Non-parental Childcare During Early Childhood and Problem Behaviour Trajectories from Ages 5 to 14 Years

Using data from the nationally representative Millennium Cohort Study, this study examined the association between age of starting and weekly hours in formal childcare between birth and 5 years with internalising and externalising behaviour trajectories from ages 5 to 14 years in England (N = 6194 children). Associations were analysed using multilevel general linear regression models, with adjustment for socio-economic position, maternal mental health, demographics, and child temperament. Later entry was associated with more internalising behaviours at age 14 years. Children who spent > 40 h per week in childcare between birth and 3 years displayed more externalising behaviour at 5 years than children who did not attend childcare. Controlling for socio-economic position and parental mental health attenuated findings.

Trends in childhood body mass index between 1936 and 2011 showed that underweight remained more common than obesity among 398 970 Danish school children

AIM

To examine trends in all body mass index (BMI) groups in children from 1936 to 2011.

METHODS

We included 197 694 girls and 201 276 boys from the Copenhagen School Health Records Register, born between 1930 and 1996, with longitudinal weight and height measurements (6-14 years). Using International Obesity Task Force criteria, BMI was classified as underweight, normal-weight, overweight and obesity. Sex- and age-specific prevalences were calculated.

RESULTS

From the 1930s, the prevalence of underweight was stable until a small increase occurred from 1950 to 1970s, and thereafter it declined into the early 2000s. Using 7-year-olds as an example, underweight changed from 10% to 7% in girls and from 9% to 6% in boys during the study period. The prevalence of overweight plateaued from 1950 to 1970s and then steeply increased from 1970s onwards and in 1990-2000s 15% girls and 11% boys at 7 years had overweight. The prevalence of obesity particularly increased from 1980s onwards and in 1990-2000s 5% girls and 4% boys at 7 years had obesity. These trends slightly differed by age.

CONCLUSION

Among Danish schoolchildren, the prevalence of underweight was greater than overweight until the 1980s and greater than obesity throughout the period. Thus, monitoring the prevalence of childhood underweight remains an important public health issue.

Effects of Tween 20 addition on electrokinetic transport in a polydimethylsiloxane microchannel

Tween 20 is frequently added to particle suspensions for reducing the particle-wall adhesion and particle-particle aggregation in microfluidic devices. However, the influences of Tween 20 on the fluid and particle behaviors have been largely ignored. We present in this work the first experimental study of the effects of Tween 20 addition on the electrokinetic transport of fluids and particles in a polydimethylsiloxane microchannel. We find that adding 0.1% v/v Tween 20 to a buffer solution can significantly reduce the electroosmotic mobility as well as the electrokinetic and electrophoretic mobilities of polystyrene particles and yeast cells. Further increasing the Tween 20 concentration within the range typically used in microfluidic applications continues reducing these mobility values, but at a smaller rate. Our finding suggests that Tween 20 should be used with care in electrokinetic microdevices when the flow rate or particle/cell throughput is an important parameter.

Small area analysis methods in an area of limited mapping: exploratory geospatial analysis of firearm injuries in Port-au-Prince, Haiti

BACKGROUND

The city of Port-au-Prince, Haiti, is experiencing an epidemic of firearm injuries which has resulted in high burdens of morbidity and mortality. Despite this, little scientific literature exists on the topic. Geospatial research could inform stakeholders and aid in the response to the current firearm injury epidemic. However, traditional small-area geospatial methods are difficult to implement in Port-au-Prince, as the area has limited mapping penetration. Objectives of this study were to evaluate the feasibility of geospatial analysis in Port-au-Prince, to seek to understand specific limitations to geospatial research in this context, and to explore the geospatial epidemiology of firearm injuries in patients presenting to the largest public hospital in Port-au-Prince.

RESULTS

To overcome limited mapping penetration, multiple data sources were combined. Boundaries of informally developed neighborhoods were estimated from the crowd-sourced platform OpenStreetMap using Thiessen polygons. Population counts were obtained from previously published satellite-derived estimates and aggregated to the neighborhood level. Cases of firearm injuries presenting to the largest public hospital in Port-au-Prince from November 22nd, 2019, through December 31st, 2020, were geocoded and aggregated to the neighborhood level. Cluster analysis was performed using Global Moran's I testing, local Moran's I testing, and the SaTScan software. Results demonstrated significant geospatial autocorrelation in the risk of firearm injury within the city. Cluster analysis identified areas of the city with the highest burden of firearm injuries.

CONCLUSIONS

By utilizing novel methodology in neighborhood estimation and combining multiple data sources, geospatial research was able to be conducted in Port-au-Prince. Geospatial clusters of firearm injuries were identified, and neighborhood level relative-risk estimates were obtained. While access to neighborhoods experiencing the largest burden of firearm injuries remains restricted, these geospatial methods could continue to inform stakeholder response to the growing burden of firearm injuries in Port-au-Prince.

South Africa and the Surgical Diaspora-A Hub for Surgical Migration and Training

BACKGROUND

The shortage of trained surgeons, anesthesiologists, and obstetricians is a major contributor to the unmet need for surgical care in low- and middle-income countries, and the shortage is aggravated by migration to higher-income countries.

METHODS

We performed a cross-sectional observational study, combining individual-level data of 43,621 physicians from the Health Professions Council of South Africa with data from the registers of 14 high-income countries, and international statistics on surgical workforce, in order to quantify migration to and from South Africa in both absolute and relative terms.

RESULTS

Of 6670 surgeons, anesthesiologists, and obstetricians in South Africa, a total of 713 (11%) were foreign medical graduates, and 396 (6%) were from a low- or middle-income country. South Africa was an important destination primarily for physicians originating from low-income countries; 2% of all surgeons, anesthesiologists, and obstetricians from low- and middle-income countries were registered in South Africa, and 6% in the other 14 recipient countries. A total of 1295 (16%) South African surgeons, anesthesiologists, and obstetricians worked in any of the 14 studied high-income countries.

CONCLUSION

South Africa is an important regional hub for surgical migration and training. A notable proportion of surgical specialists in South Africa were medical graduates from other low- or middle-income countries, whereas migration out of South Africa to high-income countries was even larger.

Associations between diabetes status and grip strength trajectory sub-groups in adulthood: findings from over 16 years of follow-up in the MRC National Survey of Health and Development

BACKGROUND

Cross-sectional studies suggest a relationship between diabetes status and weaker grip strength (GS) in adulthood and limited evidence from longitudinal studies has focussed on the association with average change in GS. We aimed to investigate whether diabetes status was related to membership of distinct GS trajectories in mid-to-late adulthood in 2,263 participants in the Medical Research Council National Survey of Health and Development.

METHODS

Grip strength (kg) was measured at 53, 60-64 and 69 years. Pre-/diabetes was defined at 53 years based on HbA1c > 5.6% and/or doctor-diagnosis of diabetes. Sex-specific latent class trajectory models were developed and multinomial logistic regression was used to investigate the association between pre-/diabetes status and membership into GS trajectory classes.

RESULTS

For both males and females, a 3-class solution ('High', 'Intermediate', 'Low') provided the best representation of the GS data and the most plausible solution. There was no evidence that pre-/diabetes status was associated with class membership in either sex: e.g., adjusted odds ratios of being in the 'Low' class (vs. 'High') for males with pre-/diabetes (vs. no-diabetes) was 1.07 (95% CI:0.45,2.55).

CONCLUSION

Using a flexible data-driven approach to identify GS trajectories between 53 and 69 years, we observed three distinct GS trajectories, all declining, in both sexes. There was no association between pre-/diabetes status at 53 years and membership into these GS trajectories. Understanding the diabetes status-GS trajectories association is vital to ascertain the consequences that projected increases in pre-/diabetes prevalence's are likely to have.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Factors associated with left ventricular hypertrophy in children with sickle cell disease; results from the DISPLACE study

Cardiopulmonary complications remain a leading cause of morbidity and mortality in sickle cell disease (SCD). The overall goals of this study were to evaluate the relationship between left ventricular hypertrophy (LVH) and laboratory markers of hemolysis and determine the association between LVH and SCD-specific therapies (hydroxyurea and chronic red cell transfusion). Data from the DISPLACE (Dissemination and Implementation of Stroke Prevention Looking at the Care Environment) study cohort was used. LVH was defined based on the left ventricular mass indexed to the body surface area as left ventricular mass index >103.0 g/m² for males and >84.2 g/m² for females. There were 1,409 children included in the analysis and 20.3% had LVH. Results of multivariable analysis of LVH showed baseline hemoglobin levels were associated with the lower odds of having LVH (odds ratio [OR]: 0.71, 95% confidence interval [CI]: 0.60– 0.84). The odds of LVH increases for every 1-year increase in age (OR: 1.07, 95% CI: 1.02-1.13). Similarly, the odds of LVH were lower among males than females (OR: 0.59, 95% CI: 0.38-0.93). The odds of LVH were higher among those on hydroxyurea compared to no therapy (OR: 1.83, 95% CI: 1.41–2.37). Overall results of the study showed that LVH occurs early in children with SCD and the risk increases with increasing age and with lower hemoglobin. Further, we found higher use of hydroxyurea among those with LVH, suggesting that the need for hydroxyurea conveys a risk of cardiovascular remodeling.

Association Between Patent Foramen Ovale and Overt Ischemic Stroke in Children With Sickle Cell Disease

Ischemic stroke is one of the most devastating complications of sickle cell anemia (SCA). Previous studies have shown that intracardiac shunting including patent foramen ovale (PFO) can be a potential risk factor for stroke in children with SCA. This study investigates the association between PFO and overt ischemic stroke in the DISPLACE (Dissemination and Implementation of Stroke Prevention Looking at the Care Environment) study cohort of 5,247 children with SCA of whom 1,414 had at least one clinical non-contrast transthoracic echocardiogram. Presence of PFO was taken from the clinical report. Further, we assessed the association between PFO and other clinical and hemolytic factors in children with SCA such as history of abnormal sickle stroke screen [elevated Transcranial Doppler ultrasound (TCD) velocity] and patient's baseline hemoglobin. In 642 children for whom all data were available, the adjusted odds ratio (OR) for overt stroke was higher in those with PFO but this was not statistically significant (OR: 1.49, 95% CI: 0.20-11.03, p = 0.6994). With an OR of 0.85, the study suggested less PFOs in those with abnormal TCD, but this was not statistically significant (95% CI: 0.17-4.25, p = 0.8463). Overall, the prevalence of PFO in this large sub study of non-contrast echocardiography amongst children with SCA is much lower than previous smaller studies using bubble contrast echocardiography. Overt stroke was non-statistically more common in children with SCA and PFO, but there was no evidence that PFO was more common in those with abnormal TCD, the most important pediatric sickle stroke screen.

The state of stroke services across the globe: Report of World Stroke Organization-World Health Organization surveys

BACKGROUND

Improving stroke services is critical for reducing the global stroke burden. The World Stroke Organization-World Health Organization-Lancet Neurology Commission on Stroke conducted a survey of the status of stroke services in low and middle-income countries (LMICs) compared to high-income countries.

METHODS

Using a validated World Stroke Organization comprehensive questionnaire, we collected and compared data on stroke services along four pillars of the stroke quadrangle (surveillance, prevention, acute stroke, and rehabilitation) in 84 countries across World Health Organization regions and economic strata. The World Health Organization also conducted a survey of non-communicable diseases in 194 countries in 2019.

RESULTS

Fewer surveillance activities (including presence of registries, presence of recent risk factors surveys, and participation in research) were reported in low-income countries than high-income countries. The overall global score for prevention was 40.2%. Stroke units were present in 91% of high-income countries in contrast to 18% of low-income countries (p < 0.001). Acute stroke treatments were offered in ∼ 60% of high-income countries compared to 26% of low-income countries (p = 0.009). Compared to high-income countries, LMICs provided less rehabilitation services including in-patient rehabilitation, home assessment, community rehabilitation, education, early hospital discharge program, and presence of rehabilitation protocol.

CONCLUSIONS

There is an urgent need to improve access to stroke units and services globally especially in LMICs. Countries with less stroke services can adapt strategies from those with better services. This could include establishment of a framework for regular monitoring of stroke burden and services, implementation of integrated prevention activities and essential acute stroke care services, and provision of interdisciplinary care for stroke rehabilitation.

Quality of stroke guidelines in low- and middle-income countries: a systematic review

OBJECTIVE

To identify gaps in national stroke guidelines that could be bridged to enhance the quality of stroke care services in low- and middle-income countries.

METHODS

We systematically searched medical databases and websites of medical societies and contacted international organizations. Country-specific guidelines on care and control of stroke in any language published from 2010 to 2020 were eligible for inclusion. We reviewed each included guideline for coverage of four key components of stroke services (surveillance, prevention, acute care and rehabilitation). We also assessed compliance with the eight Institute of Medicine standards for clinical practice guidelines, the ease of implementation of guidelines and plans for dissemination to target audiences.

FINDINGS

We reviewed 108 eligible guidelines from 47 countries, including four low-income, 24 middle-income and 19 high-income countries. Globally, fewer of the guidelines covered primary stroke prevention compared with other components of care, with none recommending surveillance. Guidelines on stroke in low- and middle-income countries fell short of the required standards for guideline development; breadth of target audience; coverage of the four components of stroke services; and adaptation to socioeconomic context. Fewer low- and middle-income country guidelines demonstrated transparency than those from high-income countries. Less than a quarter of guidelines encompassed detailed implementation plans and socioeconomic considerations.

CONCLUSION

Guidelines on stroke in low- and middle-income countries need to be developed in conjunction with a wider category of health-care providers and stakeholders, with a full spectrum of translatable, context-appropriate interventions.

Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report

BACKGROUND

Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally.

METHODS AND FINDINGS

The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees.

CONCLUSIONS

To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.

Changes over time in latent patterns of childhood-to-adulthood BMI development in Great Britain: evidence from three cohorts born in 1946, 1958, and 1970

BACKGROUND

Most studies on secular trends in body mass index (BMI) are cross-sectional and the few longitudinal studies have typically only investigated changes over time in mean BMI trajectories. We aimed to describe how the evolution of the obesity epidemic in Great Britain reflects shifts in the proportion of the population demonstrating different latent patterns of childhood-to-adulthood BMI development.

METHODS

We used pooled serial BMI data from 25,655 participants in three British cohorts: the 1946 National Survey of Health and Development (NSHD), 1958 National Child Development Study (NCDS), and 1970 British Cohort Study (BCS). Sex-specific growth mixture models captured latent patterns of BMI development between 11 and 42 years. The classes were characterised in terms of their birth cohort composition.

RESULTS

The best models had four classes, broadly similar for both sexes. The 'lowest' class (57% of males; 47% of females) represents the normal weight sub-population, the 'middle' class (16%; 15%) represents the sub-population who likely develop overweight in early/mid-adulthood, and the 'highest' class (6%; 9%) represents those who likely develop obesity in early/mid-adulthood. The remaining class (21%; 29%) reflects a sub-population with rapidly 'increasing' BMI between 11 and 42 years. Both sexes in the 1958 NCDS had greater odds of being in the 'highest' class compared to their peers in the 1946 NSHD but did not have greater odds of being in the 'increasing' class. Conversely, males and females in the 1970 BCS had 2.78 (2.15, 3.60) and 1.87 (1.53, 2.28), respectively, times higher odds of being in the 'increasing' class.

CONCLUSIONS

Our results suggest that the obesity epidemic in Great Britain reflects not only an upward shift in BMI trajectories but also a more recent increase in the number of individuals demonstrating more rapid weight gain, from normal weight to overweight, across the second, third, and fourth decades of life.

Implementation of an infant male circumcision programme, Pakistan

Objective

To retrospectively review outcomes of a health provider-led infant circumcision programme in Pakistan.

Methods

Based on World Health Organization guidelines, we trained surgical technicians and midwives to perform circumcisions using the Plastibell device at two Indus Health Network facilities. Programme tools include a training manual for health providers, information brochures for families, an enrolment form and standardized forms for documenting details of the procedure and outcomes. Infants aged 1–92 days were eligible for the study. Health workers contacted families on days 1 and 7 after the procedure to record any adverse events. We compared the characteristics of infants experiencing adverse events with infants facing no complications using multivariate logistic regression.

Findings

Between August 2016 and August 2018, 2822 circumcised male infants with mean age 22.8 days were eligible for the study. Of these, 2617 infants (92.7%) were followed up by telephone interviews of caretakers. Older infants were more likely to experience adverse events than infants circumcised between 1–30 days of age: 31–60 days: adjusted odds ratio, aOR: 2.03; 95% confidence interval, CI: 1.31–3.15; 61–92 days: aOR: 2.14; 95% CI: 1.13–4.05. Minor adverse events (100 infants; 3.8%) included failure of the bell to shed (90 infants) and minimal bleeding (10 infants). Major adverse events (eight infants; 0.3%) included bleeding that required intervention (four infants), infection (three infants) and skin tear (one infant).

Conclusion

Standardized training protocols and close monitoring enabled nonphysician health providers to perform safe circumcisions on infants aged three months or younger.

Prevalence and spatial distribution of Coxiella burnetii seropositivity in northern Australian beef cattle adjusted for diagnostic test uncertainty

Q fever is a zoonotic disease caused by infection with Coxiella burnetii transmitted from animals including, but not limited to, cattle, sheep and goats. The infection in cattle is typically sub-clinical with some evidence suggesting associated reproductive loss. There is currently limited data on the true prevalence and distribution of coxiellosis in beef cattle across northern Australia. During this study, 2,012 sera samples from beef cattle managed on commercial farms located in Queensland and the Northern Territory were tested using an indirect immunofluorescent assay (IFA) for serological evidence of IgG antibodies against C. burnetii. Bayesian latent class models were used to estimate the true prevalence, adjusted for diagnostic test sensitivity and specificity and incorporating the hierarchical structure of the cattle within farms and regions. In this study, cattle in the Northern Territory had lower estimated true prevalence than cattle within most regions of Queensland with the exception of south-east Queensland. Results from this study have described the geographic distribution and estimated the true prevalence of antibodies to C. burnetii in a sample of extensively managed beef cattle located across the tropical grazing regions of northern Australia.

The Health Determinants of Accessibility to Clubfoot Treatment in LMICs: A Global Exploration of Barriers and Solutions

BACKGROUND

Clubfoot or Congenital Talipes Equinovarus (CTEV) treatment in newborn infants involves simple, non-invasive manipulation and is primarily managed non-surgically if identified early. In low- and middle-income countries (LMICs), less than 15% of patients with CTEV access treatment. This cross-sectional questionnaire study conducted descriptive and regression analysis of institutional reasons for CTEV management in LMICs.

METHODS

A cross-sectional study was undertaken of 1,489 medical institutions in 62 LMICs. Data were evaluated from the "World Health Organization Situation Analysis tool" database. We analyzed characteristics of institutions that manage and did not manage CTEV. With the use of a multivariate linear regression model, we identified a set of factors linked to referral for non-management of CTEV.

RESULTS

A total of 72.7% (1,083/1,395) of institutions surveyed did not manage CTEV. The most common reason cited for not managing CTEV was a lack of sufficient skills, 92.1% (668/725, P<0.001). A total of 39.4% (286/725) of institutions also cited a lack of functioning equipment as a reason. Multivariate linear regression analysis showed lack of training, lack of supplies, and lack of functioning equipment were most closely related to non-management of CTEV.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

We identified that failure to manage CTEV may result from a lack of skills and medical equipment. Increasing the capacity of sustainable training programs may reduce the presently available skill deficit in treating CTEV in LMICs and provide improved health outcomes for those with CTEV. While considerable progress has been made in building capacity for the treatment and management of CTEV in LMICs, structured training programs that support conservative manipulative methods to manage CTEV should be initiated globally.

Design, Synthesis, and Structure-Activity Relationships of Novel Tetrahydroisoquinolino Benzodiazepine Dimer Antitumor Agents and Their Application in Antibody-Drug Conjugates

A series of tetrahydroisoquinoline-based benzodiazepine dimers were synthesized and tested for in vitro cytotoxicity against a panel of cancer cell lines. Structure-activity relationship investigation of various spacers guided by molecular modeling studies helped to identify compounds with picomolar activity. Payload 17 was conjugated to anti-mesothelin and anti-fucosylated monosialotetrahexosylganglioside (FucGM1) antibodies using lysosome-cleavable valine-citrulline dipeptide linkers via heterogeneous lysine conjugation and bacterial transglutaminase-mediated site-specific conjugation. In vitro, these antibody drug conjugates (ADCs) exhibited significant cytotoxic and target-mediated selectivity on human cancer cell lines. The pharmacokinetics and efficacy of these ADCs were further evaluated in gastric and lung cancer xenograft models in mice. Consistent pharmacokinetic profiles, high target specificity, and robust antitumor activity were observed in these models after a single dose of the ADC-46 (0.02 μmol/kg).

Delivery of essential surgery by family physicians

Primary health care provides the framework for delivering the socially-informed, comprehensive and patient-centred care underlying robust health-care systems and is, therefore, central to achieving universal health coverage. Family physicians are best placed to embody primary health care’s dual focus on community and population health because they are often employed in rural or district hospitals with limited human resources, particularly a lack of specialists. Here we want to illustrate how additional training for family physicians, the key clinicians in primary care, can play a critical role in reducing disparities in access to surgical, obstetric and anaesthesia care in low- and middle-income countries and in rural or remote settings. Examples are given of how training programmes can be developed in low-resource settings to equip family physicians with life-saving surgical skills and of how family physicians in high-income countries can be trained in the surgical skills essential for working overseas in low-income settings. Policy-makers should promote surgical practice among family physicians by supporting family medicine programmes that include additional surgical skills training and by expanding opportunities and incentives for family physicians to serve in rural areas. Moreover, national surgical plans should include a primary health care strategy for surgical care and, globally, family physicians should be considered in discussions of surgical care. Finally, surgeons, anaesthesiologists, obstetricians and family physicians should be encouraged to collaborate in ensuring that all patients, regardless of place of residence, receive safe and timely surgical care.

Framework for developing a national surgical, obstetric and anaesthesia plan

Background

Emergency and essential surgical, obstetric and anaesthesia (SOA) care are now recognized components of universal health coverage, necessary for a functional health system. To improve surgical care at a national level, strategic planning addressing the six domains of a surgical system is needed. This paper details a process for development of a national surgical, obstetric and anaesthesia plan (NSOAP) based on the experiences of frontline providers, Ministry of Health officials, WHO leaders, and consultants.

Methods

Development of a NSOAP involves eight key steps: Ministry support and ownership; situation analysis and baseline assessments; stakeholder engagement and priority setting; drafting and validation; monitoring and evaluation; costing; governance; and implementation. Drafting a NSOAP involves defining the current gaps in care, synthesizing and prioritizing solutions, and providing an implementation and monitoring plan with a projected cost for the six domains of a surgical system: infrastructure, service delivery, workforce, information management, finance and governance.

Results

To date, four countries have completed NSOAPs and 23 more have committed to development. Lessons learned from these previous NSOAP processes are described in detail.

Conclusion

There is global movement to address the burden of surgical disease, improving quality and access to SOA care. The development of a strategic plan to address gaps across the SOA system systematically is a critical first step to ensuring countrywide scale‐up of surgical system‐strengthening activities.

At what age do normal weight Canadian children become overweight adults? Differences according to sex and metric

BACKGROUND

The prevalence of overweight and obesity doubles between adolescence and young adulthood; however, the exact age, and appropriate metric to use to identify when overweight develops is still debated.

AIM

To examine the age of onset of overweight by sex and four metrics: body mass index (BMI), fat mass (%FM), waist circumference (WC) and waist-to-height ratio (WHtR).

SUBJECTS AND METHODS

Between 1991 and 2017, serial measures of body composition were taken on 237 (108 males) individuals (aged 8-40 years of age). Hierarchical random effects models were used to develop growth curves. Curves were compared to BMI, %FM and WC overweight age- and sex-specific cut-points.

RESULTS

In males, the BMI growth curve crossed the cut-point at 22.0 years, compared to 23.5 and 26.5 years for WHtR and %FM, respectively; WC cut-off was not reached until 36 years. In females, the BMI growth curve crossed the overweight cut-point at 21.5 years, compared to 14.2 years for %FM and 21.9 and 27.5 years for WC and WHtR, respectively.

CONCLUSION

In summary, overweight onset occurs during young adulthood with the exception of WC in males. BMI in males and %FM in females were the metrics identifying overweight the earliest.

Body size trajectories and cardio-metabolic resilience to obesity

Individuals with obesity do not represent a single homogenous group in terms of cardio‐metabolic health prospects. The concept of metabolically healthy obesity is a crude way of capturing this heterogeneity and has resulted in a plethora of research linking to future outcomes to show that it is not a benign condition. By contrast, very few studies have looked back in time and modelled the life course processes and exposures that explain the heterogeneity in cardio‐metabolic health and morbidity and mortality risk among people with the same body mass index (BMI) (or waist circumference or percentage body fat). The aim of the Medical Research Council New Investigator Research Grant (MR/P023347/1) ‘Body size trajectories and cardio‐metabolic resilience to obesity in three United Kingdom birth cohorts’ is to reveal the body size trajectories, pubertal development patterns and other factors (e.g. early‐life adversity) that might attenuate the positive associations of adulthood obesity makers (e.g. BMI) with cardio‐metabolic disease risk factors and other outcomes, thereby providing some degree of protection against the adverse effects of obesity. This work builds on the Principle Investigator's previous research as part of the Cohort and Longitudinal Studies Enhancement Resources initiative and focuses on secondary data analysis in the nationally representative UK birth cohort studies (initiated in 1946, 1958 and 1970), which have life course body size and exposure data and a biomedical sweep in adulthood. The grant will provide novel evidence on the life course processes and exposures that lead to some people developing a cardio‐metabolic complication or disease or dying while other people with the same BMI do not. This paper details the grant's scientific rationale, research objectives and potential impact.

The positive association of infant weight gain with adulthood body mass index has strengthened over time in the Fels Longitudinal Study

BACKGROUND

Infant weight gain is positively related to adulthood body mass index (BMI), but it is unknown whether or not this association is stronger for individuals born during (compared with before) the obesity epidemic.

OBJECTIVES

The aim of the study was to examine how the infant weight gain-adulthood BMI association might have changed across successive birth year cohorts spanning most of the 20th century.

METHODS

The sample comprised 346 participants in the Fels Longitudinal Study. Confounder-adjusted regression models were used to test the associations of conditional weight-for-length Z-score, capturing weight change between ages 0-2 years, with young adulthood BMI and blood pressure, including cohort [1933-1949 {N = 137}, 1950-1969 {N = 108}, 1970-1997 {N = 101}] as an effect modifier.

RESULTS

Conditional weight-for-length Z-score was positively related to adulthood BMI, but there was significant effect modification by birth year cohort such that the association was over two times stronger in the 1970-1997 cohort (β 2.31; 95% confidence interval 1.59, 3.03) compared with the 1933-1949 (0.98; 0.31, 1.65) and 1950-1969 (0.87; 0.21, 1.54) cohorts. A similar pattern was found for systolic blood pressure.

CONCLUSIONS

The infant weight gain-adulthood BMI association was over two times stronger among a cohort born during the obesity epidemic era compared with cohorts born earlier in the 20th century.

Development of a Unifying Target and Consensus Indicators for Global Surgical Systems Strengthening: Proposed by the Global Alliance for Surgery, Obstetric, Trauma, and Anaesthesia Care (The G4 Alliance)

After decades on the margins of primary health care, surgical and anaesthesia care is gaining increasing priority within the global development arena. The 2015 publications of the Disease Control Priorities third edition on Essential Surgery and the Lancet Commission on Global Surgery created a compelling evidenced-based argument for the fundamental role of surgery and anaesthesia within cost-effective health systems strengthening global strategy. The launch of the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care in 2015 has further coordinated efforts to build priority for surgical care and anaesthesia. These combined efforts culminated in the approval of a World Health Assembly resolution recognizing the role of surgical care and anaesthesia as part of universal health coverage. Momentum gained from these milestones highlights the need to identify consensus goals, targets and indicators to guide policy implementation and track progress at the national level. Through an open consultative process that incorporated input from stakeholders from around the globe, a global target calling for safe surgical and anaesthesia care for 80% of the world by 2030 was proposed. In order to achieve this target, we also propose 15 consensus indicators that build on existing surgical systems metrics and expand the ability to prioritize surgical systems strengthening around the world.

Development of an indirect ELISA for detection of antibody to wobbly possum disease virus in archival sera of Australian brushtail possums (Trichosurus vulpecula) in New Zealand

AIMS

To develop an indirect ELISA based on recombinant nucleocapsid (rN) protein of wobbly possum disease (WPD) virus for investigation of the presence of WPD virus in Australian brushtail possums (Trichosurus vulpecula) in New Zealand.

METHODS

Pre- and post-infection sera (n=15 and 16, respectively) obtained from a previous experimental challenge study were used for ELISA development. Sera were characterised as positive or negative for antibody to WPD virus based on western-blot using WPD virus rN protein as antigen. An additional 215 archival serum samples, collected between 2000-2016 from five different regions of New Zealand, were also tested using the ELISA. Bayesian modelling of corrected optical density at 450 nm (OD₄₅₀) results from the ELISA was used to obtain estimates of receiver operating characteristic (ROC) curves to establish cut-off values for the ELISA, and to estimate the prevalence of antibody to WPD virus.

RESULTS

Western blot analysis showed 5/14 (36%) pre-infection sera and 11/11 (100%) post-infection sera from experimentally infected possums were positive for antibodies to WPD virus. Bayesian estimates of the ROC curves established cut-off values of OD₄₅₀≥0.41 for samples positive, and OD₄₅₀<0.28 for samples negative for antibody to WPD virus, for sera diluted 1:100 for the ELISA. Based on the model, the estimated proportion of samples with antibodies to WPD virus was 0.30 (95% probability interval=0.196-0.418). Of the 230 archival serum samples tested using the ELISA, 48 (20.9%) were positive for antibody to WPD virus, 155 (67.4%) were negative and 27 (11.7%) equivocal, using the established cut-off values. The proportion of samples positive for WPD virus antibody differed between geographical regions (p<0.001).

CONCLUSION

The results suggested that WPD virus or a related virus has circulated among possums in New Zealand with differences in the proportion of antibody-positive samples from different geographical regions. Antibodies to WPD virus did not seem to protect possums from disease following experimental infection, as one third of possums from the previous challenge study showed evidence of pre-existing antibody at the time of challenge. These results provide further support for existence of different pathotypes of WPD virus, but the exact determinants of protection against WPD and epidemiology of infection in various regions of New Zealand remain to be established.

CLINICAL RELEVANCE

Availability of the indirect ELISA for detection of WPD virus antibody will facilitate prospective epidemiological investigation of WPD virus circulation in wild possum populations in New Zealand.

Life course factors associated with metabolically healthy obesity: a protocol for the systematic review of longitudinal studies

BACKGROUND

There is heterogeneity among obese individuals, as some appear to have healthier metabolic profiles and decreased health risks. These individuals are defined as metabolically healthy obese (MHO), whilst those with unhealthy metabolic profiles are defined as metabolically unhealthy obese (MUO). To date, most research on MHO has been cross-sectional or focused on disease prognosis. However, longitudinal studies are required to provide greater insight into the life course factors that contribute to the development of MHO. This study aims to systematically review longitudinal studies investigating the association between life course exposures and future MHO status.

METHODS

Electronic databases (MEDLINE, SCOPUS, and Web of Science) will be searched using a trialled search strategy. Studies will be included following a double-screening process according to inclusion criteria to assess eligibility. Studies eligible for inclusion will include those that have a longitudinal observational design where a life course exposure occurred or was measured at least 1 year before the outcome, investigate a human study population, are published in English after 1956, and investigate the association between ≥ 1 life course exposure and ≥ 1 outcome that reflects a measure of cardiometabolic resilience to obesity. Accepted life course exposures will include body size, body composition, pubertal development, smoking, diet, physical activity, sedentary behaviour, and psychosocial stress. The primary measure of cardiometabolic resilience to obesity will be MHO as an outcome (at follow-up). Studies investigating the development of cardiometabolic risk factors in an obese group without specifying MHO will also be accepted, such as the development of the metabolic syndrome (MetS) in an obese group. Key results of included studies will be tabulated, and a narrative synthesis will be conducted.

DISCUSSION

This will be the first systematic review to summarise the literature on the life course correlates of MHO. Importantly, it may highlight which modifiable lifestyle factors could be targeted to delay the onset of cardiometabolic complications among the obese.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017057992.

Two synthetic compounds containing chromium in different valency states

Two compounds, one an apatite and the other a perovskite, have been synthesized by sintering mixtures containing CaO and Cr2O3, and CaO, Cr2O3, and Fe2O3 respectively. The apatite formed by partial oxidation of the Cr2O3 and subsequent pick-up of moisture from the atmosphere, to give Ca5(CrO4)3OH. The perov-skite formed as a non-stoicheiometric compound Ca4(Fe,Cr)4O11 by partial oxidation of the Cr2O3 during firing. Lattice parameters and interplanar spacings are given for the two structures.

A Comparison of Four Different Methods of Fixation of Osteochondral Fragments

Fixation methods for osteochondral shell grafts were studied using replace-ment of a femoral trochlear autograft in rabbits as the model. Twenty skeletally mature rabbits were divided into four groups with five rabbits in each. The articular cartilage of the femoral trochlea, including 2.0 mm of subchondral bone, was removed using a sagittal bone saw. The grafts were immediately reattached using either small Kirschner pins (K-pins), polydioxanone pins (PDP), polydioxanone suture (PDS), or polymethylmethacrylate (PMMA) cement. Six months postoperatively the rabbits were killed and the graft sites compared to the contralateral control using radiography, gross examination, Safranin-O and H & E staining, and sulphate-35 radioactive uptake. Mild degenerative joint changes were evident radio-graphically in all of the operated joints. Articular surface defects at the graft sites were common and included small craters and erosions; a few had larger areas devoid of cartilage. Defects associated with the pin entrance sites were common in the K-pin and PD P groups. The PDS group had the least number of animals with articular surface defects. Safranin-O staining was complete in the PDS group, partial or complete in the K-pin and PD P groups, and partial in all of the joints in the PMM A group. H & E preparations of the cartilage sections were graded from 1 (normal cartilage) to 5 (multiple fissures, severe degradation). The PDS group had a mean (SD) score of 1.8 (0.8), the PD P group 2.4 (1.1), the K-pin group 2.5 (1.3), and the PMM A group 4.6 (0.6). The scores for the PMM A group were significantly greater then the scores for the other groups (p <0.05). The mean (SD) for radioactive counts per minute/mg tissue in treated graft sites as a percent of control was PDS: 130 (83); PDP : 115 (14); K-pins: 92 (42); PMMA : 91 (29). The relative percentages for radioactive uptake were not significantly different (P >0.05). Graft fixation using PDS, PDP, or K-pins was technically easy to perform and the results were generally satisfactory. Fixation using PMM A was technically demanding and histological evidence of moderate to severe cartilage degradation was present in all treated joints.

Femoral trochlear autografts in rabbits were used to study fixation methods for osteochondral graft fragments. Six months after the operations the graft sites were evaluated using radiographs, gross examination, Safranin-O and H & E staining, and sulphate-35 radioactive uptake. Grafts stabilized using polydioxanone suture had the least number of articular surface defects and the most complete Safranin-O staining.

Gene-environment interplay in depressive symptoms: moderation by age, sex, and physical illness

BACKGROUND

Numerous factors influence late-life depressive symptoms in adults, many not thoroughly characterized. We addressed whether genetic and environmental influences on depressive symptoms differed by age, sex, and physical illness.

METHOD

The analysis sample included 24 436 twins aged 40-90 years drawn from the Interplay of Genes and Environment across Multiple Studies (IGEMS) Consortium. Biometric analyses tested age, sex, and physical illness moderation of genetic and environmental variance in depressive symptoms.

RESULTS

Women reported greater depressive symptoms than men. After age 60, there was an accelerating increase in depressive symptom scores with age, but this did not appreciably affect genetic and environmental variances. Overlap in genetic influences between physical illness and depressive symptoms was greater in men than in women. Additionally, in men extent of overlap was greater with worse physical illness (the genetic correlation ranged from near 0.00 for the least physical illness to nearly 0.60 with physical illness 2 s.d. above the mean). For men and women, the same environmental factors that influenced depressive symptoms also influenced physical illness.

CONCLUSIONS

Findings suggested that genetic factors play a larger part in the association between depressive symptoms and physical illness for men than for women. For both sexes, across all ages, physical illness may similarly trigger social and health limitations that contribute to depressive symptoms.

Is infant body mass index associated with adulthood body composition trajectories? An exploratory analysis

BACKGROUND

Infant body mass index (BMI) is increasingly used as a marker of obesity risk based on its association with young-adulthood BMI.

OBJECTIVES

The aim of this study is to test the association of infant BMI with young-adulthood fat mass and fat-free mass, and how this association changes during advancing adulthood.

METHODS

Body mass index Z-score at age 9 months was measured in 350 White, non-Hispanic Fels Longitudinal Study participants. This exposure was entered into multilevel models to test its association with trajectories describing 2665 BMI observations and 1388 observations of fat mass index (FMI, kg m^-2 ) and fat-free mass index (FFMI, kg m^-2 ) between ages 20 and 60 years.

RESULTS

Partitioning young-adulthood BMI into its fat and fat-free components, infant BMI Z-score was associated with FFMI (β = 0.745; 95% confidence interval = 0.367 to 1.124) but not FMI (0.528; -0.055 to 1.110) at age 20 years. Greater infant BMI Z-score was associated with slower age-related increases in all outcomes, such that (looking at 10-year intervals) only FFMI at age 30 years was related to infant BMI Z-score (0.338; 0.119, 0.557).

CONCLUSIONS

Focus on infant BMI reduction for adulthood obesity prevention warrants caution as high infant BMI values are associated with greater lean mass, which is protective against ageing changes.