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The uncertainty surrounding high intakes of folic acid and associations with cognitive decline in older adults with low vitamin B12 status has been an obstacle to mandatory folic acid fortification for many years. We estimated the prevalence of combinations of low/normal/high vitamin B12 and folate status and compared associations with global cognitive function using two approaches, of individuals in a population-based study of those aged ≥50 years in the Republic of Ireland. Cross-sectional data from 3781 men and women from Wave 1 of The Irish Longitudinal Study on Ageing were analysed. Global cognitive function was assessed by the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA). Prevalence estimates for combinations of vitamin B12 (plasma vitamin B12 < or ≥258 pmol/l) and folate (plasma folate ≤ or >45·3 nmol/l) concentrations were generated. Negative binomial regression models were used to investigate the associations of vitamin B12 and folate status with global cognitive function. Of the participants, 1·5 % (n 51) had low vitamin B12 (<258 pmol/l) and high folate (>45·3 nmol/l) status. Global cognitive performance was not significantly reduced in these individuals when compared with those with normal status for both B-vitamins (n 2433). Those with normal vitamin B12/high folate status (7·6 %) had better cognitive performance (MMSE: incidence rate ratio (IRR) 0·82, 95 % CI 0·68, 0·99; P = 0·043, MoCA: IRR 0·89, 95 % CI 0·80, 0·99; P = 0·025). We demonstrated that high folate status was not associated with lower cognitive scores in older adults with low vitamin B12 status. These findings provide important safety information that could guide fortification policy recommendations in Europe.
Vitamin B12 deficiency is common among older adults, even with dietary intakes well in excess of current recommendations. Severe clinical B12 deficiency (i.e. pernicious anaemia) leads to irreversible neurological damage, but once diagnosed, can be treated effectively with B12 injections. A much more common cause of low vitamin B12 status in older adults is food-bound malabsorption owing to atrophic gastritis. This in turn leads to reduced gastric acid secretion, thus limiting B12 absorption from food (given the essential role of gastric acid in releasing B12 from food proteins). Proton pump inhibitor (PPI) drugs reduce gastric acid secretion, similar to atrophic gastritis, thus there is a concern that these medications may lead to vitamin B12 malabsorption. Therefore, the aim of this study was to investigate biomarker status of vitamin B12 in relation to atrophic gastritis and PPI usage. Data were accessed from The Trinity Ulster Department of Agriculture (TUDA) Ageing Cohort Study, a cross-sectional study of community-dwelling adults (n 5186, ≥ 60 years) recruited across Northern Ireland and the Republic of Ireland (2008–2012). TUDA participants were classified into 3 groups; ‘healthy’ controls, atrophic gastritis and PPI users. Vitamin B12 status was assessed using a total of four biomarkers: serum total B12; serum holotranscobalamin, holoTC; plasma methylmalonic acid, MMA; plasma homocysteine. Atrophic gastritis was identified using pepsinogen analysis (via ELISA), with a pepsinogen I : II ratio of < 3 considered indicative of atrophic gastritis. Based on results from all four biomarkers, participants with atrophic gastritis were found to have significantly lower B12 status compared to healthy controls: e.g. mean (95% CI) serum total vitamin B12, 188 (156, 218) pmol/L vs. 262 (252, 272) pmol/L P < 0.001; holoTC, 46.0 (38.1, 53.8) pmol/L vs. 60.3 (57.8, 62.8) pmol/L P < 0.001; plasma MMA, 0.65 (0.52, 0.78) μmol/L vs. 0.37 (0.32, 0.42) μmol/L P = 0.001. No differences in B12 biomarker concentrations were observed between PPI users and healthy controls. Regular consumption of fortified foods (i.e. ≥ 5 portions per week) compared to non-regular consumption (i.e. 0–4 portions per week) impacted positively on B12 biomarker status in all participants. This effect however appeared insufficient to restore normal vitamin B12 status in those with atrophic gastritis. These results show that older adults with atrophic gastritis have significantly lower vitamin B12 biomarker status, particularly in those who did not regularly consume fortified foods. Further investigations of the effect of atrophic gastritis and PPI usage on B12 status are warranted.
The early fetal environment during pregnancy is extremely important and research indicates that weight at birth can have crucial impacts for the individual's health later in life. With rates of childhood obesity estimated to be as high as 21% in some European countries, it is vital that early risk factors are identified so that interventions can be developed. We aimed to investigate if children born macrosomic (birth weight > 4kg) remained larger than normal birth weight babies up to 5 years of age.
Materials and Methods:
This is a longitudinal follow-up of 387 five-year-old children (53% born with macrosomia, 47% normal birth weight) born into the ROLO randomised control trial in the National Maternity Hospital, Dublin (ISRCTN54392969). Birth weight was previously recorded then at 6 months, 2 years, and 5 years of age child height, weight, anthropometric and skinfold measurements were collected. Body Mass Index (kg/m2) and centiles were calculated. Student t-tests and Mann-Whitney U tests were used to compare the two groups with multiple linear regression modelling to control for confounders.
Children with a birth weight > 4 kg had consistently higher weights, lengths, and BMI centiles, along with increased head and chest circumferences, compared to normal birth weight children from 6 months up to 5 years of age (p < 0.05). After controlling for child sex, intervention group, smoking during pregnancy, maternal education status, and maternal BMI, children with macrosomia were 0.61 kg heavier than non-macrosomic infants at 5 years of age (95% CI: 0.04–1.18, p < 0.05).
Children born with a high birth weight remain heavier and larger into childhood. These individuals are at a higher risk of obesity which highlights the need for monitoring and potential interventions, both during pregnancy and in infancy, to curb the current childhood obesity crisis.
Weeds remain the foremost production challenge for organic small grain farmers in the northeastern United States. Instead of crops sown in narrow, single-line rows, band sowing offers a more uniform spatial arrangement of the crop, maximizing interspecific while reducing intraspecific competition. Weeds in the inter-band zone are controlled by cultivating with aggressive sweeps; tine harrowing can target weeds in both intra- and inter-band zones. Field experiments in Maine and Vermont in 2016 and 2017 evaluated band sowing for improved weed control, crop yield, and grain quality in organic spring barley (Hordeum vulgare L. ‘Newdale’). Specifically, we compared: (1) the standard practice of sowing 16.5-cm rows at a target crop density of 325 plants m−2, (2) narrow-row sowing with increased crop density, (3) wide-row sowing with interrow hoeing, and (4) band sowing both with and (5) without inter-band hoeing. Mustard (Sinapis alba L. ‘Ida Gold’) was planted throughout the experiment as a surrogate weed. Compared with the standard practice, band sowing with hoeing reduced surrogate weed density on average by 45% across site-years. However, effects on weed biomass and yield were inconsistent, perhaps due to suboptimal timing of hoeing and adverse weather conditions. In 1 out of 4 site-years, band sowing with hoeing reduced surrogate weed biomass by 67% and increased crop yield compared with the standard treatment. Results also indicate that band sowing with hoeing may improve 1,000-kernel weight and plump kernel grain-quality parameters.
Surgery for CHD has been slow to develop in parts of the former Soviet Union. The impact of an 8-year surgical assistance programme between an emerging centre and a multi-disciplinary international team that comprised healthcare professionals from developed cardiac programmes is analysed and presented.
Material and methods
The international paediatric assistance programme included five main components – intermittent clinical visits to the site annually, medical education, biomedical engineering support, nurse empowerment, and team-based practice development. Data were analysed from visiting teams and local databases before and since commencement of assistance in 2007 (era A: 2000–2007; era B: 2008–2015). The following variables were compared between periods: annual case volume, operative mortality, case complexity based on Risk Adjustment for Congenital Heart Surgery (RACHS-1), and RACHS-adjusted standardised mortality ratio.
A total of 154 RACHS-classifiable operations were performed during era A, with a mean annual case volume by local surgeons of 19.3 at 95% confidence interval 14.3–24.2, with an operative mortality of 4.6% and a standardised mortality ratio of 2.1. In era B, surgical volume increased to a mean of 103.1 annual cases (95% confidence interval 69.1–137.2, p<0.0001). There was a non-significant (p=0.84) increase in operative mortality (5.7%), but a decrease in standardised mortality ratio (1.2) owing to an increase in case complexity. In era B, the proportion of local surgeon-led surgeries during visits from the international team increased from 0% (0/27) in 2008 to 98% (58/59) in the final year of analysis.
The model of assistance described in this report led to improved adjusted mortality, increased case volume, complexity, and independent operating skills.
It has become increasingly apparent that only the truly effective humanitarian work emphasises empowering local practitioners. One problem, though, is that we are often seen as the “experts” who have come to “save” the children. This perception may adversely affect the confidence in the country’s own providers.
Non-profit organisations performing paediatric heart surgery in developing countries were identified from two sources: the CTSnet “volunteerism” web page and an Internet search using the term “Pediatric Heart Surgery Medical Mission.” The website of each organisation was reviewed, seeking a “purpose” or “mission” statement or summary of the organisation’s work. A separate Internet search of news articles was performed. The top five articles were analysed for each organisation, and the findings are then analysed using the Principlist and Utilitarian ethical systems.
A total of 10 separate non-profit organisations were identified. The websites of eight (80%) placed significant emphasis on the educational aspects of their work and/or on interaction with local professionals. However, of 43 news articles reviewed, reporters mentioned education of, or interaction with, local professionals in only 14 (33%), and four out of 10 organisations studied had no mention of the local providers in any article.
Although non-profit organisations emphasise the teaching and programme-building aspects of their efforts, media reports largely focus on simpler and more emotional stories such as patient successes or large donations. Acknowledgement of the clinical and financial contributions of the host countries is both a duty following from the principle of justice and an important factor in long-term programme building.
Infant protein intake has been associated with child growth, however, research on maternal protein intake during pregnancy is limited. Insulin-like growth factors (IGF) play a role in early fetal development and maternal protein intake may influence child body composition via IGF-1. The aim of this study was to investigate the association of maternal protein intake throughout pregnancy on cord blood IGF-1 and child body composition from birth to 5 years of age. Analysis was carried out on 570 mother–child dyads from the Randomised cOntrol trial of LOw glycaemic index diet study. Protein intake was recorded using 3-d food diaries in each trimester of pregnancy and protein intake per kg of maternal weight (g/d per kg) was calculated. Cord blood IGF-1 was measured at birth. Infant anthropometry was measured at birth, 6 months, 2 and 5 years of age. Mixed modelling, linear regression, and mediation analysis were carried out. Birth weight centiles were positively associated with early-pregnancy protein intake (g/d per kg), while weight centiles from 6 months to 5 years were negatively associated (B=−21·6, P<0·05). These associations were not mediated by IGF-1. Our findings suggest that high protein intake in early-pregnancy may exert an in utero effect on offspring body composition with a higher weight initially at birth but slower growth rates into childhood. Further research is needed to elucidate the exact mechanisms by which dietary protein modulates fetal growth.
In countries with ample resources, no debate exists as to whether heart surgery should be provided. However, where funding is limited, what responsibility exists to care for children with congenital heart defects? If children have a “right” to surgical treatment, to whom is the “duty” to provide it assigned? These questions are subjected to ethical analysis.
Examination is initially based on the four principles of medical ethics: autonomy, beneficence, non-maleficence, and justice. Consideration of beneficence and justice is expanded using a consequentialist approach.
Social structures, including governments, exist to foster the common good. Society, whether by means of government funding or otherwise, has the responsibility, according to the means available, to assure health care for all based on the principles of beneficence, non-maleficence, and justice. In wealthy countries, adequate resources exist to fund appropriate treatment; hence it should be provided to all based on distributive justice. In resource-limited countries, however, decisions regarding provision of care for expensive or complex health problems must be made with consideration for broader effects on the general public. Preliminary data from cost-effectiveness analysis indicate that many surgical interventions, including cardiac surgery, may be resource-efficient. Given that information, utilitarian ethical analysis supports dedication of resources to congenital heart surgery in many low-income countries. In the poorest countries, where access to drinking water and basic nutrition is problematic, it will often be more appropriate to focus on these issues first.
Ethical analysis supports dedication of resources to congenital heart surgery in all but the poorest countries.
Previous reports investigating adiposity and cognitive function in the population allude to a negative association, although the relationship in older adults is unclear. The aim of this study was to investigate the association of adiposity (BMI and waist:hip ratio (WHR)) with cognitive function in community-dwelling older adults (≥60 years). Participants included 5186 adults from the Trinity Ulster Department of Agriculture ageing cohort study. Neuropsychological assessment measures included the Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB) and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Multi-variable linear regression models were used to assess the association between adiposity and cognitive function adjusting for insulin resistance, inflammation and cerebrovascular disease. The mean ages were 80·3 (sd 6·7), 71·0 (sd 7·3) and 70·2 (sd 6·3) years on the cognitive, bone and hypertensive cohorts, respectively. In the cognitive cohort, BMI was positively associated with immediate and delay memory, visuospatial/constructional ability, language and MMSE, and negatively with FAB (log-transformed), whereas WHR was negatively associated with attention. In the bone cohort, BMI was not associated with any cognitive domain, whereas WHR was negatively associated with visuospatial/constructional ability, attention and MMSE. In the hypertensive cohort, BMI was not associated with any cognitive domain, whereas WHR was negatively associated with immediate and delayed memory, visuospatial/constructional ability, language and MMSE and positively with FAB (log-transformed). In the cognitive and bone cohorts, the association of WHR and attention disappeared by further controlling for C-reactive protein and HbA1C. In this study of older adults, central adiposity was a stronger predictor of poor cognitive performance than BMI. Older adults could benefit from targeted public health strategies aimed at reducing obesity and obeseogenic risk factors to avoid/prevent/slow cognitive dysfunction.
Mandatory fortification of staple grains with folic acid and/or vitamin B12 (B12) is under debate in many countries including Ireland, which has a liberal, but voluntary, fortification policy. Older adults can be at risk of both deficiency and high folate status, although little is known on the actual prevalence and the major predictors. Population prevalence estimates from older adults (n 5290 ≥50 years) from the Irish Longitudinal Study on Ageing (TILDA) (Wave 1) are presented here. Measures included plasma total vitamin B12 and folate, whereas predictors included detailed demographic, socio-economic, geographic, seasonal and health/lifestyle data. The prevalence of deficient or low B12 status (<185 pmol/l) was 12 %, whereas the prevalence of deficient/low folate status was 15 %. High folate status (>45 nmol/l) was observed in 8·9 %, whereas high B12 status was observed in 3·1 % (>601 pmol/l). The largest positive predictor of B12 concentration was self-reported B12 injection and/or supplement use (coefficient 51·5 pmol/; 95 % CI 9·4, 93·6; P=0·016) followed by sex and geographic location. The largest negative predictor was metformin use (−33·6; 95 % CI −51·9, −15·4; P<0·0001). The largest positive predictor of folate concentration was folic acid supplement use (6·0; 95 % CI 3·0, 9·0 nmol/l; P<0·001) followed by being female and statin medications. The largest negative predictor was geographic location (−5·7; 95 % CI −6·7, −4·6; P<0·0001) followed by seasonality and smoking. B-vitamin status in older adults is affected by health and lifestyle, medication, sampling period and geographic location. We observed a high prevalence of low B12 and folate status, indicating that the current policy of voluntary fortification is ineffective for older adults.
Aspects of species life histories may increase their susceptibility to climate change. Owing to their exclusive reliance on environmental sources of heat for incubation, megapodes may be especially vulnerable. We employed a trait-based vulnerability assessment to weigh their exposure to projected climate variables of increasing temperatures, fluctuating rainfall and sea level rise and their biological sensitivity and capacity to adapt. While all 21 species were predicted to experience at least a 2 °C increase in mean annual temperature, 12 to experience a moderate or greater fluctuation in rainfall and 16 to experience rising seas, the most vulnerable megapodes are intrinsically rare and range restricted. Species that employ microbial decomposition for incubation may have an adaptive advantage over those that do not and may be more resilient to climate change. The moderate microclimate necessary for mound incubation, however, may in some areas be threatened by anthropogenic habitat loss exacerbated by warmer and seasonally drier conditions. As with many avian species, little is known about the capacity of megapodes to adapt to a changing climate. We therefore recommend that future research efforts investigate megapode fecundity, gene flow and genetic connectivity at the population level to better determine their adaptive capacity.
This review will outline the role of visiting cardiac surgical teams in low- and middle-income countries drawing on the collective experience of the authors in a wide range of locations. Requests for assistance can emerge from local programmes at a beginner or advanced stage. However, in all circumstances, careful pre-trip planning is necessary in conjunction with clinical and non-clinical local partners. The clinical evaluation, surgical procedures, and postoperative care all serve as a template for collaboration and education between the visiting and local teams in every aspect of care. Education focusses on both common and patient-specific issues. Case selection must appropriately balance the clinical priorities, safety, and educational objectives within the time constraints of trip duration. Considerable communication and practical challenges will present, and clinicians may need to make significant adjustments to their usual practice in order to function effectively in a resource-limited, unfamiliar, and multilingual environment. The effectiveness of visiting trips should be measured and constantly evaluated. Local and visiting teams should use data-driven evaluations of measurable outcomes and critical qualitative evaluation to repeatedly re-assess their interim goals. Progress invariably takes several years to achieve the final goal: an autonomous self-governing, self-financed, cardiac programme capable of providing care for children with complex CHD. This outcome is consistent with redundancy for the visiting trips model at the site, although fraternal, professional, and academic links will invariably remain for many years.
In many regions of the world domestic dogs are free roaming and live in close relationship with humans. These free-roaming domestic dogs (FRDD) can cause public health problems such as dog bites and transmission of infectious diseases. To effectively control diseases transmitted by FRDD, knowledge on the dogs’ behaviour is required. To identify predictors of home range (HR) size, we collected global positioning system data from 135 FRDD living in eight Aboriginal and Torres Strait Islander communities in Northern Australia. The core HR size ranged from 0·17 to 2·33 ha and the extended HR size from 0·86 to 40·46 ha. Using a linear mixed effect model with a Restricted Maximum Likelihood approach, the dog's sex and reproductive status were identified as predictors of roaming. Non-castrated males had the largest HRs, followed by neutered females. Also, FRDDs were found to roam further during the pre- than the post-wet season. These findings have implications for infectious disease spread. Identification of risk groups for disease spread within a population allows for more targeted disease response and surveillance. Further investigation of predictors of roaming in other FRDD populations worldwide would increase the external validity of such studies.