Developmental activities of elite junior hockey players: an analysis of early sport specialization

Early sport specialization is a popular and contentious topic in the scientific literature and popular media. The lure of extrinsic rewards has led to increasing rates of specialization among young athletes, while expert recommendations promote multisport participation. The purpose of this study was to describe and analyze developmental activities of a group of elite junior hockey players in Canada. Within this context, elements of specialization were investigated in accordance with existing theoretical frameworks and long-term athlete development models to enhance the literature. Fifteen participants from the Ontario Hockey League completed quantitative retrospective interviews, detailing past sport and recreational activities. Thirty-one developmental milestones were assessed. Accumulated hours of activity were categorized in accordance with Côté's (1999) Developmental Model of Sports Participation, along with the number and types of sports in which they participated during childhood. Jayanthi et al.'s (2015) continuum was utilized to determine the age at which the athletes became moderately and highly specialized. Accrued hours of deliberate practice reported by participants increased from ages 6 to 16 years, as did competition in organized hockey games. Reported hours of deliberate play peaked at 9 years of age and decreased thereafter. Participants played a combined 16 sports other than hockey, ranging from an average of 2.0 at age 6, to a maximum average of 5.6 at 12 years old, and decreasing each year to 2.3 by age 15. The greatest number of hours in other sports was accumulated at 12 years of age. Using a three-point scale, participants considered themselves "highly specialized" at 14 years old; however, other quantitative indicators suggested this may have occurred at 12 years of age. Relative to previous research on early sport specialization, participants in this study spent more time practicing hockey, while ceasing hockey-specific play and other sports at younger ages. Despite a diverse sport history, hockey competition was initiated earlier than recommended, showing high levels of sport commitment as young as 9 years old. The early specialization path remains a popular trajectory among coaches, parents, and athletes in Canadian ice hockey.

What empowerment indicators are important for food consumption for women? Evidence from 5 sub-Sahara African countries

This paper draws on data from five sub-Sahara African countries; Uganda, Rwanda, Malawi, Zambia, and Mozambique consisting of 10,041 married women who were cohabitating with a male spouse. The study aim was to investigate the relationship between women's empowerment and women's dietary diversity and consumption of different food items. Women's empowerment was measured using the indicators in the five domains of Women's Empowerment in Agriculture index (WEAI) and women's dietary diversity and food consumption was examined using the women's dietary diversity score (WDDS) measure. OLS and LPM regressions were used and analyses were confirmed using marginal effects from Poisson and logistic regressions. Results suggest that three out of the 10 WEAI indicators of empowerment showed different magnitude and direction in significant associations with improved WDDS and varied associations were found in three out of the five countries examined. In addition, the three significant empowerment indicators were associated with the consumption of different food groups in three out of the five countries examined suggesting that diverse food groups account for the association between the WEAI and WDDS. Improved autonomy, and input in production were associated with improved likelihoods of consumption of dairy products, and fruits and vegetables including vitamin A-rich produce. Empowerment in public speaking was associated with improved consumption of other fruits and vegetables including vitamin A-rich produce. The varied nature of empowerment indicators towards improving women's dietary diversity and food consumption suggests that different empowerment strategies might confer different benefits towards the consumption of different food groups. Further, findings imply that interventions that seek to empower women should tailor their strategies on existing contextual factors that impact on women.

FRI0649-HPR HYDROXYCHLOROQUINE PRESCRIBING AND OPHTHALMOLOGY SCREENING WITHIN RHEUMATOLOGY DEPARTMENTS IN THE NORTH-WEST OF THE UNITED KINGDOM: A PROSPECTIVE REGIONAL AUDIT

Background:

Hydroxychloroquine (HCQ) is widely used in the management of rheumatoid arthritis and connective tissue disease. The prevalence of retinopathy in patients taking long-term HCQ is approximately 7.5%, increasing to 20-50% after 20 years of therapy. Hydroxychloroquine prescribed at ≤5 mg/kg poses a toxicity risk of <1% up to five years and <2% up to ten years, but increases sharply to almost 20% after 20 years. Risk factors for retinopathy include doses >5mg/kg/day, concomitant tamoxifen or chloroquine use and renal impairment. The UK Royal College of Ophthalmologists (RCOphth) 2018 guidelines for HCQ screening recommend optimal treatment dosage and timing for both baseline and follow-up ophthalmology review for patients on HCQ, with the aim of preventing iatrogenic visual loss. This is similar to recommendations made by the American Academy of Ophthalmology (2016).

Objectives:

To determine adherence to the RCOphth guidelines for HCQ screening within the Rheumatology departments in the North-West of the UK.

Methods:

Data for patients established on HCQ and those initiated on HCQ therapy were collected over a 7 week period from 9 Rheumatology departments.

Results:

473 patients were included of which 56 (12%) were new starters and 417 (88%) were already established on HCQ. 79% of the patients were female, with median ages of 60.5 and 57 years for new and established patients respectively. The median (IQR) weight for new starters was 71 (27.9) kg and for established patients, 74 (24.7) kg.

20% of new starters exceeded 5mg/kg daily HCQ dose. 16% were identified as high risk (9% had previously taken chloroquine, 5% had an eGFR <60ml/min/m2and 2% had retinal co-pathology). Of the high-risk group, 44% were taking <5mg/kg. In total, 36% of new starters were referred for a formal baseline Ophthalmology review.

In the established patients, 74% were taking ≤5mg/kg/day HCQ dose and 16% were categorized as high risk (10% had an eGFR less than 60ml/min/m2, 3% had previous chloroquine or tamoxifen use and 2% had retinal co-pathology). In the high-risk group, 75% were not referred for spectral domain optical coherence tomography (SD-OCT). 41% of patients established on HCQ for <5 years, and 33% of patients on HCQ for >5 years were not referred for SD-OCT. Reasons for not referring included; awaiting 5 year review, previous screening already performed and optician review advised.

Since the introduction of the RCOphth guidelines, 29% patients already established on HCQ had an alteration in the dosage of HCQ in accordance with the guidelines. In the high-risk group, 16% were not on the recommended HCQ dose.

Conclusion:

This audit demonstrates inconsistencies in adherence to the RCOphth guidelines for HCQ prescribing and ophthalmology screening within Rheumatology departments in the North-West of the UK for both new starters and established patients. Plans to improve this include wider dissemination of the guidelines to Rheumatology departments and strict service level agreements with ophthalmology teams to help optimize HCQ prescribing and screening for retinopathy.

Acknowledgments:

Drs. S Jones, E MacPhie, A Madan, L Coates & Prof L Teh. Co-1st author, T David.

Disclosure of Interests:

None declared

Deworming children for soil-transmitted helminths in low and middle-income countries: systematic review and individual participant data network meta-analysis

Intestinal parasites affect millions of children globally. We aimed to assess effects of deworming children on nutritional and cognitive outcomes across potential effect modifiers using individual participant data (IPD). We searched multiple databases to 27 March 2018, grey literature, and other sources. We included randomised and quasi randomised trials of deworming compared to placebo or other nutritional interventions with data on baseline infection. We used a random-effects network meta-analysis with IPD and assessed overall quality, following a pre-specified protocol. We received IPD from 19 trials of STH deworming. Overall risk of bias was low. There were no statistically significant subgroup effects across age, sex, nutritional status or infection intensity for each type of STH. These analyses showed that children with moderate or heavy intensity infections, deworming for STH may increase weight gain (very low certainty). The added value of this review is an exploration of effects on growth and cognition in children with moderate to heavy infections as well as replicating prior systematic review results of small effects at the population level. Policy implications are that complementary public health strategies need to be assessed and considered to achieve growth and cognition benefits for children in helminth endemic areas.

Mass deworming for improving health and cognition of children in endemic helminth areas: A systematic review and individual participant data network meta-analysis

Background

Soil transmitted (or intestinal) helminths and schistosomes affect millions of children worldwide.

Objectives

To use individual participant data network meta-analysis (NMA) to explore the effects of different types and frequency of deworming drugs on anaemia, cognition and growth across potential effect modifiers.

Search Methods

We developed a search strategy with an information scientist to search MEDLINE, CINAHL, LILACS, Embase, the Cochrane Library, Econlit, Internet Documents in Economics Access Service (IDEAS), Public Affairs Information Service (PAIS), Social Services Abstracts, Global Health CABI and CAB Abstracts up to March 27, 2018. We also searched grey literature, websites, contacted authors and screened references of relevant systematic reviews.

Selection Criteria

We included randomised and quasirandomised deworming trials in children for deworming compared to placebo or other interventions with data on baseline infection.

Data Collection and Analysis

We conducted NMA with individual participant data (IPD), using a frequentist approach for random-effects NMA. The covariates were: age, sex, weight, height, haemoglobin and infection intensity. The effect estimate chosen was the mean difference for the continuous outcome of interest.

Results

We received data from 19 randomized controlled trials with 31,945 participants. Overall risk of bias was low. There were no statistically significant subgroup effects across any of the potential effect modifiers. However, analyses showed that there may be greater effects on weight for moderate to heavily infected children (very low certainty evidence).

Authors' Conclusions

This analysis reinforces the case against mass deworming at a population-level, finding little effect on nutritional status or cognition. However, children with heavier intensity infections may benefit more. We urge the global community to adopt calls to make data available in open repositories to facilitate IPD analyses such as this, which aim to assess effects for the most vulnerable individuals.

Evidence From Ghana Indicates That Childhood Cancer Treatment in Sub-Saharan Africa Is Very Cost Effective: A Report From the Childhood Cancer 2030 Network

Purpose

No published study to date has examined total cost and cost-effectiveness of maintaining a pediatric oncology treatment center in an African setting, thus limiting childhood cancer advocacy and policy efforts.

Methods

Within the Korle Bu Teaching Hospital in Accra, Ghana, costing data were gathered for all inputs related to operating a pediatric cancer unit. Cost and volume data for relevant clinical services (eg, laboratory, pathology, medications) were obtained retrospectively or prospectively. Salaries were determined and multiplied by proportion of time dedicated toward pediatric patients with cancer. Costs associated with inpatient bed use, outpatient clinic use, administrative fees, and overhead were estimated. Costs were summed for a total annual operating cost. Cost-effectiveness was calculated based on annual patients with newly diagnosed disease, survival rates, and life expectancy.

Results

The Korle Bu Teaching Hospital pediatric cancer unit treats on average 170 new diagnoses annually. Total operating cost was $1.7 million/y. Personnel salaries and operating room costs were the most expensive inputs, contributing 45% and 21% of total costs. Together, medications, imaging, radiation, and pathology services accounted for 7%. The cost per disability-adjusted life-year averted was $1,034, less than the Ghanaian per capita income, and thus considered very cost effective as per WHO-CHOICE methodology.

Conclusion

To our knowledge, this study is the first to examine institution-level costs and cost-effectiveness of a childhood cancer program in an African setting, demonstrating that operating such a program in this setting is very cost effective. These results will inform national childhood cancer strategies in Africa and other low- and middle-income country settings.

Impact of behaviour change communication interventions on sales of fortified sunflower oil in Tanzania: A spatial-temporal analysis and association study

The Masava project was implemented in Manyara and Shinyanga regions in Tanzania to improve vitamin A intake by making available vitamin A-fortified sunflower oil with a subsidy through a mobile phone-based e-Voucher system. This study was conducted to assess the impact of the behaviour change communication (BCC) campaign of the project on volume of sales of vitamin A-fortified sunflower oil. The e-Voucher system provides real-time data on the number of e-Vouchers redeemed. The number, type, and locations of BCC events were obtained from the implementation agency. Multivariate linear regression was used to examine the associations between (a) the number and type of BCC events conducted in a ward and the volume of subsequent fortified oil redeemed in the ward and (b) distance of clinic shows, a component of the BCC campaign, from participating retailers and the volume of fortified oil redeemed in the store. After 1 year of the campaign, the volume of fortified oil redeemed monthly increased by more than 5 times in Manyara and by more than three times in Shinyanga. Among the different types of BCC events conducted, only clinic shows and cooking shows were significantly associated with the volume of redemptions (p < .05). Compared with retailers where at least one clinic show was conducted within 0.5 km from its location, the volume of redemptions was significantly lower at retailers where no clinic show conducted within 3.0 km from its location (p < .05). These findings suggest that future health promotion interventions in rural Africa should involve health clinics.

Experience with the Jostra Rotaflow and QuadroxD oxygenator for ECMO

Since April 1988, we have been able to offer extracorporeal membrane oxygenation (ECMO) to patients who are either failing ventilation or who need cardiopulmonary support following cardiac surgery. During this time, we have supported 211 patients, the majority of whom have been supported with the Avecor (Affinity, Avecor Cardiovascular Inc., Minneapolis, MN, USA) spiral wound silicone-membrane oxygenator. Microporous hollow-fibre oxygenators have been used (18%) at our center. However, due to their early failure, they have necessitated conversion to a device that potentially would last for the entire ECMO course, i.e., Avecor and, subsequently, have not been used routinely until the introduction of the QuadroxD (Jostra Medizintechnik AG, Hirrlingen, Germany). The recent development of the poly-4-methyl-1-pentene diffusion membrane allows us to utilize hollow-fibre technology with a true (nonmicroporous) membrane. This has enabled us to use this low-resistance device with all its inherent advantages, without plasma leakage necessitating circuit changeover. From July 2000, we have used the QuadroxD oxygenator for our patients requiring ECMO support. This has been in patients with weights ranging from 2.16-51.0 kg ( n = 23), with the longest support being for 1119 hours. This new technology has enabled us to utilize a single device for all patient sizes, so we now have an ECMO circuit set up at all times, minimizing the time required for support to be available, potentially improving survivor morbidity.

Pump-induced haemolysis: a comparison of short-term ventricular assist devices

Centrifugal pumps are superior to roller pumps for extended support durations in terms of pump-induced haemolysis. In this study, we evaluated the commonly used Biomedicus BP 50 and compared it with the Jostra Rotaflow and a standard roller pump in an in vitro test circuit. Each circuit was run for a six-day period and repeated five times. Plasma haemoglobin values showed the roller pump to become more haemolytic than the Biomedicus ( p = 0.022) and the Rotaflow. A statistically significant difference between the Biomedicus and the Rotaflow was observed on day six of the trial ( p = 0.016), with the Rotaflow showing lower levels of haemolysis than the Biomedicus. These results support the use of the new generation centrifugal pump, the Rotaflow, as a suitable device for short-term ventricular assist.

Extracorporeal membrane modality conversions

We report the case of a patient with cardiovascular and respiratory failure due to severe anaphylaxis requiring multiple extracorporeal membrane oxygenation (ECMO) cannulation strategies to provide adequate oxygen delivery and ventilatory support during a period of rapid physiological change. ECMO provides partial or complete support of oxygenation-ventilation and circulation. The choice of which ECMO modality to use is governed by anatomical (vessel size, cardiovascular anatomy and previous surgeries) and physiological (respiratory and/or cardiac failure) factors. The urgency with which ECMO needs to be implemented (emergency cardiopulmonary resuscitation (eCPR), urgent, elective) and the institutional experience will also influence the type of ECMO provided. Here we describe a 12-year-old schoolgirl who, having been resuscitated with peripheral veno-venous (VV) ECMO for severe hypoxemia due to status asthmaticus in the setting of acute anaphylaxis, required escalation to peripheral veno-arterial (VA) ECMO for precipitous cardiovascular deterioration. Insufficient oxygen delivery for adequate cellular metabolic function and possible cerebral hypoxia due to significant differential hypoxia necessitated ECMO modification. After six days of central (transthoracic) VA ECMO support and 21 days of intensive care unit (ICU) care, she made a complete recovery with no neurological sequelae. The use of ECMO support warrants careful consideration of the interplay of a patient's pathophysiology and extracorporeal circuit dynamics. Particular emphasis should be placed on the potential for mismatch between cardiovascular and respiratory support as well as the need to meet metabolic demands through adequate cerebral, coronary and systemic oxygenation. Cannulation strategies occasionally require alteration to meet and anticipate the patient's evolving needs.

A comparison study of haemolysis production in three contemporary centrifugal pumps

One challenge in providing extracorporeal circulation is to supply optimal flow while minimising adverse effects, such as haemolysis. To determine if the recent generation constrained vortex pumps with their inherent design improvements would lead to reduced red cell trauma, we undertook a study comparing three devices. Utilizing a simulated short-term ventricular assist circuit primed with whole human blood, we examined changes in plasma free haemoglobin values over a six-day period. The three pumps investigated were the Maquet Rotaflow, the Levitronix PediVAS and the Medos Deltastream DP3.This study demonstrated that all three pumps produced low levels of haemolysis and are suitable for use in a clinical environment. The Levitronix PediVAS was significantly less haemolytic than either the Rotaflow (p<0.05) or the DP3 (p<0.05). There was no significant difference in plasma free haemoglobin between the Rotaflow and the DP3 (p=0.71).

Examining the relationship between relative age, competition level, and dropout rates in male youth ice-hockey players

The relative age effect suggests that athletes born in the first two quartiles of a given selection year experience a selection advantage and therefore a greater opportunity for success. We describe two studies examining the relationship between relative age, competition level, and dropout rates of Ontario Minor Hockey Association male ice-hockey players from ages 10 to 15 years (n = 14 325). In Study 1, dropout was highest among players born in quartiles three and four [χ(2) (3) = 16.32, P < 0.05; w = 0.06], while Study 2 found dropped out players to have less movement between competition levels compared to retained players. This study confirms a relationship between relative age and dropout from ice-hockey and adds further depth to our understanding of this persistent phenomenon.

Palliative care for dementia--time to think again?

It is estimated that there are 35.6 million people with dementia worldwide and this is projected to increase to over 115 million by the year 2050. Dementia is a progressive neurodegenerative disease that significantly reduces survival. End-of-life care received by this group is often poor and does not equate to that offered in other life limiting illnesses. This review highlights results from a large UK study of informal carers of people with dementia to explore what are determinants of care for people with dementia and their family carers. New perspectives as to models of care for end-of-life care for patients with dementia are discussed together with how these may be implemented and delivered within wider community settings and contexts, where many people with dementia may be cared for in the future.

A peer-led decision support intervention improves decision outcomes in black women with breast cancer

Previous reports suggest that Black breast cancer patients receive less patient-centered cancer care than their White counterparts. Interventions to improve patient-centered care (PCC) in Black breast cancer patients are lacking. Seventy-six women with histologically confirmed breast cancer were recruited from the Washington, DC area. After a baseline telephone interview, women received an in-person decision support educational session led by a trained survivor coach. The coach used a culturally appropriate guidebook and decision-making model-TALK Back!(©) A follow-up assessment assessed participants' acceptability of the intervention and intermediate outcomes. After the intervention, participants reported increased: self-efficacy in communicating with providers (70 %) and self-efficacy in making treatment decisions (70 %). Compared to baseline scores, post-intervention communication with providers significantly increased (p= .000). This is the first outcome report of an intervention to facilitate PCC in Black breast cancer patients. Testing this intervention using RCTs or similar designs will be important next steps.

Fetal left brachiocephalic vein in normal and abnormal conditions

OBJECTIVES

To establish values of fetal left brachiocephalic vein (LBCV) dimensions during normal pregnancy and determine whether routine assessment of the LBCV may help in identifying fetuses with congenital abnormalities of this vessel.

METHODS

Fetal LBCV was assessed prospectively during ultrasound examinations in 431 normal singleton pregnancies. The visualization rate of the transverse view of the upper fetal chest at the level of drainage of the LBCV into the superior vena cava (SVC) by two-dimensional (2D) and 2D plus color Doppler ultrasound was evaluated. Reference ranges of LBCV diameter during non-complicated pregnancies were established. Interobserver and intraobserver measurement variability was analyzed. In addition, a retrospective review of the hospital medical records of 91 pregnancies with fetuses diagnosed with LBCV abnormalities was performed.

RESULTS

Sonographic assessment of the fetal LBCV was consistently achieved in the second and third trimesters and in some fetuses in the first trimester of pregnancy. In normal fetuses LBCV diameter increased significantly throughout pregnancy, with a mean value of 0.7 mm at 11 weeks and 4.9 mm at term. Dilation of the fetal LBCV was noted in five cases of intracranial arteriovenous malformation and six cases of supracardiac type total anomalous pulmonary venous connection. Abnormal course of the LBCV was noted in 12 fetuses. In 63 fetuses with a persistent left SVC and a right SVC the LBCV was absent.

CONCLUSION

This is the first study describing an effective sonographic approach for the assessment of fetal LBCV dimensions during pregnancy. The normative data may provide an additional means of detecting rare anomalies of systemic and pulmonary veins during pregnancy.

Defining the fetal cardiac axis between 11 + 0 and 14 + 6 weeks of gestation: experience with 100 consecutive pregnancies

OBJECTIVE

The purpose of this study was to establish normal fetal cardiac axis values during the first and early second trimesters of pregnancy.

METHODS

This was a prospective observational cohort study in which the fetal cardiac axis was assessed during ultrasound examinations in 100 consecutive fetuses between 11 + 0 and 14 + 6 weeks of gestation. Transabdominal, and, when indicated, transvaginal, approaches were used. Intraobserver and interobserver reproducibility were calculated.

RESULTS

The cardiac axis ranged from 34.5 to 56.8° (mean (SD) 47.6 ± 5.6°) in 94 fetuses with normal cardiac anatomy. The fetal cardiac axis tended to be significantly higher in fetuses at 11 + 0 to 11 + 6 weeks of gestation than in fetuses at 12 + 0 to 14 + 6 weeks of gestation. Congenital heart defects were found in six out of 100 fetuses, four of which had abnormal cardiac axis values at 11 + 0 to 14 + 6 weeks of gestation.

CONCLUSION

Cardiac axis measurement is possible in the first and early second trimesters of pregnancy. The assessment of cardiac axis at an early gestational age may help to identify pregnancies at high risk for congenital heart defects. Copyright

Iodine Status and Availability of Iodized Salt: An Across-Country Analysis

Background

Iodine deficiency has serious consequences, and the Universal Salt Iodization initiative has attempted to reduce the extent of deficiency.

Objective

We aim to see how far across-country variations in urinary iodine in school-age children can be explained by environmental factors, particularly soil iodine and the availability of iodized salt.

Methods

We use simple multivariate regression for two separate datasets, one for 30 developing countries, and one for 13 developed countries, using data on availability of iodized salt and soil iodine levels.

Results

Median urinary iodine excretion is significantly and positively related to household availability of iodized salt (elasticity, 0.73) for developing countries, but the soil coefficient is not significant, probably because the dummy variable is not well measured. For the developed countries, there is a positive and significant effect of salt penetration rates (elasticity, 0.83) and a positive and significant effect of soil iodine (elasticity, 0.77). There is also a suggestion that countries with more serious soil deficits are more likely to iodize salt, so that univariate regressions of urinary iodine excretion on salt availability or penetration rates underestimate the beneficial effects of iodized salt availability on iodine nutrition.

Conclusions

There are limitations to cross-sectional (ecologic) studies such as this, and the data are not perfect. Nevertheless, the results provide support for policies to iodize salt, given the widespread deficiency of iodine in diets worldwide.

Cross-contamination in the Molecular Detection of Bartonella from Paraffin-embedded Tissues

The genus Bartonella comprises a group of gram-negative, fastidious bacteria. Because of diagnostic limitations of culture and serologic testing, polymerase chain reaction (PCR) has become a powerful tool for the detection of Bartonella spp. in blood and tissue samples. However, because many wild and domestic animals harbor Bartonella spp., transfer of Bartonella DNA during sample collection or histologic processing could result in false-positive PCR test results. In this study, we describe evidence of Bartonella DNA dissemination and transfer in the necropsy room and during the subsequent processing of formalin-fixed paraffin-embedded tissues. Bartonella DNA was amplified from different areas of the necropsy room, from the liquid paraffin in the tissue processor, and from different parts of the microtome. Unless stringent procedures are established and followed to avoid cross-contamination, the molecular detection of Bartonella spp. from tissue samples obtained at necropsy or processed in a multispecies histopathology laboratory will not be reliable.

The costs and cost-effectiveness of mass treatment for intestinal nematode worm infections using different treatment thresholds

Background

It is estimated that almost a half of all of people living in developing countries today are infected with roundworms, hookworms, or whipworms or combinations of these types of intestinal nematode worms. They can all be treated using safe, effective, and inexpensive single-dose generic drugs costing as little as USD 0.03 per person treated when bought in bulk. The disease caused by intestinal nematodes is strongly related to the number of worms in the gut, and it is typical to find that worms tend to be aggregated or clumped in their distribution so that <20% of people may harbour >80% of all worms. This clumping of worms is greatest when the prevalence is low. When the prevalence rises above 50%, the mean worm burden increases exponentially, worms are less clumped, and more people are likely to have moderate to heavy infections and may be diseased. Children are most at risk. For these reasons, the World Health Organization (WHO) currently recommends mass treatment of children ≥1 year old without prior diagnosis when the prevalence is ≥20% and treatment twice a year when the prevalence is ≥50%.

Methods and Findings

The risk of moderate to heavy infections with intestinal nematodes was estimated by applying the negative binomial probability distribution, then the drug cost of treating diseased individuals was calculated based on different threshold numbers of worms. Based on this cost analysis, a new three-tier treatment regime is proposed: if the combined prevalence is >40%, treat all children once a year; >60% treat twice a year; and >80% treat three times a year. Using average data on drug and delivery costs of USD 0.15 to treat a school-age child and USD 0.25 to treat a pre-school child (with provisos) the cost of treating children aged 2–14 years was calculated for 105 low- and low-middle-income countries and for constituent regions of India and China based on estimates of the combined prevalence of intestinal nematode worms therein. The annual cost of the three-tier threshold was estimated to be USD 224 million compared with USD 276 million when the current WHO recommendations for mass treatment were applied.

Conclusion

The three-tier treatment thresholds were less expensive and more effective as they allocated a greater proportion of expenditures to treating infected individuals when compared with the WHO thresholds (73% compared with 61%) and treated a larger proportion of individuals with moderate to heavy worm burdens, arbitrarily defined as more than 10 worms per person (31% compared with 21%).

Almost one in every two people in the developing world is infected with one or more types of intestinal nematode worms. When fewer than 50% of people are infected, most carry only a few worms; but when more than 50% are infected, the number carrying moderate to heavy numbers increases markedly, as does the risk of disease. The WHO recommends annual mass deworming of children when 20% or more are infected and twice a year if 50% or more are infected. We estimated the cost of this to treat children with 10+ worms, an arbitrary moderate to heavy infection. We concluded that it is not cost-effective to mass treat children when fewer than 40% are infected because the majority are uninfected and few are likely be diseased. We propose annual treatment when 40% or more children are infected, twice a year at 60%, and three times a year at 80% or more. This would cost USD 224 million annually to treat all children aged 2–14 years in 107 developing countries compared with USD 276 million using current WHO guidelines. The new three-tier guidelines also treat a larger proportion of infected children and treat children with moderate to heavy worm burdens more often.

Clinical investigation of the novel iron-chelating agent, CP94, to enhance topical photodynamic therapy of nodular basal cell carcinoma

BACKGROUND

Photodynamic therapy (PDT) involves the activation of a photosensitizer by visible light to produce activated oxygen species within target cells, resulting in their destruction. Evidence-based guidelines support the efficacy of PDT using topical 5-aminolaevulinic acid (ALA-PDT) in actinic keratoses, Bowen disease and basal cell carcinoma (BCC). Efficacy for nodular BCC appears inferior to that for superficial BCC unless prior debulking or repeat treatments are performed. Objectives The aim of this study was to assess the safety and efficacy of adding a novel iron-chelating agent, CP94 (1,2-diethyl-3-hydroxypyridin-4-one hydrochloride), to topical ALA, to temporarily increase the accumulation of the photosensitizer in the tumour.

METHODS

A mixed topical formulation of ALA + increasing concentrations of CP94 was used to carry out PDT on previously biopsied nodular BCC with no prior lesion preparation using standard light delivery. The area was assessed clinically and surgically excised 6 weeks later for histological examination.

RESULTS

Enhanced PDT using 40% CP94 resulted in significantly greater clearance rates in nodular BCC than with ALA-PDT alone, in our protocol of single-treatment PDT with no lesion preparation.

CONCLUSIONS

The results of this study demonstrate the safe and effective use of an enhanced ALA-PDT protocol for nodular BCC using CP94, with no adverse reactions to this modification. This is the first time this formulation has been used in patients. This formulation is now the focus of further study.

The economics of food fortification

This paper summarizes some of the literature on the cost effectiveness and cost benefit of food fortification with selected micronutrients most relevant for developing countries. Micronutrients covered include iron, iodine, vitamin A, and zinc. The main focus is on commercial fortification, although home fortification and biofortification are mentioned. Fortification with iron, vitamin A, and zinc averts significant numbers of infant and child deaths and is a very attractive preventive health-care intervention. Fortification with iron, iodine, and potentially zinc provides significant economic benefits and the low unit cost of food fortification ensures large benefit:cost ratios, with effects via cognition being very important for iron and iodine. Fortification will not reach all individuals and is most attractive as an investment where there is a convenient food vehicle, where processing is more centralized, and where either the deficiency is widespread or the adverse effects are very costly even though only a small group is affected.

Teaching and learning speech and language therapy skills: the effectiveness of classroom as clinic in speech and language therapy student education

BACKGROUND

Terms such as 'clinical intuition' have often been applied to the practice of speech and language therapy. Various authors have aimed to make the process of therapy practice more explicit, and it is argued that recently developed descriptive/analytic frameworks have the potential to engender the critical mindset necessary for student speech and language therapists to become good reflective practitioners, with the potential for enhancing clinical education.

AIMS

To investigate whether and how aspects of clinical skills education could be usefully addressed in an academic, as opposed to a clinical, setting. The study aimed to address the question of whether use of an interaction analysis system, in conjunction with video observation, and 'practice simulation' in a teaching-learning programme could be shown to have a positive impact on: (1) students' perceptions of their own understanding and practice of therapy, and their perceptions of themselves as self-reflective practitioners; and whether (2) this was borne out by students' ability to observe and interpret therapeutic interaction, as measured by (i) an objective written assessment; (ii) an objective video observation assessment; and (iii) assessment of their abilities in clinical practice.

METHODS & PROCEDURES

Thirty-six students from City University took part in an experimental, placebo-controlled study using a deferred intervention design. Assessments designed to reflect changes resulting from the teaching-learning curriculum were carried out pre- and post-intervention with experimental and control groups. Quantitative and qualitative results were obtained.

OUTCOMES & RESULTS

The intervention programme was found to have had a significant impact on students' perceptions of their understanding of therapy, but not on their perceptions of their practice of therapy. The experimental group scored significantly better on a written assessment of 'interpretation of therapy interaction', but were no better than the control group on a 'Video observation' assessment. Owing to attrition and the poor quality of videos submitted for assessment, it was not possible to measure changes in actual clinical practice. Qualitative feedback from the teaching-learning programme suggests that students generally found the approach to be beneficial.

CONCLUSIONS

While there were some encouraging results, it is still uncertain whether addressing the actual practice of therapy in an academic setting gives 'added value' to the work carried out on clinical placements. However, there is no doubt that bringing this type of programme under the umbrella of an academic institution would greatly increase the consistency of teaching and the range of experiences available to students.

East African running dominance revisited: a role for stereotype threat?

Regardless of the possible existence of physiological advantages in East African runners, belief that such differences exist creates a psychological atmosphere that can have significant consequences on performance. This is known as stereotype threat and can feature in many sports.

Trends in diet, nutritional status, and diet-related noncommunicable diseases in China and India: the economic costs of the nutrition transition

Undernutrition is being rapidly reduced in India and China. In both countries the diet is shifting toward higher fat and lower carbohydrate content. Distinct features are high intakes of foods from animal sources and edible oils in China, and high intakes of dairy and added sugar in India. The proportion of overweight is increasing very rapidly in China among all adults; in India the shift is most pronounced among urban residents and high-income rural residents. Hypertension and stroke are relatively higher in China and adult-onset diabetes is relatively higher in India. Established economic techniques were used to measure and project the costs of undernutrition and diet-related noncommunicable diseases in 1995 and 2025. Current WHO mortality projections of diet-related noncommunicable diseases, dietary and body composition survey data, and national data sets of hospital costs for healthcare, are used for the economic analyses. In 1995, China's costs of undernutrition and costs of diet-related noncommunicable diseases were of similar magnitude, but there will be a rapid increase in the costs and prevalence of diet-related noncommunicable diseases by 2025. By contrast with China, India's costs of undernutrition will continue to decline, but undernutrition costs did surpass overnutrition diet-related noncommunicable disease costs in 1995. India's rapid increase in diet-related noncommunicable diseases and their costs projects similar economic costs of undernutrition and overnutrition by 2025.

Commentary on "evidence that iron deficiency anemia causes reduced work capacity"

This commentary assesses the strength of the causal evidence presented by Haas and Brownlie in this supplement and examines the potential magnitude of iron-deficiency anemia on welfare. From both the laboratory and field experiments, the evidence is strong and suggests that the potential magnitude of the effect of iron-deficiency anemia on work productivity is substantial. This commentary briefly discusses some of the limitations of using the estimates of effects on physiological capacity for measuring the effect on the social and economic well-being of individuals and society. Biological data are relevant to social and economic development, but additional field studies may be as important as the laboratory experiments to answer questions that also affect work productivity, household maintenance and child raising activities, and hence affect social and economic development. We extend the critical evidence review of human field studies that received disproportionately less attention than the laboratory studies in Haas and Brownlie. We provide some estimates of the magnitude of effects on well-being based on how this information has been used. Future field studies that examine the effect of iron-deficiency anemia and work output in an economic sense should measure increases in productivity but should complement this information with data on wages, income or some measure of profits to derive a money metric measure of increased productivity. Additional information on individual time allocation in household work, child care and leisure may also be required to capture social benefits deriving from improved work capacity.

Neurogenin2 expression in ventral and dorsal spinal neural tube progenitor cells is regulated by distinct enhancers

The basic helix-loop-helix transcription factor Neurogenin2 (NGN2) is expressed in distinct populations of neural progenitor cells within the developing central and peripheral nervous systems. Transgenic mice containing ngn2/lacZ reporter constructs were used to study the regulation of ngn2 in the developing spinal cord. ngn2/lacZ transgenic embryos containing sequence found 5' or 3' to the ngn2 coding region express lacZ in domains that reflect the spatial and temporal expression profile of endogenous ngn2. A 4.4-kb fragment 5' of ngn2 was sufficient to drive lacZ expression in the ventral neural tube, whereas a 1.0-kb fragment located 3' of ngn2 directed expression to both dorsal and ventral domains. Persistent -gal activity revealed that the NGN2 progenitor cells in the dorsal domain give rise to a subset of interneurons that send their axons to the floor plate, and the NGN2 progenitors in the ventral domain give rise to a subset of motor neurons. We identified a discrete element that is required for the activity of the ngn2 enhancer specifically in the ventral neural tube. Thus, separable regulatory elements that direct ngn2 expression to distinct neural progenitor populations have been defined.

Examining interaction in language therapy

Discussions around a 'theory of therapy' have prompted attempts to delineate the components of therapy for language impairment in aphasia. Here it is suggested that the therapy components associated with how language therapy is enacted need more precise specification, especially in relation to what is entailed by interaction between therapist and person with aphasia. Presented too is a system used for the analysis of interaction in language impairment therapy for aphasia and its possible applications are discussed. Components of the system are described and a sample analysis presented. The methodological difficulties entailed in making comparisons of therapy enactment are discussed. It is suggested furthermore that unless more is known about precisely defined interactions in therapy, it will be difficult to answer basic questions not only about how language therapy is being carried out, but also, subsequently, whether the ways in which therapy tasks are enacted have a significant impact on the outcome.

Preoperative and postoperative considerations for carbon dioxide laser resurfacing

Cutaneous laser resurfacing is a tremendous advance in the treatment of photoaged skin. With the recent developments in laser technology, the procedure has become widely utilized among many physician subspecialists. The latest laser systems permit controlled vaporization of skin so that most novice operators feel comfortable with the technique in a short period of time. Nevertheless, there are many issues that need to be addressed before performing the procedure. First, not every person is an appropriate candidate for laser resurfacing. Second, both the physician and the patient must be aware of the preoperative preparation and prolonged postoperative care involved with the procedure. Finally, the physician must be able to identify and treat, and the patient must be educated about, the side effects and potential complications associated with the procedure. It is only by addressing these issues that the clinical results obtained by CO2 laser resurfacing can be maximized.

Safety and toxicity of nonoxynol-9 gel as a rectal microbicide

BACKGROUND AND OBJECTIVES

Methods of HIV and STD prevention, which can be controlled by the receptive partner, are a high priority for research and development. Studies on the safety of Nonoxynol-9 (N-9) on the vaginal mucosa have yielded conflicting results. No Phase I study has evaluated the effect of N-9 on the rectal mucosa.

GOALS

To assess the safety of 52.5 mg of N-9 in a 1.5-g gel when applied one to four applicators per day to the rectum and penis.

STUDY DESIGN

The study included 25 HIV-negative and 10 HIV-positive, monogamous gay male couples in which each partner was exclusively insertive or receptive while using N-9 gel. Each participant served as his own control during placebo gel use compared to during N-9 gel use. Receptive partners underwent anoscopic examination after 1 week of placebo use and after 2, 5, and 6 weeks of N-9 gel use, with rectal biopsies obtained after 1 week of placebo use and after 5 and 6 weeks of N-9 gel use. Insertive partners had safety monitoring after 1 week of placebo use and after 2, 5, and 6 weeks of N-9.

RESULTS

No rectal ulcers were detected; superficial rectal erosions were noted in two HIV-negative participants. Abnormal or slightly abnormal histologic abnormalities of rectal biopsies were detected in 31 (89%) receptive participants after N-9 gel use compared to 24 (69%) participants after 1 week of placebo gel use. Meatal ulceration, not caused by herpes simplex virus, was detected in one HIV-negative participant.

CONCLUSION

Low-dose N-9 gel was not associated with macroscopic rectal and penile epithelial disruption or inflammation, but histologic abnormalities were commonly observed during N-9 gel as well as during placebo gel use.