Hospital wastewater (HWW) treatment in low- and middle-income countries: A systematic review of microbial treatment efficacy

BACKGROUND

Proper treatment of hospital wastewater (HWW) is crucial to minimize the long-term effects on human health and aquatic ecosystems. However, the majority of HWW generated in low and middle-income countries (LMICs), is discharged without adequate treatment. This systematic review aims to fill the knowledge gap in LMICs by examining the efficacy of HWW treatment and the types of technologies used.

METHODS

Studies included in the review offered valuable insights into the current state of HWW management in LMICs. Between 2000 and 2022, only 36 research studies focused on hospital-based wastewater treatment within LMICs. Data were extracted on wastewater treatment technologies in hospitals or healthcare settings in LMICs. Data on sampling techniques, effectiveness, microorganisms and risk of bias of included studies were recorded.

RESULTS

A total of 36 articles met the eligibility criteria: mentioned about 1) hospitals 2) wastewater treatment 3) LMICs and 4) treatment efficacy. Twenty-two studies were conducted in Asia (22/36), 17 were conducted in countries with high Human Development Index. Constructed wetland, and activated sludge process were the most common technologies used in LMICs. A few studies utilized membrane bioreactors and ozone/UV treatment. Fourteen studies reported the concentration reduction to assess the microbial efficacy of the treatment process, 29/36 studies did not meet the national standards for effluent discharge. Reporting on sampling methods, wastewater treatment processes and efficacy of HWW treatment were at high risk of bias. Extreme heterogeneity in study methods and outcomes reporting precluded meta-analysis.

CONCLUSIONS

The existing evidence indicates inadequate microbial treatment in low- and middle-income country hospitals, with this systematic review emphasizing the need for improvement in healthcare waste management. It underscores the importance of long-term studies using innovative treatment methods to better understand waste removal in LMIC hospitals and calls for further research to develop context-specific healthcare waste treatment approaches in these regions.

Is it selfish to be filamentous in biofilms? Individual-based modeling links microbial growth strategies with morphology using the new and modular iDynoMiCS 2.0

Microbial communities are found in all habitable environments and often occur in assemblages with self-organized spatial structures developing over time. This complexity can only be understood, predicted, and managed by combining experiments with mathematical modeling. Individual-based models are particularly suited if individual heterogeneity, local interactions, and adaptive behavior are of interest. Here we present the completely overhauled software platform, the individual-based Dynamics of Microbial Communities Simulator, iDynoMiCS 2.0, which enables researchers to specify a range of different models without having to program. Key new features and improvements are: (1) Substantially enhanced ease of use (graphical user interface, editor for model specification, unit conversions, data analysis and visualization and more). (2) Increased performance and scalability enabling simulations of up to 10 million agents in 3D biofilms. (3) Kinetics can be specified with any arithmetic function. (4) Agent properties can be assembled from orthogonal modules for pick and mix flexibility. (5) Force-based mechanical interaction framework enabling attractive forces and non-spherical agent morphologies as an alternative to the shoving algorithm. The new iDynoMiCS 2.0 has undergone intensive testing, from unit tests to a suite of increasingly complex numerical tests and the standard Benchmark 3 based on nitrifying biofilms. A second test case was based on the "biofilms promote altruism" study previously implemented in BacSim because competition outcomes are highly sensitive to the developing spatial structures due to positive feedback between cooperative individuals. We extended this case study by adding morphology to find that (i) filamentous bacteria outcompete spherical bacteria regardless of growth strategy and (ii) non-cooperating filaments outcompete cooperating filaments because filaments can escape the stronger competition between themselves. In conclusion, the new substantially improved iDynoMiCS 2.0 joins a growing number of platforms for individual-based modeling of microbial communities with specific advantages and disadvantages that we discuss, giving users a wider choice.

The impact of adolescent suicide on clinicians: a mixed-methods study

BACKGROUND

Clinician reactions to client suicide may include shock, grief, guilt, self-doubt, shame, anger, and fears of blame and medico-legal consequences. Clinicians will often differ in their reactions to the suicide and the type of supports required. Adolescent suicide-specific literature is limited.

AIMS

We sought to explore clinician reactions and perceptions of support following child and adolescent suicide.

METHODS

One hundred and fifteen staff working for a Child and Adolescent Mental Health Service were invited to complete an online survey with quantitative and qualitative components, and an in-depth semi-structured interview. Results were presented to teams for reflection and further feedback.

RESULTS

Eight clinicians participated in the semi-structured interview, and 33 in the online survey. Thirteen were the primary clinician, and 21 were part of a multi-disciplinary team when a client suicided. Respondents were predominantly female, from a range of disciplines. Fifty per cent of primary clinicians found the support good to very good. The rest were neutral. However, 26% of team members found support poor to very poor. Clinicians reported questioning their clinical effectiveness and chosen vocation. Some reported a need to disconnect or withdraw to preserve motivation and empathy for the work. They received significant support from their team, and teams were very anxious for the well-being of primary clinicians.

CONCLUSIONS

Health services must find ways of helping staff feel that their sense of vocation is valued and nurtured. These strategies will likely include fostering team cohesiveness and mutual support and allowing opportunities to temporarily step back and recover after challenging experiences.

In vitro digestion of designed emulsions based on milk protein and guar gum systems

There is a growing interest in designing novel food microstructures that can control nutrient digestion and provide satiety for tackling obesity. In this study, phase separated microstructures of skimmed milk powder (SMP) and guar gum (GG) were the main focus, and these can be considered as water-in-water (W/W) emulsions. Through the incorporation of oil into these systems, it was possible to form model systems of SMP-GG-OIL, showing the lipid phase within the protein phase within the polysaccharide phase. The in vitro digestibility of such phase separated model systems of SMP-GG-OIL with different microstructures was investigated using a pH stat method. Confocal laser scanning microscopy also revealed structural changes that occurred to the emulsified lipid droplets as they passed through a gastrointestinal (GI) model. The microstructures were created based on the tie-lines on a previously established phase diagram of SMP-GG, and shown to be able to control lipid digestion. For a selected tie-line, the lipolysis follows the order: protein continuous > bi-continuous > polysaccharide continuous system, at a certain level of oil addition. The mechanism involved in the lipolysis of the designed formulations/microstructures was dependent upon the protein, rather than GG, and was driven by the protein concentration. These findings provide insights for potential applications in functional food designing in the food industry.

Bystander cardiopulmonary resuscitation for paediatric out-of-hospital cardiac arrest in England: An observational registry cohort study

INTRODUCTION

Bystander cardiopulmonary resuscitation (BCPR) is strongly advocated by resuscitation councils for paediatric out-of-hospital cardiac arrests (OHCAs). However, there are limited reports on rates of BCPR in children and its relationship with return of spontaneous circulation (ROSC) or survival outcomes.

OBJECTIVE

We describe the rate of BCPR and its association with any ROSC and survival- to- hospital-discharge.

METHODS

We conducted retrospective analysis of prospectively collected paediatric (<18 years of age) OHCA cases in England; we included specialist registry patients treated by emergency medical services (EMS) with known BCPR status and outcome between January 2014 and November 2018. Data included patient demographics, aetiology, witness status, initial rhythm, EMS, season, time of day and bystander status. Associations between BCPR, and any ROSC and survival-to-hospital-discharge outcomes were explored using multivariable logistic regression.

RESULTS

There were 2363 paediatric OHCAs treated across 11 EMS regions. BCPR was performed in 69.6% (1646/2363) of the cases overall (range 57.7% (206/367) to 83.7% (139/166) across EMS regions). Only 34.9% (550/1572) of BCPR cases were witnessed. Overall, any ROSC was achieved in 22.8% (523/2289) and survival to hospital discharge in 10.8% (225/2066). Adjusted odds ratio (aOR) for any ROSC was significantly improved following BCPR compared to no BCPR (aOR 1.37, 95% CI 1.03-1.81), but adjusted odds ratio for survival-to-hospital-discharge were similar (aOR 1.01, 95% CI 0.66-1.55).

CONCLUSIONS

BCPR was associated with improved rates of any ROSC but not survival-to-hospital-discharge. Variations in EMS BCPR rates may indicate opportunities for regional targeted increase in public BCPR education.

A method for correcting underestimation of enteric pathogen genome quantities in environmental samples

Exposure to enteric pathogens in the environment poses a serious risk for infection and disease. The accurate detection and quantification of enteric pathogens in environmental samples is critical for understanding pathogen transport and fate and developing risk assessment models. In this study, we successfully applied TaqMan real-time PCR assays to quantitatively detect five human-specific pathogens (Shigella/EIEC, Salmonella Typhi, Vibrio cholera, Norovirus, and Giardia) in samples from open drains, canals, floodwater, septic tanks, and anaerobic baffled reactors (ABR) collected in Mirpur, Dhaka, Bangladesh from April to October 2019. Overall, the grab and sediment samples showed low inhibition but the ultrafiltration samples collected from open drain had significantly higher (P = 0.0049) degree of PCR inhibition (median Ct = 31.06) compared to the extraction controls (Ct = 28.54). We developed a two-step method to adjust underestimation of pathogen quantities due to PCR inhibition and non-optimum PCR efficiency. Compared to other sample types, ultrafiltration samples demonstrated a wide range of concentration increase (1.0%-182.5%) by pathogens after adjusting for PCR inhibition and non-optimum efficiencies. These quantitative qPCR assays are successful in quantifying multiple enteric pathogens in environmental samples, and the adjustment method would be useful for correcting underestimates of pathogen quantities due to partial PCR inhibition and non-optimum efficiency.

Faecal contamination of groundwater self-supply in low- and middle income countries: Systematic review and meta-analysis

Self-supply is a ubiquitous response by households to the public water supply inadequacies found worldwide. Self-supply is invested in and managed by an individual household, accessible on-premises and unregulated. Vulnerability to faecal contamination is a concern due to reliance on low-cost technologies and shallow groundwater. This review aims to evaluate the evidence base on the safety of groundwater self-supply in low- and middle income countries in relation to faecal contamination. Differences in microbial water quality between source types, settings, countries and ownership were investigated. A search of peer-reviewed studies in low- and middle income countries was conducted in online databases, including PubMed, Web of Science, ProQuest and Environmental Complete. Studies were included if they had sufficient detail about the water samples to be related to groundwater self-supply, contained extractable data on faecal indicator bacteria (FIB) including thermotolerant coliform or Escherichia coli and were published in English between 1990 and April 2020. A total of 30 studies were included, resulting in 100 datasets and 26,981 water samples across the studies. FIB were present in 36% self-supply samples. The odds of FIB being detected was significantly higher for unimproved sources (OR=8.19, 95% CI [4.04-16.59], p<0.001) and for sources in low income countries (OR=3.85, 95% CI [1.85-7.69], p<0.001). Self-supply was significantly more likely to be contaminated than piped supply (OR=3.45, 95% CI [1.52-7.82], p=0.003). However, water quality was highly heterogeneous (I²=90.9%). Egger's test found no evidence of small study publication bias for self-supply compared to public supply. No evidence of bias due to lack of randomization or season was found, but study design and quality could potentially bias the results. To achieve Sustainable Development Goal 6.1 on safe drinking water for all, more attention is needed from governments to engage with self-supply and formulate balanced policy responses.

Housing conditions and health in Indigenous Australian communities: current status and recent trends

Ensuring sufficient and adequately maintained housing in Indigenous Australian communities remains an ongoing policy challenge for government, with major implications for the health of Indigenous Australians. This study sought to characterise the current status of housing conditions experienced by Indigenous Australians, with special reference to the Northern Territory. The assessment examined a range of indicators relating to crowding, dwelling condition, 'health hardware', and provision of maintenance and repairs. While acknowledging data deficiencies and inconsistencies, the analysis produced mixed results. There was evidence of a reduction in crowding but little observable improvement in the provision of maintenance and repairs. Some housing-related health outcomes have shown improvement, though these have tended to coincide with mass treatment campaigns. Achieving the goal of healthy homes - and ultimately closing the gap on Indigenous disadvantage - requires further investment in new houses that are appropriately designed and constructed, alongside an increased emphasis on cyclical maintenance.

Reducing sugar and aroma in a confectionery gel without compromising flavour through addition of air inclusions

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Slight aeration of confectionery gels does not impact chewiness perception.

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Air as a low calorie inclusion in gels enhances sweetness perception over time.

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Reduction of aroma, sugar and calories in gels without affecting flavour perception.

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X-ray computed tomography to measure bubble size and distribution.

Sugar plays an important role in both the flavour and structure of confectionery. Targets have been set to reduce sugar; however, common strategies often result in changes in flavour and consumer rejection. In this study, an approach was developed to reduce sugar in confectionery gels by aeration, without significantly affecting perceived chewiness. Gelatine based gels with a 23% and 38% reduction in density were formulated using aeration. Mean bubble size was consistent across all gels (0.05–0.06 mm). Time-intensity sensory evaluation was carried out by a trained sensory panel (n = 10). With aeration, no significant difference in overall flavour perception was observed in the 23% and 38% reduced sugar and aroma gels. Air inclusions create a greater surface area, therefore accelerating mass transfer of volatiles and release of sucrose at the food-saliva interface. Consequently, we propose that less calorie dense products can be produced without compromising flavour by using gel aeration technologies.

Flavour distribution and release from gelatine-starch matrices

Microstructure design of protein-polysaccharide phase separated gels has been suggested as a strategy to nutritionally improve food products. Varying the phase volumes of a phase separated matrix may affect texture and overall flavour balance of the final product, which are both important for consumer acceptance. The aims of this study were to investigate how modifying the phase volumes of a gelatine-starch biphasic mixture affected aroma release, and how addition of sucrose affects phase separation, flavour distribution and aroma release. Biphasic gels of different microstructures with the same effective concentration of gelatine and starch in each phase were developed. Microstructure significantly affected aroma release in vitro but not in vivo when panellists (n = 5) chewed and swallowed the sample. Addition of sucrose (0-60%) to the biphasic mixture significantly reduced water activity, affected the microstructure and affected aroma distribution in each phase and subsequent release rates depending on the physicochemical properties of the aroma volatile. In general, affinity for the gelatine phase for the less hydrophobic, more volatile compounds was not significantly affected by sucrose concentration. Whereas an increased affinity for the starch phase for the more hydrophobic, less volatile compounds was observed with increased sucrose as the starch phase becomes more dispersed at sucrose concentrations between 40 and 60%. The results of this study may be of interest to researchers and industry to enable prediction of how reformulation, such as reduction of sucrose, to meet nutritional guidelines may affect the overall aroma balance of a phase separated food matrix.

Modelling faecal pathogen flows and health risks in urban Bangladesh: Implications for sanitation decision making

Faecal-oral infections are a major component of the disease burden in low-income contexts, with inadequate sanitation seen as a contributing factor. However, demonstrating health effects of sanitation interventions - particularly in urban areas - has proved challenging and there is limited empirical evidence to support sanitation decisions that maximise health gains. This study aimed to develop, apply and validate a systems modelling approach to inform sanitation infrastructure and service decision-making in urban environments by examining enteric pathogen inputs, transport and reduction by various sanitation systems, and estimating corresponding exposure and public health impacts. The health effects of eight sanitation options were assessed in a low-income area in Dhaka, Bangladesh, with a focus on five target pathogens (Shigella, Vibrio cholerae, Salmonella Typhi, norovirus GII and Giardia). Relative to the sanitation base case in the study site (24% septic tanks, 5% holding tanks and 71% toilets discharging directly to open drains), comprehensive coverage of septic tanks was estimated to reduce the disease burden in disability-adjusted life years (DALYs) by 48-72%, while complete coverage of communal scale anaerobic baffled reactors was estimated to reduce DALYs by 67-81%. Despite these improvements, a concerning health risk persists with these systems as a result of effluent discharge to open drains, particularly when the systems are poorly managed. Other sanitation options, including use of constructed wetlands and small bore sewerage, demonstrated further reductions in local health risk, though several still exported pathogens into neighbouring areas, simply transferring risk to downstream communities. The study revealed sensitivity to and a requirement for further evidence on log reduction values for different sanitation systems under varying performance conditions, pathogen flows under flooding conditions as well as pathogen shedding and human exposure in typical low-income urban settings. Notwithstanding variability and uncertainties in input parameters, systems modelling can be a feasible and customisable approach to consider the relative health impact of different sanitation options across various contexts, and stands as a valuable tool to guide urban sanitation decision-making.

Perspectives from CO+RE: How COVID-19 changed our food systems and food security paradigms

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Toward Engineering Biosystems With Emergent Collective Functions

Many complex behaviors in biological systems emerge from large populations of interacting molecules or cells, generating functions that go beyond the capabilities of the individual parts. Such collective phenomena are of great interest to bioengineers due to their robustness and scalability. However, engineering emergent collective functions is difficult because they arise as a consequence of complex multi-level feedback, which often spans many length-scales. Here, we present a perspective on how some of these challenges could be overcome by using multi-agent modeling as a design framework within synthetic biology. Using case studies covering the construction of synthetic ecologies to biological computation and synthetic cellularity, we show how multi-agent modeling can capture the core features of complex multi-scale systems and provide novel insights into the underlying mechanisms which guide emergent functionalities across scales. The ability to unravel design rules underpinning these behaviors offers a means to take synthetic biology beyond single molecules or cells and toward the creation of systems with functions that can only emerge from collectives at multiple scales.

The state of water and fat during the maturation of Cheddar cheese

Cheddar cheese predicted to develop into different quality classes has been evaluated by time domain Nuclear Magnetic Resonance, Thermogravimetric analysis and quantitative sensory analysis. The water and fat proton signals in the transverse relaxation decay curves have been deconvoluted. Proton transverse relaxation values for both the water and fat fractions decrease and the relative %age of the proton peak area, predominantly from the fat increases over a 450-day ripening period. The thermodynamic free water percentage increases during maturation. Water and fat attributes can distinguish between Cheddar cheese batches after 56 days. Cheese batches which have lower transverse relaxation values for the water and fat proton fractions and a higher relative %age of the proton peak area predominantly from fat at 56 days, mature after 270 days to be more yellow, rubbery and smooth, have a less sour and lingering aftertaste and are also harder to form into a cheese ball.

Measuring consumer emotional response and acceptance to sustainable food products

With current global challenges such as population growth, climate change and water scarcity, it is critical to develop sustainable strategies to achieve food security. One way to tackle this is by developing new products that use alternative and more sustainable ingredients. Bambara groundnut is a low-impact African legume as it can be grown on marginal soils and is resistant to high temperatures. The aim of this study was to investigate UK consumer acceptability and emotional response to snack products containing Bambara groundnut flour as an alternative sustainable ingredient. A key objective was to understand the contribution that measuring emotional response would reveal. Additionally the impact of extrinsic information on consumer acceptability and emotional response to snack products was investigated by sharing information concerning Bambara groundnut's sustainability and nutritional credentials. 100 UK participants were recruited to evaluate two biscotti and two cracker products. For each category a standard product made from standard ingredients sourced commercially, and one made replacing some of standard flour with Bambara flour were obtained. For each sample, participants were asked to rate their overall liking and emotional response based on sensory properties of the product (the blind condition). Participants were invited back for a second session, where they were informed about global resource challenges, and the sustainable features and nutritional value of Bambara, and which products contained this as an ingredient (informed condition). Under the blind condition, no significant differences in overall liking were observed between standard and Bambara products, indicating UK consumers accept the sensory properties of products that contain Bambara flour. Interestingly, the extrinsic information shifted consumer emotional response towards more positive emotions and less negative emotions when consuming products containing Bambara flour. It also made them felt less guilty when consuming the Bambara products, suggesting consumers engage with the idea of sustainable ingredients, and that this sustainable ingredient has potential for future new product development. It also highlighted the value of measuring emotional response for novel products to understand what may drive purchase behaviour when products are matched for liking. Food neophobia status did not impact product acceptability and emotional response between Bambara and standard products, however overall a lower emotional response was found for medium neophobic consumers in general who are more likely to evade novel products.

VIDAS® Enzyme-Linked Immunofluorescent Assay for Detection of Listeria in Foods: Collaborative Study

The VIDAS LIS method and the traditional culture methods for detection of Listeria species in food were evaluated in a multilaboratory comparative study. The 6 foods tested were either naturally contaminated or inoculated with 3 different concentrations of Listeria. Results for each food and each contamination level with the VIDAS LIS method were as good as or better than those obtained with the traditional culture method. Of 1558 samples tested, 935 were positive: 839 by the VIDAS method and 809 by standard culture methods. Overall false negative rates were 10.3 and 13.5% for the VIDAS LIS and culture methods, respectively. The false positive rate for the VIDAS LIS assay was 1.4% based on 9 VIDAS LIS positive assays that did not confirm positive by isolation of Listeria. The agreement between the VIDAS LIS and culture methods for all samples tested was 86%.

Faecal contamination of groundwater in rural Vanuatu: prevalence and predictors

Groundwater is an important source of water for coastal communities in Pacific Island Countries. This study assessed the prevalence and predictors of faecal contamination in groundwater sources across 11 islands in Vanuatu. Escherichia coli was detected in 49% of sources and E. coli concentration exceeded 10 MPN (most probable number)/100 mL for 23% of sources. When adjusting for other variables, the detection of E. coli was significantly associated with severe pump stand corrosion, suggestive of contaminated run-off directly entering boreholes. E. coli concentration >10 MPN/100 mL was also significantly associated with: (i) hand-dug wells (as compared to drilled boreholes); (ii) severe pump stand corrosion; (iii) water points underlain by volcanic rocks (as compared to coral limestone); and (iv) rainfall in the previous 24 h. Encasing pump stands in concrete - as some communities had done - was found to have a significant protective effect. While baseline statistics for Sustainable Development Goal target 6.1 suggest that 87% of Vanuatu's rural population have access to at least a basic (improved) water source, the results from this study point to extensive microbial water quality concerns linked to degraded water supply infrastructure in need of rehabilitation.

Psychosocial, psychiatric and work-related risk factors associated with suicide in Ireland: optimised methodological approach of a case-control psychological autopsy study

BACKGROUND

Suicide has profound effects on families and communities, but is a statistically rare event. Psychological autopsies using a case-control design allow researchers to examine risk factors for suicide, using a variety of sources to detail the psychological and social characteristics of decedents and to compare them to controls. The Suicide Support and Information System Case Control study (SSIS-ACE) aimed to compare psychosocial, psychiatric and work-related risk factors across three groups of subjects: suicide decedents, patients presenting to hospital with a high-risk self-harm episode, and general practice controls.

METHODS

The study design includes two inter-related studies; one main case-control study: comparing suicide cases to general practice (GP) controls, and one comparative study: comparing suicide cases to patients presenting with high-risk self-harm. Consecutive cases of suicide and probable suicide are identified through coroners' registration of deaths in the defined region (Cork City and County, Ireland) and are frequency-matched for age group and gender with GP patient controls recruited from the same GP practice as the deceased. Data sources for suicide cases include coroners' records, interviews with health care professionals and proxy informants; data sources for GP controls and for high-risk self-harm controls include interviews with control, with proxy informants and with health care professionals. Interviews are semi-structured and consist of quantitative and qualitative parts. The quantitative parts include a range of validated questionnaires addressing psychiatric, psychosocial and occupational factors. The study adopts several methodological innovations, including accessing multiple data sources for suicide cases and controls simultaneously, recruiting proxy informants to examine consistency across sources.

CONCLUSIONS

The study allows for the investigation of consistency across different data sources and contributes to the methodological advancement of psychological autopsy research. The study will also inform clinical and public health practice. The comparison between suicide cases and controls will allow investigation of risk and protective factors for suicide more generally, while the comparison with high-risk self-harm patients will help to identify the factors associated specifically with a fatal outcome to a self-harm episode. A further enhancement is the particular focus on specific work-related risk factors for suicide.

Multiple water source use in rural Vanuatu: are households choosing the safest option for drinking?

Households in low- and middle-income countries commonly make use of multiple water sources. However, it remains unclear to what extent their drinking water choices are optimal from a health perspective. This matched cohort study across 10 islands in Vanuatu examined communities with both a groundwater and rainwater source to determine whether their preferred drinking option was the safest in microbial terms. In communities that preferred to drink rainwater, 56.5% of rainwater sources had 'high-risk' or 'very high risk' Escherichia coli contamination (> 10 MPN/100 mL) compared with 26.1% of groundwater sources (p = 0.092). Moreover, a preference for drinking rainwater was significantly associated with rainwater sources having 'high-risk' or 'very high risk' levels of E. coli contamination (p = 0.045). Results show that communities do not necessarily choose the safest water source for drinking. Findings also highlight the need to bolster local capacity to manage water quality risks and for Sustainable Development Goal monitoring to distinguish between protected and unprotected rainwater tanks.

Gestational Age, Health, and Educational Outcomes in Adolescents

BACKGROUND AND OBJECTIVES

As outcomes for extremely premature infants improve, up-to-date, large-scale studies are needed to provide accurate, contemporary information for clinicians, families, and policy makers. We used nationwide New Zealand data to explore the impact of gestational age on health and educational outcomes through to adolescence.

METHODS

We performed a retrospective cohort study of all births in New Zealand appearing in 2 independent national data sets at 23 weeks' gestation or more. We report on 2 separate cohorts: cohort 1, born January 1, 2005 to December 31, 2015 (613 521 individuals), used to study survival and midterm health and educational outcomes; and cohort 2, born January 1, 1998 to December 31, 2000, and surviving to age 15 years (146 169 individuals), used to study high school educational outcomes. Outcomes described by gestational age include survival, hospitalization rates, national well-being assessment outcomes at age 4 years, rates of special education support needs in primary school, and national high school examination results.

RESULTS

Ten-year survival increased with gestational age from 66% at 23 to 24 weeks to >99% at term. All outcomes measured were strongly related to gestational age. However, most extremely preterm children did not require special educational support and were able to sit for their national high school examinations.

CONCLUSIONS

Within a publicly funded health system, high-quality survival is achievable for most infants born at periviable gestations. Outcomes show improvement with gestational ages to term. Outcomes at early-term gestation are poorer than for children born at full term.

Risk factors associated with rural water supply failure: A 30-year retrospective study of handpumps on the south coast of Kenya

An improved understanding of failure risks for water supplies in rural sub-Saharan Africa will be critical to achieving the global goal of safe water for all by 2030. In the absence of longitudinal biophysical and operational data, investigations into water point failure risk factors have to date been limited to cross-sectional research designs. This retrospective cohort study applies survival analysis to identify factors that predict failure risks for handpumps installed on boreholes along the south coast of Kenya from the 1980s. The analysis is based on a unique dataset linking attributes of >300 water points at the time of installation with their operational lifespan over the following decades. Cox proportional hazards and accelerated failure time models suggest water point failure risks are higher and lifespans are shorter when water supplied is more saline, static water level is deeper, and groundwater is pumped from an unconsolidated sand aquifer. The risk of failure also appears to grow as distance to spare part suppliers increases. To bolster the sustainability of rural water services and ensure no community is left behind, post-construction support mechanisms will need to mitigate heterogeneous environmental and geographical challenges. Further studies are needed to better understand the causal pathways that underlie these risk factors in order to inform policies and practices that ensure water services are sustained even where unfavourable conditions prevail.

Using preceding hospital admissions to identify children at risk of developing acute rheumatic fever

AIMS

New Zealand (NZ) Māori and Pacific children have high rates of acute rheumatic fever (ARF). Around 150 new cases arise each year. As part of the national ARF prevention programme, funding is available to improve housing. To obtain maximum benefit from interventions, an effective tool is needed for targeting high-risk children. This study aimed to assess the effectiveness of using hospitalisations for identifying children at risk of subsequent ARF.

METHODS

Three potentially avoidable hospitalisation (PAH) groups were investigated, including diseases thought to be influenced by housing. All were developed using expert opinion or systematic reviews. These were: (i) the PAH conditions associated with the housing environment (PAHHE) group; (ii) the Crowding group; and (iii) the Ministry of Health (MoH) group. We analysed NZ public hospital discharge data (2000-2014). The prevalence of ARF among patients hospitalised in each group was calculated to estimate sensitivity and potential effectiveness. The number needed to screen (NNS) to identify one ARF case was estimated as a measure of efficiency.

RESULTS

Nearly one-third of ARF patients experienced a PAH as children (before developing ARF). Sensitivity for detecting future ARF ranged from <5% (MoH group) to 27% (PAHHE group). NNS ranged from 502.4 (PAHHE) to 707.5 (MoH).

CONCLUSIONS

Because ARF is relatively rare, observing hospitalisations is not particularly efficient for targeting prevention activities for this condition alone. However, housing interventions are likely to improve multiple outcomes; thus, the hospital setting is still useful for identifying at-risk children who could benefit from such programmes.

Risk of rehospitalisation and death for vulnerable New Zealand children

OBJECTIVES

There is considerable need to improve the effectiveness of healthcare to reduce morbidity and mortality. Child hospitalisations are influenced by determinants of health, including the home environment. Our aims were: (1) To investigate whether children hospitalised with potentially avoidable conditions thought to be associated with the home have an increased risk of rehospitalisation and death, (2) To investigate whether children hospitalised with particular subgroups of potentially avoidable conditions have an increased risk of rehospitalisation and death, (3) To assess the usefulness of these subgroups for identifying at-risk children.

DESIGN

We used four existing groups of potentially avoidable conditions developed based on expert opinion: 1. the potentially avoidable hospitalisations (PAH) group, associated with social/environmental conditions, 2. the potentially avoidable hospitalisations attributable (at least in part) to the home environment (PAHHE) group, 3. the crowding group, and 4. the Ministry of Health (MoH) group. We analysed national New Zealand hospital discharge data (2000-2014). Rehospitalisation and death were described using Kaplan-Meier curves. Group effectiveness for identifying at-risk children was assessed using Cox proportional hazard models with children hospitalised for non-PAH conditions as comparison.

RESULTS

In total, 1425085 hospital admissions occurred, for 683115 unique children. Rehospitalisation was relatively common (71.0%). Death was rare (0.6%). All groups performed moderately well identifying at-risk children. Children with PAH have increased risk of rehospitalisation (adjusted HR (aHR):2.30-3.60) and death (aHR:3.07-10.44). PAH group had highest sensitivity (75.1%). The MoH group has the highest positive predictive value (rehospitalisation: 86.2%, death: 2.5%).

CONCLUSIONS

Children in the MoH group are very likely to benefit from housing interventions. Rehospitalisation and early mortality are useful assessment measures. Rehospitalisation exerts a considerable burden, and child deaths are catastrophic.

Consumer-orientated development of hybrid beef burger and sausage analogues

Hybrid meat analogues, whereby a proportion of meat has been partially replaced by more sustainable protein sources, have been proposed to provide a means for more sustainable diets in the future. Consumer testing was conducted to determine consumer acceptability of different formulations of Hybrid beef burgers and pork sausages in comparison with both meat and meat‐free commercial products. Acceptability data were generated using the 9‐point hedonic scale. Check‐all‐that‐apply (CATA) questioning was used to determine the sensory attributes perceived in each product as well as information on the attributes of consumers’ ideal products. It was identified that Hybrid products were generally well liked among consumers and no significant differences in consumer acceptability (p > .05) were identified between Hybrid and full meat products, whereas meat‐free products were found to be less accepted. However, Hybrid sausages received higher acceptability scores (6.00–6.51) than Hybrid burgers (5.84–5.92) suggesting that format may have a large impact on consumer acceptability of Hybrid products. Correspondence Analysis (CA) indicated that Hybrid products were grouped with meat products in their sensory attributes. Penalty analysis found that a “meaty flavor” was the largest factor driving consumer acceptability in both burgers and sausages. Cluster analysis of consumer acceptability data identified key differences in overall acceptability between different consumer groups (consumers who only eat meat products and consumers who eat both meat and meat‐free products). The Hybrid concept was found to bridge the acceptability gap between meat and meat‐free products; however, further product reformulation is required to optimize consumer acceptability.

Prior Consumption of a Fat Meal in Healthy Adults Modulates the Brain's Response to Fat

BACKGROUND

The consumption of fat is regulated by reward and homeostatic pathways, but no studies to our knowledge have examined the role of high-fat meal (HFM) intake on subsequent brain activation to oral stimuli.

OBJECTIVE

We evaluated how prior consumption of an HFM or water load (WL) modulates reward, homeostatic, and taste brain responses to the subsequent delivery of oral fat.

METHODS

A randomized 2-way crossover design spaced 1 wk apart was used to compare the prior consumption of a 250-mL HFM (520 kcal) [rapeseed oil (440 kcal), emulsifier, sucrose, flavor cocktail] or noncaloric WL on brain activation to the delivery of repeated trials of a flavored no-fat control stimulus (CS) or flavored fat stimulus (FS) in 17 healthy adults (11 men) aged 25 ± 2 y and with a body mass index (in kg/m²) of 22.4 ± 0.8. We tested differences in brain activation to the CS and FS and baseline cerebral blood flow (CBF) after the HFM and WL. We also tested correlations between an individual's plasma cholecystokinin (CCK) concentration after the HFM and blood oxygenation level-dependent (BOLD) activation of brain regions.

RESULTS

Compared to the WL, consuming the HFM led to decreased anterior insula taste activation in response to both the CS (36.3%; P < 0.05) and FS (26.5%; P < 0.05). The HFM caused reduced amygdala activation (25.1%; P < 0.01) in response to the FS compared to the CS (fat-related satiety). Baseline CBF significantly reduced in taste (insula: 5.7%; P < 0.01), homeostatic (hypothalamus: 9.2%, P < 0.01; thalamus: 5.1%, P < 0.05), and reward areas (striatum: 9.2%; P < 0.01) after the HFM. An individual's plasma CCK concentration correlated negatively with brain activation in taste and oral somatosensory (ρ = -0.39; P < 0.05) and reward areas (ρ = -0.36; P < 0.05).

CONCLUSIONS

Our results in healthy adults show that an HFM suppresses BOLD activation in taste and reward areas compared to a WL. This understanding will help inform the reformulation of reduced-fat foods that mimic the brain's response to high-fat counterparts and guide future interventions to reduce obesity.

Elafibranor, an Agonist of the Peroxisome Proliferator-Activated Receptor-α and -δ, Induces Resolution of Nonalcoholic Steatohepatitis Without Fibrosis Worsening

BACKGROUND & AIMS

Elafibranor is an agonist of the peroxisome proliferator-activated receptor-α and peroxisome proliferator-activated receptor-δ. Elafibranor improves insulin sensitivity, glucose homeostasis, and lipid metabolism and reduces inflammation. We assessed the safety and efficacy of elafibranor in an international, randomized, double-blind placebo-controlled trial of patients with nonalcoholic steatohepatitis (NASH).

METHODS

Patients with NASH without cirrhosis were randomly assigned to groups given elafibranor 80 mg (n = 93), elafibranor 120 mg (n = 91), or placebo (n = 92) each day for 52 weeks at sites in Europe and the United States. Clinical and laboratory evaluations were performed every 2 months during this 1-year period. Liver biopsies were then collected and patients were assessed 3 months later. The primary outcome was resolution of NASH without fibrosis worsening, using protocol-defined and modified definitions. Data from the groups given the different doses of elafibranor were compared with those from the placebo group using step-down logistic regression, adjusting for baseline nonalcoholic fatty liver disease activity score.

RESULTS

In intention-to-treat analysis, there was no significant difference between the elafibranor and placebo groups in the protocol-defined primary outcome. However, NASH resolved without fibrosis worsening in a higher proportion of patients in the 120-mg elafibranor group vs the placebo group (19% vs 12%; odds ratio = 2.31; 95% confidence interval: 1.02-5.24; P = .045), based on a post-hoc analysis for the modified definition. In post-hoc analyses of patients with nonalcoholic fatty liver disease activity score ≥4 (n = 234), elafibranor 120 mg resolved NASH in larger proportions of patients than placebo based on the protocol definition (20% vs 11%; odds ratio = 3.16; 95% confidence interval: 1.22-8.13; P = .018) and the modified definitions (19% vs 9%; odds ratio = 3.52; 95% confidence interval: 1.32-9.40; P = .013). Patients with NASH resolution after receiving elafibranor 120 mg had reduced liver fibrosis stages compared with those without NASH resolution (mean reduction of 0.65 ± 0.61 in responders for the primary outcome vs an increase of 0.10 ± 0.98 in nonresponders; P < .001). Liver enzymes, lipids, glucose profiles, and markers of systemic inflammation were significantly reduced in the elafibranor 120-mg group vs the placebo group. Elafibranor was well tolerated and did not cause weight gain or cardiac events, but did produce a mild, reversible increase in serum creatinine (effect size vs placebo: increase of 4.31 ± 1.19 μmol/L; P < .001).

CONCLUSIONS

A post-hoc analysis of data from trial of patients with NASH showed that elafibranor (120 mg/d for 1 year) resolved NASH without fibrosis worsening, based on a modified definition, in the intention-to-treat analysis and in patients with moderate or severe NASH. However, the predefined end point was not met in the intention to treat population. Elafibranor was well tolerated and improved patients' cardiometabolic risk profile. ClinicalTrials.gov number: NCT01694849.

Abstract P5-02-07: Effect of multidisciplinary case conferences on physician decision making: Breast diagnostic rounds

Background: Participation in multidisciplinary case conferences (MCCs) continues to be highly variable, in spite of proven benefits. One contention is the lack of perceived utility on patient management.

Purpose: To evaluate the utility of MCCs on physician decision making in benign and malignant breast disease management.

Methods: At the Foothills Medical Centre, diagnostic breast MCCs occur biweekly. Patients with interesting or challenging diagnostic or management issues were discussed by attending surgeons, radiologists, pathologists, nurse coordinators and oncologists. Prior to case discussion, the presenting physician was asked to specify his/her management plan. Their response was recorded and compared to the management plan consensus after the MCC discussion. For each case a clinical summary and question was provided by the presenting physician, followed by a review of diagnostic images and/or pathology. After group discussion, a management consensus was achieved and documented. A management change was defined as a difference compared to the pre-MCC plan or if there was no definite management plan prior to MCC.

Results: From November 5th, 2014 to May 6th, 2015, 52 patients were discussed in 11 MCCs (1 to 8 patients per MCC). No MCCs were cancelled due to insufficient patients. Of these, 23 (44%) had a change in the management plan compared to the pre-MCC intent including 7 cases where there was no clear plan prior to MCC. Among the 23 cases with a management change, 12 (52%) were due to new or clarified information from radiology review, 6 (26%) were due to new or clarified details from pathology review and 5 (22%) changes occurred from both radiology and pathology review. All cases presented resulted in a consensus management recommendation.

Conclusion: The MCCs had a substantial impact on physician decision making. Nearly half of cases presented resulted in a change in clinical recommendation, the majority of which were based on new/clarified diagnostic imaging or pathology information. Presentation of cases at MCCs should be encouraged given their clinical impact on patient care, especially for challenging diagnostic or management issues.

Citation Format: Foster T, Bouchard-Fortier A, Olivotto I, Quan ML. Effect of multidisciplinary case conferences on physician decision making: Breast diagnostic rounds. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-02-07.

Impact of extraneous proteins on the gastrointestinal fate of sunflower seed (Helianthus annuus) oil bodies: a simulated gastrointestinal tract study

In this study, we examined the physicochemical nature of sunflower seed oil bodies (in the absence and presence of added protein) exposed to gastrointestinal conditions in vitro: crude oil bodies (COB); washed oil bodies (WOB); whey protein isolate-enriched oil bodies (WOB-WPI); and, sodium caseinate enriched-oil bodies (WOB-SC). All oil body emulsions were passed through an in vitro digestion model that mimicked the stomach and duodenal environments, and their physicochemical properties were measured before, during, and after digestion. Oil bodies had a positive charge under gastric conditions because the pH was below the isoelectric point of the adsorbed protein layer, but they had a negative charge under duodenal conditions which was attributed to changes in interfacial composition resulting from adsorption of bile salts. Oil bodies were highly susceptible to flocculation and coalescence in both gastric and duodenal conditions. SDS-PAGE analysis indicated degradation of oleosin proteins (ca. 18-21 kDa) to a greater or lesser extent (dependent on the emulsion) during the gastric phase in all emulsions tested; there is evidence that some oleosin remained intact in the crude oil body preparation during this phase of the digestion process. Measurements of protein displacement from the surface of COBs during direct exposure to bile salts, without inclusion of a gastric phase, indicated the removal of intact oleosin from native oil bodies.

Crusted scabies in remote Australia, a new way forward: lessons and outcomes from the East Arnhem Scabies Control Program

Crusted scabies is a highly infectious, debilitating and disfiguring disease, and remote Aboriginal communities of northern Australia have the highest reported rates of the condition in the world. We draw on monitoring data of the East Arnhem Scabies Control Program to discuss outcomes and lessons learnt through managing the condition in remote communities. Using active case finding, we identified seven patients with crusted scabies in three communities and found most had not presented to health services despite active disease. We compared presentations and hospitalisations for a cumulative total of 99 months during a novel preventive program with 99 months immediately before the program for the seven cases and seven sentinel household contacts. Our preventive long-term case management approach was associated with a significant 44% reduction in episodes of recurrent crusted scabies (from 36 to 20; P = 0.025) in the seven cases, and a non-significant 80% reduction in days spent in hospital (from 173 to 35; P = 0.09). It was also associated with a significant 75% reduction in scabies-related presentations (from 28 to 7; P = 0.017) for the seven sentinel household contacts. We recommend active surveillance and wider adoption of this preventive case management approach, with ongoing evaluation to refine protocols and improve efficiency. Contacts of children presenting with recurrent scabies should be examined to exclude crusted scabies. In households where crusted scabies is present, a diagnosis of parental neglect due to recurrent scabies and weight loss in children should be made with extreme caution. Improved coordination of care by health services, and research and development of new therapies including immunotherapies for crusted scabies, must be a priority.

Predictors of sustainability for community-managed handpumps in sub-Saharan Africa: evidence from Liberia, Sierra Leone, and Uganda

Rural water supply sustainability has remained an enduring policy challenge in sub-Saharan Africa for decades. Drawing on the largest data set assembled on rural water points in sub-Saharan Africa to date, this paper employs logistic regression analyses to identify operational, technical, institutional, financial, and environmental predictors of functionality for over 25 000 community-managed handpumps in Liberia, Sierra Leone, and Uganda. Risk factors significantly associated with nonfunctionality across all three countries were (a) system age, (b) distance from district/county capital, and (c) absence of user fee collection. In at least one of the three countries, other variables found to have significant multivariable adjusted associations with functionality status included well type, handpump type, funding organization, implementing organization, spare parts proximity, availability of a handpump mechanic, regular servicing, regular water committee meetings, women in key water committee positions, rainfall season, and perceived water quality. While the findings reinforce views that a multifaceted range of conditions is critical for the sustainability of community-managed handpumps, they also demonstrate that these factors remain absent from a high proportion of cases. Governments and development partners must significantly strengthen postconstruction support for operation and maintenance systems, and greater efforts are needed to test and evaluate alternative models for managing handpump water supplies.

Genetic variation in DNMT3B and increased global DNA methylation is associated with suicide attempts in psychiatric patients

Recently, a significant epigenetic component in the pathology of suicide has been realized. Here we investigate candidate functional SNPs in epigenetic-regulatory genes, DNMT1 and DNMT3B, for association with suicide attempt (SA) among patients with co-existing psychiatric illness. In addition, global DNA methylation levels [5-methyl cytosine (5-mC%)] between SA and psychiatric controls were quantified using the Methylflash Methylated DNA Quantification Kit. DNA was obtained from blood of 79 suicide attempters and 80 non-attempters, assessed for DSM-IV Axis I disorders. Functional SNPs were selected for each gene (DNMT1; n = 7, DNMT3B; n = 10), and genotyped. A SNP (rs2424932) residing in the 3' UTR of the DNMT3B gene was associated with SA compared with a non-attempter control group (P = 0.001; Chi-squared test, Bonferroni adjusted P value = 0.02). Moreover, haplotype analysis identified a DNMT3B haplotype which differed between cases and controls, however this association did not hold after Bonferroni correction (P = 0.01, Bonferroni adjusted P value = 0.56). Global methylation analysis showed that psychiatric patients with a history of SA had significantly higher levels of global DNA methylation compared with controls (P = 0.018, Student's t-test). In conclusion, this is the first report investigating polymorphisms in DNMT genes and global DNA methylation quantification in SA risk. Preliminary findings suggest that allelic variability in DNMT3B may be relevant to the underlying diathesis for suicidal acts and our findings support the hypothesis that aberrant DNA methylation profiles may contribute to the biology of suicidal acts. Thus, analysis of global DNA hypermethylation in blood may represent a biomarker for increased SA risk in psychiatric patients.