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Adolescent diet, physical activity and nutritional status are generally known to be sub-optimal. This is an introduction to a special issue of papers devoted to exploring factors affecting diet and physical activity in adolescents, including food insecure and vulnerable groups.
Eight settings including urban, peri-urban and rural across sites from five different low- and middle-income countries.
Focus groups with adolescents and caregivers carried out by trained researchers.
Our results show that adolescents, even in poor settings, know about healthy diet and lifestyles. They want to have energy, feel happy, look good and live longer, but their desire for autonomy, a need to ‘belong’ in their peer group, plus vulnerability to marketing exploiting their aspirations, leads them to make unhealthy choices. They describe significant gender, culture and context-specific barriers. For example, urban adolescents had easy access to energy dense, unhealthy foods bought outside the home, whereas junk foods were only beginning to permeate rural sites. Among adolescents in Indian sites, pressure to excel in exams meant that academic studies were squeezing out physical activity time.
Interventions to improve adolescents’ diets and physical activity levels must therefore address structural and environmental issues and influences in their homes and schools, since it is clear that their food and activity choices are the product of an interacting complex of factors. In the next phase of work, the Transforming Adolescent Lives through Nutrition consortium will employ groups of adolescents, caregivers and local stakeholders in each site to develop interventions to improve adolescent nutritional status.
We examined demographic, clinical, and psychological characteristics of a large cohort (n = 368) of adults with dissociative seizures (DS) recruited to the CODES randomised controlled trial (RCT) and explored differences associated with age at onset of DS, gender, and DS semiology.
Prior to randomisation within the CODES RCT, we collected demographic and clinical data on 368 participants. We assessed psychiatric comorbidity using the Mini-International Neuropsychiatric Interview (M.I.N.I.) and a screening measure of personality disorder and measured anxiety, depression, psychological distress, somatic symptom burden, emotional expression, functional impact of DS, avoidance behaviour, and quality of life. We undertook comparisons based on reported age at DS onset (<40 v. ⩾40), gender (male v. female), and DS semiology (predominantly hyperkinetic v. hypokinetic).
Our cohort was predominantly female (72%) and characterised by high levels of socio-economic deprivation. Two-thirds had predominantly hyperkinetic DS. Of the total, 69% had ⩾1 comorbid M.I.N.I. diagnosis (median number = 2), with agoraphobia being the most common concurrent diagnosis. Clinical levels of distress were reported by 86% and characteristics associated with maladaptive personality traits by 60%. Moderate-to-severe functional impairment, high levels of somatic symptoms, and impaired quality of life were also reported. Women had a younger age at DS onset than men.
Our study highlights the burden of psychopathology and socio-economic deprivation in a large, heterogeneous cohort of patients with DS. The lack of clear differences based on gender, DS semiology and age at onset suggests these factors do not add substantially to the heterogeneity of the cohort.
The rocky shores of the north-east Atlantic have been long studied. Our focus is from Gibraltar to Norway plus the Azores and Iceland. Phylogeographic processes shape biogeographic patterns of biodiversity. Long-term and broadscale studies have shown the responses of biota to past climate fluctuations and more recent anthropogenic climate change. Inter- and intra-specific species interactions along sharp local environmental gradients shape distributions and community structure and hence ecosystem functioning. Shifts in domination by fucoids in shelter to barnacles/mussels in exposure are mediated by grazing by patellid limpets. Further south fucoids become increasingly rare, with species disappearing or restricted to estuarine refuges, caused by greater desiccation and grazing pressure. Mesoscale processes influence bottom-up nutrient forcing and larval supply, hence affecting species abundance and distribution, and can be proximate factors setting range edges (e.g., the English Channel, the Iberian Peninsula). Impacts of invasive non-native species are reviewed. Knowledge gaps such as the work on rockpools and host–parasite dynamics are also outlined.
The Wisconsin Twin Project comprises multiple longitudinal studies that span infancy to early adulthood. We summarize recent papers that show how twin designs with deep phenotyping, including biological measures, can inform questions about phenotypic structure, etiology, comorbidity, heterogeneity, and gene–environment interplay of temperamental constructs and mental and physical health conditions of children and adolescents. The general framework for investigations begins with rich characterization of early temperament and follows with study of experiences and exposures across childhood and adolescence. Many studies incorporate neuroimaging and hormone assays.
Introduction: Low acuity patients have been controversially tagged as a source of emergency department (ED) misuse. Authorities for many Canadian health regions have set up policies so these patients preferably present to walk-in clinics (WIC). We compared the cost and quality of the care given to low acuity patients in an academic ED and a WIC of Québec City during fiscal year 2015-16. Methods: We conducted an ambidirectional (prospective and retrospective) cohort study using a time-driven activity-based costing method. This method uses duration of care processes (e.g., triage) to allocate to patient care all direct costs (e.g., personnel, consumables), overheads (e.g., building maintenance) and physician charges. We included consecutive adult patients, ambulatory at all time and discharged from the ED or WIC with a diagnosis of upper respiratory tract infection (URTI), urinary tract infection (UTI) or low back pain. Mean cost [95%CI] per patient per condition was compared between settings after risk-adjustment for age, sex, vital signs, number of regular medications and co-morbidities using generalized log-gamma regression models. Proportions [95%CI] of antibiotic prescription and chest X-Ray use in URTI, compliance with provincial guidelines on use of antibiotics in UTI, and column X-Ray use in low back pain were compared between settings using a Pearson Chi-Square test. Results: A total of 409 patients were included. ED and WIC groups were similar in terms of age, sex and vital signs on presentation, but ED patients had a greater burden of comorbidities. Adjusted mean cost (2016 CAN$) of care was significantly higher in the ED than in the WIC (p < 0.0001) for URTI (78.42[64.85-94.82] vs. 59.43[50.43-70.06]), UTI (78.88[69.53-89.48] vs. 53.29[43.68-65.03]), and low back pain (87.97[68.30-113.32] vs. 61.71[47.90-79.51]). For URTI, antibiotics were more frequently prescribed in the WIC (44.1%[34.3-54.3] vs. 5.8%[1.2-16.0]; p < 0.0001) and chest X-Rays, more frequently used in the ED (26.9%[15.6-41.0] vs. 13.7%[7.7-22.0]; p = 0.05). No significant differences were observed in the compliance with guidelines on use of antibiotics in UTI and in the use of column X-Ray in low back pain. Conclusion: Total cost of care for low acuity patients is lower in walk-in clinics than in EDs. However, our results suggest that quality-of-care issues should be considered in determining the best alternate setting for treating ambulatory emergency patients.
Objectives: Studies of neurocognitively elite older adults, termed SuperAgers, have identified clinical predictors and neurobiological indicators of resilience against age-related neurocognitive decline. Despite rising rates of older persons living with HIV (PLWH), SuperAging (SA) in PLWH remains undefined. We aimed to establish neuropsychological criteria for SA in PLWH and examined clinically relevant correlates of SA. Methods: 734 PLWH and 123 HIV-uninfected participants between 50 and 64 years of age underwent neuropsychological and neuromedical evaluations. SA was defined as demographically corrected (i.e., sex, race/ethnicity, education) global neurocognitive performance within normal range for 25-year-olds. Remaining participants were labeled cognitively normal (CN) or impaired (CI) based on actual age. Chi-square and analysis of variance tests examined HIV group differences on neurocognitive status and demographics. Within PLWH, neurocognitive status differences were tested on HIV disease characteristics, medical comorbidities, and everyday functioning. Multinomial logistic regression explored independent predictors of neurocognitive status. Results: Neurocognitive status rates and demographic characteristics differed between PLWH (SA=17%; CN=38%; CI=45%) and HIV-uninfected participants (SA=35%; CN=55%; CI=11%). In PLWH, neurocognitive groups were comparable on demographic and HIV disease characteristics. Younger age, higher verbal IQ, absence of diabetes, fewer depressive symptoms, and lifetime cannabis use disorder increased likelihood of SA. SA reported increased independence in everyday functioning, employment, and health-related quality of life than non-SA. Conclusions: Despite combined neurological risk of aging and HIV, youthful neurocognitive performance is possible for older PLWH. SA relates to improved real-world functioning and may be better explained by cognitive reserve and maintenance of cardiometabolic and mental health than HIV disease severity. Future research investigating biomarker and lifestyle (e.g., physical activity) correlates of SA may help identify modifiable neuroprotective factors against HIV-related neurobiological aging. (JINS, 2019, 25, 507–519)
From 1565 to 1570, Spain established no fewer than three networks of presidios (fortified military settlements) across portions of its frontier territories in La Florida and New Spain. Juan Pardo's network of six forts, extending from the Atlantic coast over the Appalachian Mountains, was the least successful of these presidio systems, lasting only from late 1566 to early 1568. The failure of Pardo's defensive network has long been attributed to poor planning and an insufficient investment of resources. Yet recent archaeological discoveries at the Berry site in western North Carolina—the location of both the Native American town of Joara and Pardo's first garrison, Fort San Juan—warrants a reappraisal of this interpretation. While previous archaeological research at Berry concentrated on the domestic compound where Pardo's soldiers resided, the location of the fort itself remained unknown. In 2013, the remains of Fort San Juan were finally identified south of the compound, the first of Pardo's interior forts to be discovered by archaeologists. Data from excavations and geophysical surveys suggest that it was a substantial defensive construction. We attribute the failure of Pardo's network to the social geography of the Native South rather than to an insufficient investment of resources.
Traumatic stressors during childhood and adolescence are associated with psychopathology, mostly studied in the context of post-traumatic stress disorder (PTSD) and depression. We investigated broader associations of traumatic stress exposure with psychopathology and cognition in a youth community sample.
The Philadelphia Neurodevelopmental Cohort (N = 9498) is an investigation of clinical and neurobehavioral phenotypes in a diverse (56% Caucasian, 33% African American, 11% other) US youth community population (aged 8–21). Participants were ascertained through children's hospital pediatric (not psychiatric) healthcare network in 2009–2011. Structured psychiatric evaluation included screening for lifetime exposure to traumatic stressors, and a neurocognitive battery was administered.
Exposure rate to traumatic stressful events was high (none, N = 5204; one, N = 2182; two, N = 1092; three or more, N = 830). Higher stress load was associated with increased psychopathology across all clinical domains evaluated: mood/anxiety (standardized β = .378); psychosis spectrum (β = .360); externalizing behaviors (β = .311); and fear (β = .256) (controlling for covariates, all p < 0.001). Associations remained significant controlling for lifetime PTSD and depression. Exposure to high-stress load was robustly associated with suicidal ideation and cannabis use (odds ratio compared with non-exposed 5.3 and 3.2, respectively, both p < 0.001). Among youths who experienced traumatic stress (N = 4104), history of assaultive trauma was associated with greater psychopathology and, in males, vulnerability to psychosis and externalizing symptoms. Stress load was negatively associated with performance on executive functioning, complex reasoning, and social cognition.
Traumatic stress exposure in community non-psychiatric help-seeking youth is substantial, and is associated with more severe psychopathology and neurocognitive deficits across domains, beyond PTSD and depression.
Objectives: Human immunodeficiency virus (HIV) disproportionately affects Hispanics/Latinos in the United States, yet little is known about neurocognitive impairment (NCI) in this group. We compared the rates of NCI in large well-characterized samples of HIV-infected (HIV+) Latinos and (non-Latino) Whites, and examined HIV-associated NCI among subgroups of Latinos. Methods: Participants included English-speaking HIV+ adults assessed at six U.S. medical centers (194 Latinos, 600 Whites). For overall group, age: M=42.65 years, SD=8.93; 86% male; education: M=13.17, SD=2.73; 54% had acquired immunodeficiency syndrome. NCI was assessed with a comprehensive test battery with normative corrections for age, education and gender. Covariates examined included HIV-disease characteristics, comorbidities, and genetic ancestry. Results: Compared with Whites, Latinos had higher rates of global NCI (42% vs. 54%), and domain NCI in executive function, learning, recall, working memory, and processing speed. Latinos also fared worse than Whites on current and historical HIV-disease characteristics, and nadir CD4 partially mediated ethnic differences in NCI. Yet, Latinos continued to have more global NCI [odds ratio (OR)=1.59; 95% confidence interval (CI)=1.13–2.23; p<.01] after adjusting for significant covariates. Higher rates of global NCI were observed with Puerto Rican (n=60; 71%) versus Mexican (n=79, 44%) origin/descent; this disparity persisted in models adjusting for significant covariates (OR=2.40; CI=1.11–5.29; p=.03). Conclusions: HIV+ Latinos, especially of Puerto Rican (vs. Mexican) origin/descent had increased rates of NCI compared with Whites. Differences in rates of NCI were not completely explained by worse HIV-disease characteristics, neurocognitive comorbidities, or genetic ancestry. Future studies should explore culturally relevant psychosocial, biomedical, and genetic factors that might explain these disparities and inform the development of targeted interventions. (JINS, 2018, 24, 163–175)
Introduction: Medical transport services are essential in the regionalization of trauma care. Given the limited number of designated trauma centers, transport times can be prolonged, with patient care managed by paramedics for the duration of their transfer. Pain management is a paramount component, but oligoanalgesia can occur. The primary objective of this study was to evaluate pain management practices during transport of trauma patients by air. Methods: We conducted a 12-month review of ORNGE electronic paramedic records. ORNGE is the exclusive provider of air and land transport in Ontario, Canada. Cases from 1 January 2015 to 31 December 2015 were screened. Patients were identified according to inclusion (≥18 years old requiring transportation to designated trauma center) and exclusion criteria (GCS<14; intubation; accompanied by a nurse or physician). Information was collected in a standardized, piloted data form used by a single trained data extractor. Demographics, injury description, and transportation parameters were recorded. Outcomes included pain assessment according to changes on a 10-point numeric rating scale (NRS), patterns of analgesia administration, and analgesia-related adverse events (AEs). Results were reported as mean, (standard deviation), [range], or percentage. Results: Of 600 potential records, 372 patients met our inclusion criteria with the following characteristics: age 47.0 [19-92] years; 70.4% male; 97.0% blunt injury. Duration of transport was 82.4 (46.3) minutes. Pain was initially assessed in 90.0% of patients. Overall, NRS at baseline was 4.9 (2.8). Of the 62.4% who received analgesia, NRS at baseline was 5.9 (2.5). Fentanyl was most commonly administered (78.5%) at 44.3 [25-60] mcg. NRS after the first dose of analgesia decreased by 1.1 (1.6) points. A total of 73.7% of patients received further analgesia, equal to 2.4 [1-19] additional doses. While 23.4% of patients had no change in NRS after the first dose of analgesia, subsequent doses resulted in no change in NRS in over 65% [65.4-71.3] of patients. A total of 43 AEs (6.7%) were recorded after 638 doses of analgesia, and the most common AE was nausea (39.5%). Conclusion: The majority of patients were assessed for pain. Although the first analgesia administration had minimal effect on NRS, subsequent doses appeared to have even less of an impact. AEs were infrequent.
Introduction: While methods have been developed to assess pain and provide analgesia to hospitalized intubated patients, little is known about current EMS practices in providing similar care during air and land medical transports. Therefore, we sought to determine if opioid analgesia is provided to intubated patients during transportation in out-of-hospital setting. Methods: We conducted a health record review examining electronic records of intubated patients transported by Ornge in 2015. Ornge is the exclusive provider of air and land transport of critically ill patients in Ontario, Canada with over 18,000 transports per year. We identified cases using Ornge’s database and selected intubated patients meeting inclusion criteria. A standardized data extraction form was piloted and used by a single trained data extractor. The primary outcome was frequency of administration and dose adequacy of an opioid analgesic. Secondary outcomes included: choice of analgesics used (fentanyl, hydromorphone or morphine), adverse events, and impact of age, sex, or reason for transfer on pain management. We present descriptive statistics. Results: Our strategy identified 500 potential cases, of which 448 met our inclusion criteria. Among those 448 patients, 154 (34.4%) were females, 328 (73.4%) received analgesia and 211 (64.3%) received more than one dose during transport (median frequency of 2 doses, IQR=1 to 3). The average transport time was 148 minutes and repeated dosing (>1 repeat dose) occurred primarily (45.5%) in transports of over 180 minutes. Fentanyl was the most commonly used analgesic (97.6%) and most commonly used dose was 50 micrograms (51.8%). Adverse events occurred in 8 (2.5%) patients with 5 patients having new hypotension (MAP <65 mm Hg). There was no significant difference in administration of analgesia based on patient’s age or sex (68.8% of females and 75.3% of male patients received analgesia). Interestingly, 30.8% of patients repatriated to originating-hospital received analgesia compared to 72.3% of patients receiving analgesia for all other reasons for transfers. Conclusion: More than 73% of intubated patients transported by Ornge received an opioid analgesic, most commonly fentanyl. We found no clinically relevant difference in the administration of analgesics based on age, sex or reason for transfer other than home repatriation.
Introduction: Redirecting low acuity patients from emergency departments to primary care walk-in clinics has been identified as a priority by many health authorities. Promoting family physicians for the management of ambulatory patients with urgent health concerns reflects the assumption that primary care facilities can offer high-quality and more affordable ambulatory emergency care. However, no performance assessment framework has been developed for ambulatory emergency care and consequently, quality of care provided in these alternate settings has never been formally compared. Primary objective: To identify structure, process and outcome indicators for ambulatory emergency care. Methods: We will identify and develop quality indicators (QIs) for ambulatory emergency care using a RAND/UCLA Appropriateness Method (RAM) composed of three different steps. First, we will perform a scoping literature review to inventory 1) all previously recommended QIs assessing care provided to ambulatory emergency patients in the ED or the primary care settings; 2) all conditions evaluated with the retrieved QIs; and 3) all outcomes measured by the same QIs. Second, a steering committee composed of the research team and of international experts in performance assessment in emergency and primary care will be presented with the lists of QI-related conditions and outcomes. They will be asked to identify potential outcome indicators for ambulatory emergency care by generating any relevant combinations of one condition and one outcome (e.g. acute asthma exacerbation/re-consultation). Committee members will be given the latitude to use and pair any conditions or outcomes not included in the lists as long as they think the resulting indicators are compatible with the study objectives. Using a structured nominal group approach, they will combine their suggestions and refine the list of potential QIs. This list of potential outcome indicators composed of pairs “condition/outcome” will be merged with the list of already published QIs identified during the literature review. Third, as per the RAM standards, we will assemble an international multidisciplinary panel (n=20) of patients, emergency and primary care providers, researchers and decision makers, after recommendations from international emergency and primary care associations, and from the Canadian Strategy for Patient-Oriented Research (SPOR) Support Units. Through iterative rounds of ratings using both web-based survey tools and videoconferencing, panelists will independently assess all candidate QIs. They will be asked to rate on a nine-level scale to what extent each QI is a relevant and useful measure of ambulatory emergency care quality. From one round to the next, QIs with a median panelist rating score of one to three will be excluded. Those with a median score of seven or more will be automatically included in the final list. QIs with median score of four to six will be retained for future deliberations among the panelists. Rounds of ratings will be conducted until all QIs are classified. Impact: The QIs identified will be used to develop a performance assessment framework for ambulatory emergency care. This will represent an essential step toward testing the assumption that EDs and primary care walk-in clinics provide equivalent care quality to low acuity patients.
Changes in respiratory pathogen testing can affect disease burden estimates. Using linked data, we describe changes in respiratory virus testing among children born in Western Australia in 1996–2012. We extracted data on respiratory specimens from these children from birth to age 9 years. We estimated testing rates by age, year, Aboriginal status and geographical location. Predictors of testing among children hospitalised at least once before their 10th birthday were identified using logistic regression. We compared detection methods for respiratory viruses from nasal/nasopharyngeal (NP) specimens by age and year. Of 83 199 virology testing records in 2000–2012, 80% were nasal/NP specimens. Infants aged <1 month had the highest testing rates. Testing rates in all children increased over the study period with considerable yearly fluctuations. Among hospitalised children, premature children <32 weeks gestation had over three times the odds of being tested (95% CI 3·47–4·13) than those born at term. Testing using molecular methods increased from 5% to 87% over the study period. Proportion of positive samples increased from 36·3% to 44·4% (P < 0·01); this change was greatest in children aged 2–9 years. These findings will assist in interpreting results from future epidemiology studies assessing the pathogen-specific burden of disease.
To determine the length and position of a thyroidectomy scar that is cosmetically most appealing to naïve raters.
Images of thyroidectomy scars were reproduced on male and female necks using digital imaging software. Surgical variables studied were scar position and length. Fifteen raters were presented with 56 scar pairings and asked to identify which was preferred cosmetically. Twenty duplicate pairings were included to assess rater reliability. Analysis of variance was used to determine preference.
Raters preferred low, short scars, followed by high, short scars, with long scars in either position being less desirable (p < 0.05). Twelve of 15 raters had acceptable intra-rater and inter-rater reliability.
Naïve raters preferred low, short scars over the alternatives. High, short scars were the next most favourably rated. If other factors influencing incision choice are considered equal, surgeons should consider these preferences in scar position and length when planning their thyroidectomy approach.
The Universe is permeated by hot, turbulent, magnetized plasmas. Turbulent plasma is a major constituent of active galactic nuclei, supernova remnants, the intergalactic and interstellar medium, the solar corona, the solar wind and the Earth’s magnetosphere, just to mention a few examples. Energy dissipation of turbulent fluctuations plays a key role in plasma heating and energization, yet we still do not understand the underlying physical mechanisms involved. THOR is a mission designed to answer the questions of how turbulent plasma is heated and particles accelerated, how the dissipated energy is partitioned and how dissipation operates in different regimes of turbulence. THOR is a single-spacecraft mission with an orbit tuned to maximize data return from regions in near-Earth space – magnetosheath, shock, foreshock and pristine solar wind – featuring different kinds of turbulence. Here we summarize the THOR proposal submitted on 15 January 2015 to the ‘Call for a Medium-size mission opportunity in ESAs Science Programme for a launch in 2025 (M4)’. THOR has been selected by European Space Agency (ESA) for the study phase.
This study aimed to review available disaster training options for health care providers, and to provide specific recommendations for developing and delivering a disaster-response-training program for non-disaster-trained emergency physicians, residents, and trainees prior to acute deployment.
A comprehensive review of the peer-reviewed and grey literature of the existing training options for health care providers was conducted to provide specific recommendations.
A comprehensive search of the Pubmed, Embase, Web of Science, Scopus, and Cochrane databases was performed to identify publications related to courses for disaster preparedness and response training for health care professionals. This search revealed 7,681 unique titles, of which 53 articles were included in the full review. A total of 384 courses were found through the grey literature search, and many of these were available online for no charge and could be completed in less than six hours. The majority of courses focused on management and disaster planning; few focused on clinical care and acute response.
There is need for a course that is targeted toward emergency physicians and trainees without formal disaster training. This course should be available online and should utilize a mix of educational modalities, including lectures, scenarios, and virtual simulations. An ideal course should focus on disaster preparedness, and the clinical and non-clinical aspects of response, with a focus on an all-hazards approach, including both terrorism-related and environmental disasters.
HansotiB, KelloggDS, AberleSJ, BroccoliMC, FedenJ, FrenchA, LittleCM, MooreB, SabatoJJr., SheetsT, WeinbergR, ElmesP, KangC. Preparing Emergency Physicians for Acute Disaster Response: A Review of Current Training Opportunities in the US. Prehosp Disaster Med. 2016;31(6):643–647.