for more than 80 years--Nancy Drew has to find the mysterious ghost that seems to be haunting Twin Elms, and make sure no more prized possessions disappear under her nose. Now with a brand-new look, this is an edition that collectors won't want to miss
Carolyn Keene is a pen name used by a variety of authors for the classic Nancy Drew Mystery series. The first author to use the pseudonym was Mildred Wirt Benson, who wrote 23 of the original 30 books. Other writers who have adapted the "Carolyn Keene" moniker include Leslie McFarlane, James Duncan Lawrence, Walter Karig, and Nancy Axelrod.
Publisher : Penguin Publishing Group
Imprint : Grosset & Dunlap
Author : Carolyn Keene
Monday to Saturday: 10.00am-5.00pm
Sunday and Public Holidays: 11.00am–4.00pm
BOOKS: 53 North Terrace, PORT ELLIOT, SA 5212 phone: (08) 8554 2301 ABN: 63 589 746 258
TRADING: 56 North Terrace, PORT ELLIOT, SA 5212 phone: (08) 8554 3540 ABN: 63 589 746 258

redpajama_set_name: RedPajamaCommonCrawl


The documents related to the Adaptive Authentication (Cloud) 14.0.1 patch release to UAT are now available in the new RSA Adaptive Authentication (Cloud) User Acceptance Testing RSA Link page. Only the documents that have been changed for this patch release have been added to this UAT documentation page and contain a UAT watermark. When the Adaptive Authentication (Cloud) 14.0.1 patch is released to production, these documents will be finalized and uploaded to the existing RSA Adaptive Authentication (Cloud) 14.0 documentation page.


Come out and see us at the American Dry Stripping & Xtreme Coatings tent at the 26th Annual Club Corvette Show & Swap Meet, on Sunday, July 8, 2018, at Moroso Performance Products in Guilford, CT.
Registration starts at 8:30 a.m. and judging starts at noon.
Pre-register before July 1st for $5 discount.
Guest judging by WTNH Channel 8 meteorologist Gil Simmons.
Rain date is Sunday, July 15.


"Stress can be any unsolved problem a person experiences – from dealing with a daily list of things which need to be done, a challenging task at work, a social occasion or an ongoing sense of difficulty with a partner, parent or child," says Matt Ronan of Evolv health store in Enniscorthy, Co Wexford.
"The immune system is the front line of defence for good health," says Ellen Cox of essential oil company Atlantic Aromatics. "When we are stressed it is one of the first systems in the body to be affected, weakening our ability to fight off everyday infections.
"The body has a very structured way in which it handles stress," says Susie Perry-Debice, "admittedly this response is still tailor-made for our flight-or-fight caveman ancestors and is in much need of a 21st century upgrade! The adrenal glands respond to stress by producing the hormones cortisol and adrenalin.
"Stress can have an awful impact on the body, from the body's ability to fight disease, depression, weight gain or loss, adrenal fatigue, impaired immune system and mental health problems," agrees Helena Murphy.
Berries – packed with antioxidants which combat damaging free-radicals released by stress in the body.
Cashew nuts – a great source of zinc which can help reduce anxiety. Other good sources of zinc are chicken and beef.
Green leafy vegetables – contain folate, which produces dopamine, a chemical that helps you to keep calm. Try eating more spinach, cabbage and broccoli.
Salmon – packed with omega-3 fatty acids that have anti-inflammatory properties which in turn can help your body cope with stress hormones.
Seeds – such as flax, pumpkin and sunflower all contain magnesium, the stress-fighting mineral.
Turkey – contains the amino acid tryptophan that makes you sleepy and helps produce the feel-good hormone serotonin. Other good sources are nuts, seeds, tofu, fish, oats, lentils, eggs and beans.
Yogurt – a good probiotic yogurt gives you the benefit of live native bacteria to settle your digestive system, as well as calcium and protein.


All Planning Applications for Landbeach considered by the Planning Committee since May 2003. For individual reports, please click on the 'Meetings' tab above. For further details on all Landbeach Planning Applications, please visit our Planning Applications Database and select Landbeach from the drop-down list of parishes.
This is only a consultation response. The application will be determined in due course by Cambridgeshire County Council.
Delete "Officers are of the view that the proposal is at the upper limit of 'less than substantial harm'…" and substitute "South Cambridgeshire District Council's Planning Committee takes the view that the proposal would cause substantial harm…" and then replace "…serious harm…" with "…significant harm…".


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Unboxing: Shadowrun Sixt...
Review: Yakuza Kiwami 2 ...
Review: Yakuza 6: The So...
Evansville Esports April...
Tabletop Review: No Security: Horror Scenarios in the Great Depression
Alex Lucard | December 3, 2013 | Archive, Tabletop Gaming, Top Story | No Comments
No Security: Horror Scenarios in the Great Depression
Publisher: Hebanon Games
Get it Here: DriveThruRPG.com
MAGICAL REVIEW UPDATE TIME GO!
So, in the hours since this went live a few things have happened. First, you'll notice the link under the header no longer works. That's because the link has been taken down by Hebanon Games. It turns out that there were a few communication errors between Hebanon Games and DriveThruRPG.com. First, the reviewed piece was not meant to be a digital/PDF only release and certainly not for twenty dollars. It was in fact meant to be a Print of Demand physical release – something I speculated in the original body of text below. Somehow though (We don't know if Hebanon Games or DriveThruRPG made the mistake, but there's no point in assigning blame) the link to purchase the collection went live as a PDF only release on 11/30 and a review copy was sent to me. The review below is a result of that review copy. Nowhere on the purchase/information page on DriveThruRPG was it mentioned that the piece was meant to be a PoD release and as mentioned in the review, it was being sold on the site ONLY with the option of a PDF purchase. I've talked to Caleb Stokes (Head of Hebanon games and author of No Security) since then, and he assures me this was just one big comedy of errors that neither he nor the staff at DriveThruRPG/RPGNow caught until after my review went live.
Regardless, the error has been caught, the offending page has been removed, as has the option to purchase this product. Instead it will be made live once the Print on Demand version is fully approved and ready for sale. Note that everything in my review is still accurate about what I was sent to review, but that my feeling about paying twenty dollars for a physical copy of No Security would be completely different and extremely enthusiastic. I'll happily purchase a physical copy of the product for myself and Mark B. (A fellow DHGF staffer that has come to love No Security from my reviews) for the twenty dollar price tag. Hell, I gave Hebanon twenty-five dollars for the free versions on Kickstarter, so I'm obviously a fan. Now if the page goes live again WITHOUT the PoD option – FOR THE LOVE OF NYOGTHA, DO NOT BUY IT. It means the error is back. By all means, give your hard earned cash to Hebanon Games, but either do through the actual PDF links or wait until the Print on Demand version is actually available. Trust me, the wait will be worth it.
UPDATE OVER
I originally backed the No Security Kickstarter in June of 2012. 250 backers raised a little over $6,800 in order to let author Caleb Stokes make a series of systemless horror based tabletop adventures set in the 1930s. While many of these adventures were originally written for some Cthulhu based system (Call, Dark, etc), by going systemless, the adventures could be adapted to just about anything, from d20 to… Earthdawn I guess, if someone really wanted to. The end result was six adventures that were made free to the general public, which was a wonderful idea. I reviewed all six and found three of the six to be exceptional, one to be a fine but flawed release and two to be niche and/or underwhelming. Still, four out of six is a pretty good record, and the worst thing I had to say about the weakest two is that they simply required a very specific GM and troupe tandem to make them work. Instead of trying to rehash all six of my earlier reviews and combine them into a babbling mess, I'll instead provide links to them all here in order of release. As well, this review will focus on the collection itself rather than the individual parts that make it up. We've already been down that road together after all.
Bryson Springs (Originally released June, 2012)
The Red Tower (Originally released July, 2012)
Lover in the Ice (Originally released November, 2012)
The Fall Without End (Originally released January, 2013)
Revelations(Originally released August, 2013)
The Wives of March (Originally released October, 2013
This No Security Collection contains five of the six adventures and bundles them together into one PDF with a twenty dollar price tag. This is NOT a set of five pdfs, but rather one larger merged one. Please keep that in mind. There are fourteen new pages in this release, none of which are actual content. You get two cover pages (One with the author and company's name – one without. Odd), a new piece of art, a page of copyright information, a table of contents, a foreword by someone I've never heard of before, a two page note from Caleb, two pages of Kickstarter backer names, an ad for the sixth adventure (Lover in the Ice) not found in this collection, two pages of ads for products by the guy who did the foreword, and a page of ads/links for Role Playing Public Radio, which is the site that gave birth to No Security. So the extra pages are pretty frivolous and unimportant. They add nothing new to the collected pieces, so if you already have the previous releases, you're not gaining anything by picking this up. I should also point out that the adventures are not grouped in the order of release, nor by alphabetical order. I'm not really sure how or why the adventures were grouped in the order they are, but there is no rhyme or reason to the placement.
Which brings me to the big elephant in the room. While three of the five are well done, and all five are ones I've recommended in the past to read and download, I can't really recommend this collected edition for a multitude of factors. First up, it's much easier and saner to have these five adventures in separate PDFs. You can find what you are looking for easier, and as you'll never need all five at once, collecting these five in one package doesn't make sense for an electronic edition, but it would for a physical copy. Alas, DriveThruRPG is not currently offering a Print on Demand version of No Security, which would be the only reason to pick this collected edition up. Secondly, this collection only contains five of the six adventures. Lover in the Ice is left out, and although I can't say for certain why, I think it's due to the extreme mature content of that adventure which may offend or disturb some readers. I've also been told it may be because of a bone Hebanon games had to throw to DriveThruRPG.com to get listed over there. Although Lover in the Ice does contain multiple triggers and some material that is more sleazy or creepy than disturbing or scary, it does seem odd to leave out one adventure from the collection. Still, Lover in the Ice is well written, even if it's not for everyone (I certainly wouldn't play it with a rape victim or anyone of the female gender for that matter), it's a big piece of the No Security collection and if something had to be left out, I'd have put that in instead of The Wives of March.
Since I bring up The Wives of March I should add that it is the weakest, most convoluted and easiest to break adventure in the collection, and as such, I definitely wouldn't have started the collection with it. It'll leave newcomers with a bad first impression. If anything, I'd have grouped the adventures in order of ease to run or easiest for gamers to experience. The Wives of March would be sixth of six in either of those cases. The Red Tower or Bryson Springs would have been far better choices to start the collection off with, as they are extremely well done adventures even new gamers can play through without frustration while still having a very memorable time.
Finally, the big reason I can't recommend this collection is that these adventures were meant to be free to the public. That was the original spirit of the Kickstarter after all, and it was how all six were originally released. Of course, the No Security website was constantly hacked by some pricks and so Caleb had to take it down and move the pieces to DriveThruRPG.com, which is a shame and shows that even the best and most noble of ideas can be shattered by losers with a keyboard and too much time on their hands. Anyway, five of the six adventures are now available as "Pay What You Want" releases, meaning you can still get them for free, or you can kick some money towards Hebanon Games as a thank you for making these. Meanwhile, this collection is a set twenty dollars, and even though it is 99.99 percent the same content as the individual pieces, it's not free. In fact, it's a whoppingly overpriced twenty dollars. I hate saying that, as I love Hebanon Games and No Security, but twenty bucks is way too high an asking price for a collection of systemless adventures.
Case in point: Lover in the Ice, the only No Security adventure with a set price tag, is $1.99. So as all adventures are roughly the same length and feature the same quality content, that would mean all six adventures could feasibly be set at $1.99 as the suggested "Pay What You Want" price and no one would raise an eyebrow. Simple multiplication tells us six adventures times $1.99 would mean you would pay about $11.94 for all six adventures if you picked them up separately and wanted to give Hebanon Games some cash. Now, the price tag for only five of those adventures in this collection is twenty dollars. That's more than twice what the assumed price for five of the six adventures would be if you picked them up separately. That's insane. Worse yet, bundled collections are supposed to be cheaper than if you picked up the individual pieces on their own, yet the reverse is true here. That's a big no-no. Of course, the twenty dollar price tag also flies in the face of the idea that these adventures were mean to be free to the general public – hence the Kickstarter. So why pay twenty dollars for something that was meant to be free, that you can still get for free and that has a price tag that is twice what the estimated value of all the collected pieces are worth? The obvious answer is – you wouldn't. No one would – unless you really really liked Caleb and just wanted to throw money at him, and you could just do that by sending him a check or paypay'ing him. As such, this entire No Security collection ends up looking overpriced, strangely thought out and completely nonsensical in form and follow through.
The problem is the No Security collection is just too overpriced for what you get, even if you ignore (or were ignorant of the fact) that these adventures were meant to be free to the public. Most big name companies release electronic versions of their games for less (except Paizo because their fans are insane enough to pay the exorbitant amounts they ask). For example, Chaosium just released Secrets of Tibet for Call of Cthulhu. It's 178 pages long and it costs only $11.53 for the electronic version, or you can preorder the physical copy for $20.96 – the same as what you would pay for the digital version of the No Security collection. Most third party or indie game releases are priced even cheaper because they don't have the built in audience that will pay higher amounts. Hell, even Numenera, which is arguably the biggest release of 2013, only asks $1.99 for their core rulebook PDF, and it's more than twice the length of this. I hate to harp on the crazy price tag attached to this collection so much, but when you can get all five adventures for less (technically for free), then there has to be SOMETHING to make the consumer want to pay twenty dollars for the bundle – something that isn't in the free versions. Unfortunately, that isn't the case with this collection, so in spite of the overwhelming quality (I can't overstate how much I like the individual releases) and fine art each individual piece contains, this No Security collection is the first real abject failure for Hebanon Games as a company. My advice would be to pull this collection down and rethink everything. Why are they doing a bundled piece? Who is the target market? Why would someone pay twenty dollars for something they can already get for free? How do you justify charging money for something that WAS meant to be free in the first place? So on and so forth. As the product currently stands though, the No Security collection has no target audience and no real reason to exist. Just download the individual pieces, as they are well done. If you like what you see, throw some money at Hebanon Games for their hard work. Now, would I pay twenty dollars for a physical collection of all six adventures? You're damn right. Would I pay twenty for a digital copy of something already available for free in the same format? Ha ha ha. No.
Tags: No Security
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E3 2011: 10 Thoughts on… Dark Souls (Sony Playstation 3, Microsoft Xbox 360)
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Tabletop Review: Call of Cthulhu: Sense Impacts
Warning: A non-numeric value encountered in /nfs/c12/h02/mnt/222827/domains/diehardgamefan.com/html/wp-includes/functions.php on line 64
Alexander Lucard
Alexander Lucard was the Editor-in-Chief of Diehard GameFAN and Director of Operations for the InsidePulse network. He has since retired from writing, but clearly shows up now and again. He has worked in video game journalism since 2002 and was also a paid consultant for Konami and The Pokemon Company. Alex has previously written for Tips N Tricks, Gamespot, White Wolf, TSR, Wizards of the Coast, Eden Studios, 411mania, Not a True Ending and more. His writing could also be found in the monthly periodicals Massive Online Gamer and Pokemon Collector Magazine.
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진괘는 아래에 있는 양기가 지면(地面)의 음기를 뚫고 나오는 모습을 본뜬 것이다.
震(Zhèn) is 5th hexagram in I Ching.
震is formed with meaning of thunder(雨) above and the arousing(辰) below.
This hexagram gives the intimation of ease and development.
When the movement comes, it will be found looking out with apprehension. This feeling of dread leads to happiness.


text:
Q: Sum of subarray values Array
(
    [1~course2 20:00] => Array
        (
            [0] => Array
                (
                    [pid] => 30
                    [anz_tn] => 6
                )

            [1] => Array
                (
                    [pid] => 30
                    [anz_tn] => 4
                )

            [2] => Array
                (
                    [pid] => 30
                    [anz_tn] => 5
                )
        )

    [2~Course2 08:30] => Array
        (
            [0] => Array
                (
                    [pid] => 30
                    [anz_tn] => 5
                )

            [1] => Array
                (
                    [pid] => 11
                )

            [2] => Array
                (
                    [anz_tn] => 4
                )
)

....
How can I get the sum of all the "anz_tn" for each subarray? (sum of all [0]['anz_tn'],[1]['anz_tn'], etc..)
I've tried to use $all[][$i]['anz_tn'] but this fails. ($all is the main array, $i is the count of subarrays). Is there a way using array_sum?
Thanks!

A: please try like this,
$sumArray = array();

foreach ($myArray as $k=>$subArray) {
  foreach ($subArray as $id=>$value) {
    if ($id == 'anz_tn')
      $sumArray[$id]+=$value;
  }
}

print_r($sumArray);

A: Thank you, Manadh!
This was pointing me in the right direction. One level of the array was missing (resulting in 'unsupported operand error'), so in the end I came up with this:
$sumArray = array();
foreach ($groupasweek as $s1k=>$s1v) {
    foreach ($s1v as $s2k=>$s2v) {
        foreach ($s2v as $id=>$value) {
            if ($id == 'anz_tn') {
                $sumArray[$s1k][$id] += $value;
            }
        }
    }
}

Btw, where can I accept an answer?

redpajama_set_name: RedPajamaStackExchange


text:
\section{Introduction}

Knowledge-driven systems for decision-making in health care applications are powerful tools to help provide actionable and explainable insights to patients and practitioners. In such systems, knowledge about the particular patient - current condition, historical ailments, etc.  - is central to enable personalized health care.

An example of such a system for personalized health care is a diet and lifestyle decision-making tool for diabetic patients. This system may utilize knowledge from several domain-specific knowledge graphs (KGs), such as a KG of diabetes health care guidelines from the American Diabetes Association and a KG of food and nutrition such as FoodKG \cite{foodkg}. Knowledge about a particular patient is used here to perform context-aware reasoning and personalization of down-stream applications. For example, what the system recommends as a "healthy" meal may differ for among patients based on personal aspects like their current weight or exercise habits

To facilitate reasoning and decision-making based on personal context, such systems can benefit from integrating personal knowledge about the patient. This extended abstract presents a brief review of existing work surrounding the concept of personal knowledge graphs (PKG), how they could be integrated into personalized healthcare as personal \textit{health} knowledge graphs (PHKG), and the key gaps in existing literature that must be addressed to realize their full potential.

\section{Related Work}

Currently there is limited consensus on what exactly a PKG is. In some works \cite{ghidini_personalized_2019,Safavi2019PersonalizedKG}, the term has been used to express the idea of a personalized \textit{view} or \textit{summarization} of a broader KG. Such an interpretation of the term touches on a relevant aspect of personalization, but it fails to encompass capturing knowledge \textit{about} the person as we desire.

Balog and Kenter \cite{goog_pkg} define a PKG as ``a  source  of structured knowledge about entities and the relation between them, where the entities and the relations between them are of personal, rather than general, importance." Within this definition, the PKG only encapsulates knowledge that is relevant to the particular user. Further details about entities are captured by linking to other KGs. For example, the PKG may contain the entity ``my bicycle," but details about this bicycle are expressed through links to other relevant KGs rather than storing them in the PKG.

Some aspects of this definition for PKGs have been captured in existing work. To collect personal knowledge, \cite{microsoft_pkg} mined personal knowledge from natural language utterances based on Freebase relationships. Their work focused specifically on personally relevant relations, such as place of birth, profession, and family, but the scope of relationships that could be captured was rather limited. A means to access and use knowledge from heterogeneous data sources was developed by \cite{thymeflow_18}. Their system, Thymeflow, collects personal knowledge from sources such as email, contacts, calendar, and location history to allow querying. This knowledge is further enriched through means such as connecting location history, calendar events, and geographic coordinates

We consider PKGs that capture personal health information that can be used in knowledge driven healthcare to be PHKGs. PHKGs remain a somewhat under-explored topic. A vision for PHKGs applied to treatment of chronic diseases was proposed in \cite{knoesisphkg}, which described some challenges involved in the design and use of PHKGs. Their design ideas include capturing personal data from IoT devices and linking the knowledge about patient health to several disease-specific ontologies, similar to the ontology-driven, personalization methods from \cite{ontology_p}. However, to the best of our knowledge, there is no concrete implementation of PHKGs.

\section{Applying PKGs to Health}

Knowledge-driven systems to support health care decision-making can benefit from using a PKG of health knowledge, or a PHKG. For example, a PHKG might capture knowledge about a patient's allergies, eating habits, and specifics of their diabetes disease and treatments. This knowledge would be integrated with other domain-specific KGs to perform reasoning that is tailored to the particular patient, for example by recommending a meal for the patient based on their allergy restrictions and prescribed carbohydrate intake limit.

We anticipate several benefits to be gained from using PHKGs for personalization in such systems: personal health knowledge, if correctly linked,
can smoothly integrate into reasoning engines; health-related data from heterogeneous sources should be accessible in a consistent fashion; and PHKGs and the supporting methodology should be reusable in further health care applications that link to new knowledge graphs. However, due to the limited existing work on PKGs and even more sparse literature on PKGs for health, there are still many hurdles left to overcome.

\section{Outstanding Challenges}

We identify the following key challenges that must be addressed in order to develop and utilize PHKGs for personalized, knowledge-driven systems for health care applications.

\textbf{1) Collection and Storage of Personal Health Knowledge:} Personal health knowledge can come from a variety of heterogeneous sources \cite{smartdata}, which requires the development of infrastructure to collect and process. Furthermore, collecting personal medical information (e.g. from electronic health records) will require considerations of privacy and access restriction. A comprehensive methodology of how to structure and store personal health information must also be developed so that new personal health knowledge can be introduced to the PHKG in a consistent manner.

\textbf{2) Linking Personal Health Knowledge to External KGs:} Because the entities captured in a PHKG should only be that which is personally related to a particular user, entities must be linked to external KGs to provide additional knowledge. To help disambiguate, entity linking will likely have to rely on the provenance of where and how the entities were added to the PHKG. Disambiguation challenges may also arise in the presence of conflicting health knowledge (e.g. conflicting information about healthy daily calorie intake) or poorly defined terms (e.g. defining what constitutes a ``healthy" meal). It is also possible that entity linking will be highly application-dependent, which may suggest the importance of developing a standardized \textit{workflow} for defining entity links from the PHKG.

\textbf{3) Maintenance of Personal Health Knowledge:} Once the PHKG has been populated, challenges remain in how to maintain the captured knowledge. Maintenance of PHKGs will involve updating personal knowledge in the PHKG (based on changes detected in external KGs) as well as propagating changes made within the PHKG out to the external KGs. Updating knowledge in one location may lead to inconsistencies among linked knowledge, and how to resolve such conflicts is unclear. Additionally, we must carefully consider how and when to trigger updates: continuously monitoring all changes in all linked KGs is not feasible, but the health condition of an individual may fluctuate frequently. The practical challenges of accessing private information must again be considered for maintenance. PHKG implementations will need to address trade-offs between constantly having the most up-to-date knowledge about a patient versus respecting the patient's personal privacy.

\section{Conclusion}

A great deal of work remains to help realize the emerging paradigm of PHKGs. A variety of research and implementation challenges surrounding the collection, linkage, and maintenance of personal health knowledge must be addressed to leverage PHKGs for personalized, knowledge-driven decision-making tools for health care. Some key research questions that will need to be addressed include how to best develop a structure with which to capture personal health knowledge and how to effectively collect and use personal health knowledge while maintaining privacy.

\section*{Acknowledgments}
This work is partially supported by IBM Research AI through the AI Horizons Network

\medskip

redpajama_set_name: RedPajamaArXiv


text:
Gov Oyebanji reiterates commitment to quality education
Posted on January 13, 2023 by Press Release
Ekiti State Governor, Mr Biodun Oyebanji has reiterated the commitment of his administration to quality education in the state.
The Governor who made this known on Thursday while receiving a Team from the Build a School Initiative in Africa (BASIA) led by its President and CEO, Dr Victor Ukorebi, in his office, appreciated the NGO for partnering Ekiti State Government and for building five blocks classrooms for 240 students in Ajoni LCDA.
Oyebanji who said his administration is committed to qualitative education at all levels, noted that education is one of his administration's six point agenda under Human Capital Development.
'If you look at our six point agenda you will see human capital development, that is where education seats and for us in Ekiti we believe that ideas rules the world and the only way you can get idea is through knowledge, the only way to get knowledge is through education and we also know that the quality of education, relevance of knowledge you are getting and functionality is very important so as a government we have decided to prioritize access to education' Oyebanji said.
He therefore assured the NGO of his readiness to partner with them to be able to maximize the opportunity brought to Ekiti.
Speaking earlier, the President and CEO, Build a School Initiative in Africa (BASIA) Dr Victor Ukorebi appreciated the governor for granting his team audience and intimated the governor with the mission of the NGO which is to to facilitate, accelerate, amplify and provide world-class educational infrastructure for children in Africa's poorest communities so as to reduce out of school children in Africa.
Dr Ukorebi, who applauded Ekiti for being accommodative, friendly and education conscious, said the building is built to stand the test of time and that they come back to maintain the structure in every 3 years.
In his remark, the Ajoni LCDA Chairman, Prince Michael Ogungbemi who is the first beneficiary of the partnership appreciated the NGO and explained that the project was done through counterpart funding Also Present at the meeting were Secretary to the State Government, Dr Habibat Adubiaro, Special Adviser on Education, Dr Kofoworola Aderiye, Special Adviser on Governance, Reforms and Innovation, Mr Seun Fakuade.
Vice President Osinbajo sees more robust relationship between Nigeria, Spain through energy sector →
← President Buhari to be honoured by Abu Dhabi Peace Forum in Nouakchott


text:
#include <aws/iotsitewise/model/AggregatedValue.h>
#include <aws/core/utils/json/JsonSerializer.h>

#include <utility>

using namespace Aws::Utils::Json;
using namespace Aws::Utils;

namespace Aws
{
namespace IoTSiteWise
{
namespace Model
{

AggregatedValue::AggregatedValue() :
    m_timestampHasBeenSet(false),
    m_quality(Quality::NOT_SET),
    m_qualityHasBeenSet(false),
    m_valueHasBeenSet(false)
{
}

AggregatedValue::AggregatedValue(JsonView jsonValue) :
    m_timestampHasBeenSet(false),
    m_quality(Quality::NOT_SET),
    m_qualityHasBeenSet(false),
    m_valueHasBeenSet(false)
{
  *this = jsonValue;
}

AggregatedValue& AggregatedValue::operator =(JsonView jsonValue)
{
  if(jsonValue.ValueExists("timestamp"))
  {
    m_timestamp = jsonValue.GetDouble("timestamp");

    m_timestampHasBeenSet = true;
  }

  if(jsonValue.ValueExists("quality"))
  {
    m_quality = QualityMapper::GetQualityForName(jsonValue.GetString("quality"));

    m_qualityHasBeenSet = true;
  }

  if(jsonValue.ValueExists("value"))
  {
    m_value = jsonValue.GetObject("value");

    m_valueHasBeenSet = true;
  }

  return *this;
}

JsonValue AggregatedValue::Jsonize() const
{
  JsonValue payload;

  if(m_timestampHasBeenSet)
  {
   payload.WithDouble("timestamp", m_timestamp.SecondsWithMSPrecision());
  }

  if(m_qualityHasBeenSet)
  {
   payload.WithString("quality", QualityMapper::GetNameForQuality(m_quality));
  }

  if(m_valueHasBeenSet)
  {
   payload.WithObject("value", m_value.Jsonize());

  }

  return payload;
}

} // namespace Model
} // namespace IoTSiteWise
} // namespace Aws

redpajama_set_name: RedPajamaGithub


text:
Ed Drobina named Violet Township administrator
NATE ELLIS THISWEEKNEWS.COM @ThisWeekNate
Dec 18, 2019 at 7:14 PM Dec 18, 2019 at 10:34 PM
Violet Township officials have chosen longtime Pickerington service director Ed Drobina to serve as the township's next administrator.
The township trustees voted unanimously Dec. 18 to hire Drobina to lead day-to-day operations.
Drobina, 60, has worked for Pickerington for 16 years, including the past 13 as its service director.
He takes the post after former township operations director John Eisel died July 5 while vacationing with his family in Cumberland, Kentucky.
Although Drobina will hold a different title as administrator, his duties will be the same as Eisel's were. The change in the position's title means township fire Chief Mike Little will report to the township's board of trustees and not the director of operations, according to trustees chairman Darrin Monhollen.
"I am very excited to go and assist our neighbors in Violet Township," Drobina said. "It's just a new opportunity and it gives me an opportunity, to continue doing what I like doing, and that is helping people."
Drobina will start with the township Jan. 6. He'll receive an annual base salary of $125,000, and he'll also receive a $250 monthly vehicle stipend.
It's unclear yet whether Drobina will receive employee benefits, such as medical insurance, from the township.
"Mr. Drobina is a highly qualified, experienced professional that has an extremely high-level, global understanding of the Violet Township area," Monhollen said.
"Ed has been a well-respected asset to the city of Pickerington and will provide a unique perspective as to how Violet Township government may best work collaboratively with Pickerington city government.
"Mr. Drobina's willingness to accept the challenge of being our township administrator is a win-win for both the residents of the incorporated and unincorporated areas of Violet Township," Monhollen said.
Drobina's hire is a change of fortune from how the city of Pickerington filled its top administrative post in August, when it hired 18-year township engineer Greg Butcher to serve as city manager.
Drobina said he leaves the city on good terms and echoed Monhollen's sentiments that he and Butcher changing municipal sides should strengthen government relations between Pickerington and Violet Township.
"I think it's going to help the communications of the city and township," Drobina said.
Drobina wasn't among the 12 applicants to apply for the administrator's post as of Oct. 18.
Monhollen said township officials recruited Drobina after officials reached an "impasse" with it's three finalists for the position. They were Jillian Boone, Fairfield County Common Pleas Court, court administrator and magistrate; Holly Mattei, Violet Township, development director who resigned, effective Dec. 20; and Deborah McDonnell, Allegany County, New York, county administrator.
"As chairman, I contacted (Pickerington) Mayor (Lee) Gray to solicit his thoughts regarding Ed being a potential candidate for the township administrator's position," Monhollen said.
"The communication developed into Mayor Gray stating that Mr. Drobina is an outstanding employee with a tremendous wealth of knowledge who is extremely well respected in the region."
Drobina said he expects to be a "bridge" hire for the township for the next 18 months to two years.
He said he won't know what his priorities for the township will be "until I get in there and look at the budgets, projects and what they have started."
Drobina will take the township post just days after being sworn in as the village of Carroll's next mayor.
He was elected as a write-in candidate in November, after his wife Tammy chose not to seek re-election following two terms in office.
Butcher said Drobina's last day with the city of Pickerington was Dec. 20.
He said city officials had been preparing for the possibility of Drobina retiring.
"Violet Township approached him with the opportunity of being their new administrator," Butcher said. "It's an exciting opportunity for Ed. It allows him to transition to a new local government within the Pickerington community.
"The city of Pickerington will be replacing Ed," he said. "The timeline has not been established yet."
nellis@thisweeknews.com
@ThisWeekNate


Marquee on the Mountain Hamilton is a new townhouse project by Wyatt Development Group. The new development will be located at 820 Rymal Road East, Hamilton, ON L8W 1B7. It is in city of Hamilton. Marquee on the Mountain is 2 storey building with 14 number of units.The Estimated occupancy of Marquee on the Mountain is in 2019. Sales of Marquee on the Mountain From $529,900 to $589,900 CAD.
Ceiling Height From 9'0" to 14'0"
*Marquee on the Mountain last updated on February 13, 2019 by 99homes.ca. Designated trademarks and brands are the property of their respective owners. 99homes.ca is not liable for the use or misuse of the site's information.


text:
La Coppa Italia di Serie B 2016-2017 è stata la 19ª edizione della Coppa Italia di categoria, disputata con regolamento invariato rispetto all'edizione precedente. La fase finale, organizzata dalla società Maritime Futsal, si è giocata dal 17 al 19 marzo 2017 presso il PalaJonio di Augusta. Il testimonial della manifestazione è stato il calciatore Totò Schillaci.

Formula
Il torneo si svolge in due fasi: i sedicesimi e gli ottavi di finale (1ª fase) si disputano in gara unica in casa della miglior classificata mentre quarti di finale, semifinali e finale (2ª fase) si giocano in una sede unica. Tutti gli incontri sono a eliminazione diretta.

Squadre qualificate
Al torneo sono iscritte d'ufficio complessivamente trentadue squadre: le ventotto società classificatesi dal primo al quarto posto nei sette gironi e le quattro società meglio classificatesi tra le squadre classificate al 5º posto nei sette gironi, al termine del girone di andata.

Prime classificate

Quinte classificate
La determinazione delle quattro società meglio classificatesi tra le quinte, sarà effettuata tenendo conto nell'ordine:
Del valore medio dei punti conseguiti al termine del girone di andata;
Del valore medio della differenza fra reti segnate e subite al termine del girone di andata;
Del miglior valore medio di gol segnati al termine del girone di andata;
Del minor valore medio di reti subite al termine del girone di andata;
Del maggior valore medio del numero di vittorie realizzate al termine del girone di andata;
Del minor valore medio del numero di sconfitte subite al termine del girone di andata;
Del maggior valore medio del numero di vittorie esterne ottenute al termine del girone di andata;
Del minor valore medio del numero di sconfitte interne subite al termine del girone di andata;
Del sorteggio.

Sedicesimi di finale
Gli accoppiamenti sono disposti dalla Divisione Calcio a 5 ed effettuati, per quanto possibile, secondo il criterio di vicinorietà. La determinazione delle società meglio classificata, che disputerà l'incontro in casa, sarà effettuata tenendo conto dei medesimi criteri adottati per le quinte classificate. Al termine della gara risulta vincente la squadra che avrà ottenuto il maggior punteggio. In caso di parità al termine della gara si giocheranno due tempi supplementari di 5 minuti ciascuno. Qualora anche al termine dei tempi supplementari le squadre risultassero in parità si procederà all'effettuazione dei tiri di rigore. Gli incontri si sono disputati tra martedì 17 gennaio e martedì 31 gennaio 2017. In contrasto con la Divisione Calcio a 5 per via del sorteggio, la società Bulls San Giusto ha depositato rinuncia di partecipazione alla competizione.

Ottavi di finale
Gli accoppiamenti sono disposti dalla Divisione Calcio a 5 ed effettuati, per quanto possibile, secondo il criterio di vicinorietà. La determinazione delle società meglio classificata, che disputerà l'incontro in casa, sarà effettuata tenendo conto dei medesimi criteri adottati per le quinte classificate. Al termine della gara risulta vincente la squadra che avrà ottenuto il maggior punteggio. In caso di parità al termine della gara si giocheranno due tempi supplementari di 5 minuti ciascuno. Qualora anche al termine dei tempi supplementari le squadre risultassero in parità si procederà all'effettuazione dei tiri di rigore. Gli incontri si sono disputati martedì 14 e mercoledì febbraio 2017.

Fase finale

Regolamento
Il torneo prevede gare ad eliminazione diretta di sola andata. Qualora, alla fine dei tempi regolamentari, le gare valevoli per i quarti di finale e/o le gare di semifinale, si concludano con un risultato di parità, la vincente verrà determinata dai tiri di rigore. Limitatamente alla gara di finale, in caso di parità al termine del tempo regolamentare, verranno disputati due tempi supplementari di 5 minuti ciascuno. Il sorteggio del tabellone della final eight si è tenuto il 24 febbraio 2017 a Roma presso la sede della Divisione Calcio a 5.

Tabellone

Risultati

Quarti di finale

Semifinali

Finale

Classifica marcatori
Di seguito, la classifica dei marcatori della fase finale:

Note

Coppa Italia Serie B di calcio a 5
Calcio a 5 nel 2017

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