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OBJECTIVE: To determine the causal relationship between exposure to early hyperoxemia and death or major disability in infants with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN: We analyzed data from the Infant Cooling Evaluation (ICE) trial that enrolled newborns ≥35 weeks' gestation with moderate-severe HIE, randomly allocated to hypothermia or normothermia. The primary outcome was death or major sensorineural disability at 2 years. We included infants with arterial pO2 measured within 2 hours of birth. Using a directed acyclic graph, we established that markers of severity of perinatal hypoxia-ischemia and pCO2 were a minimally sufficient set of variables for adjustment in a regression model to estimate the causal relationship between arterial pO2 and death/disability. RESULTS: Among 221 infants, 116 (56%) had arterial pO2 and primary outcome data. The unadjusted analysis revealed a U-shaped relationship between arterial pO2 and death or major disability. Among hyperoxemic infants (pO2 100-500 mmHg) the proportion with death or major disability was 40/58 (0.69), while the proportion in normoxemic infants (pO2 40-99 mmHg) was 20/48 (0.42). In the adjusted model, hyperoxemia increased the risk of death or major disability (adjusted risk ratio 1.61, 95% CI 1.07-2.00, P = .03) in relation to normoxemia. CONCLUSION: Early hyperoxemia increased the risk of death or major disability among infants who had an early arterial pO2 in the ICE trial. Limitations include the possibility of residual confounding and other causal biases. Further work is warranted to confirm this relationship in the era of routine therapeutic hypothermia.

The elemental abundances of stars, particularly the refractory elements (e.g., Fe, Si, Mg), play an important role in connecting stars to their planets. Most Sun-like stars do not have refractory abundance measurements since obtaining a large sample of high-resolution spectra is difficult with oversubscribed observing resources. In this work we infer abundances for C, N, O, Na, Mn, Cr, Si, Fe, Ni, Mg, V, Ca, Ti, Al, and Y for solar analogs with Gaia RVS spectra (R=11,200) using the Cannon, a data-driven method. We train a linear model on a reference set of 34 stars observed by Gaia RVS with precise abundances measured from previous high resolution spectroscopic efforts (R > 30,000--110,000). We then apply this model to several thousand Gaia RVS solar analogs. This yields abundances with average upper limit precisions of 0.04--0.1 dex for 17,412 stars, 50 of which are identified planet (candidate) hosts. We subsequently test the relative refractory depletion of these stars with increasing element condensation temperature compared to the Sun. The Sun remains refractory depleted compared to other Sun-like stars regardless of our current knowledge of the planets they host. This is inconsistent with theories of various types of planets locking up or sequestering refractories. Furthermore, we find no significant abundance differences between identified close-in giant planet hosts, giant planet hosts, and terrestrial/small planet hosts and the rest of the sample within our precision limits. This work demonstrates the utility of data-driven learning for future exoplanet composition and demographics studies., Comment: 24 pages, 10 figures, 4 tables, 1 appendix. Accepted in ApJ. Tables 1 and 2 available upon request

RIVM rapport:Het westnijlvirus veroorzaakt westnijlkoorts. Dit virus komt voor bij vogels en wordt overgebracht door muggen die zich voeden met bloed van besmette vogels. Deze muggen verspreiden het virus naar andere vogels, en soms ook naar mensen en zoogdieren, zoals paarden. In 2020 zijn enkele mensen in Nederland besmet geraakt. Dat was de aanleiding om een 'surveillance'-project op te zetten om inzicht te krijgen hoe vaak het westnijlvirus in Nederland voorkomt. Wanneer een mens besmet raakt, worden artsen en bewoners van gebieden waar het virus is gevonden geïnformeerd. Vanwege de dier op mens besmetting is belangrijk dat artsen uit de gezondheidszorg en dierenartsen met elkaar samen werken (one health). Het virus is tussen 2021 en 2023 in de gaten gehouden. In deze jaren zijn in Nederland geen infecties bij mensen aangetoond, wel bij enkele dieren (kippen, een paard en een blauwe reiger). Het type virus waarmee de reiger was geïnfecteerd, was bijna hetzelfde als het virus uit 2020. Dit toont aan dat het westnijlvirus tussen 2021 en 2023 nog wel in Nederland circuleerde. Het is belangrijk om dit virus ook de komende jaren in Nederland in de gaten te houden. Dan kan snel worden gehandeld mocht iemand van dit virus ziek worden. Een werkgroep gaat uitwerken hoe dat de komende jaren het beste kan worden georganiseerd. Het is in ieder geval belangrijk de samenwerking tussen de verschillende betrokken partijen te behouden. De meeste mensen worden niet ziek van een infectie met het virus. Ongeveer 1 op 5 van de besmette mensen krijgt milde griepachtige symptomen zoals koorts, hoofdpijn en spierpijn. Slechts een klein deel (1 procent) van de besmette mensen krijgt een ernstige ziekte zoals hersenvliesontsteking of hersenontsteking., West Nile virus causes West Nile fever. The virus can be found in birds and is transmitted through mosquitoes that feed on the blood of infected birds. These mosquitoes then spread the virus to other birds. In some cases, they also spread the virus to humans and other mammals, such as horses. In 2020, several people in the Netherlands were infected. This event led to a 'surveillance' project to gain insight into the prevalence of West Nile virus in the Netherlands. Whenever an individual is infected, doctors and residents in the area where the virus has been found will be informed. Because the virus is transmitted from animals to humans, it is important that doctors in healthcare and veterinarians work together ('one health'). The virus was extra monitored from 2021 to 2023. During this period, no people in the Netherlands were found to be infected, although some animals were (chickens, a horse and a grey heron). The type of West Nile virus with which the heron was infected was almost the same as the virus from 2020. This shows that the West Nile virus continued to circulate in the Netherlands between 2021 and 2023. It remains important to monitor West Nile virus in the Netherlands in the coming years. Monitoring will make it possible to act promptly in the event someone is infected with this virus. A working group will determine a plan of action for the coming years. In any case, it will be important to maintain the current collaboration between the various parties involved. Most people do not become ill after being infected with the virus. Approximately one in five infected people will develop mild flu-like symptoms, such as fever, a headache and muscle pain. Only a small proportion (1%) of infected people will develop a serious illness, such as meningitis or encephalitis.

Let $R$ be a commutative ring and let $n \geq 1.$ We study $\Gamma(s)$, the generating function and Ann$(s)$, the ideal of characteristic polynomials of $s$, an $n$--dimensional sequence over $R$. We express $f(X_1,\ldots,X_n) \cdot \Gamma(s)(X_1^{-1},\ldots ,X_n^{-1})$ as a partitioned sum. That is, we give (i) a $2^n$--fold ``border'' partition (ii) an explicit expression for the product as a $2^n$--fold sum; the support of each summand is contained in precisely one member of the partition. A key summand is $\beta_0(f,s)$, the ``border polynomial'' of $f$ and $s$, which is divisible by $X_1\cdots X_n$. We say that $s$ is {\em eventually rectilinear} if the elimination ideals Ann$(s)\cap R[X_i]$ contain an $f_i(X_i)$ for $1 \leq i \leq n$. In this case, we show that $\mbox{Ann}(s)$ is the ideal quotient $(\sum_{i=1}^n(f_i)\ :\ \beta_0(f,s)/(X_1\cdots X_n)).$ When $R$ and $R[[X_1,X_2, \ldots ,X_n]]$ are factorial domains (e.g. $R$ a principal ideal domain or ${\Bbb F}[X_1,\ldots,X_n]$), we compute {\em the monic generator} $\gamma _i$ of $\mbox{Ann}(s) \cap R[X_i]$ from known $f_i \in \mbox{Ann}(s) \cap R[X_i]$ or from a finite number of $1$--dimensional linear recurring sequences over $R$. Over a field ${\Bbb F}$ this gives an $O(\prod_{i=1}^n \delta \gamma _i^3)$ algorithm to compute an ${\Bbb F}$--basis for $\mbox{Ann}(s)$., Comment: This is my original latex document submitted to Journal of Symbolic Computation without the typographical errors which were introduced: 'The Journal apologizes for the typographical errors in Norton (1995) introduced in the subediting process'; see this journal, (1995)20, 769-770

Tumor metabolism has emerged as a hallmark of cancer and is involved in carcinogenesis and tumor growth. Reprogramming of tumor metabolism is necessary for cancer cells to sustain high proliferation rates and enhanced demands for nutrients. Recent studies suggest that metabolic plasticity in cancer cells can decrease the efficacy of anticancer therapies by enhancing antioxidant defenses and DNA repair mechanisms. Studying radiation-induced metabolic changes will lead to a better understanding of radiation response mechanisms as well as the identification of new therapeutic targets, but there are few robust studies characterizing the metabolic changes induced by radiation therapy in cancer. In this review, we will highlight studies that provide information on the metabolic changes induced by radiation and oxidative stress in cancer cells and the associated underlying mechanisms.

During the last glacial period, the Laurentide Ice Sheet (LIS) underwent episodes of rapid iceberg discharge, recorded in ocean sediments as "Heinrich events" (HEs). Two competing models attempt to describe the stimulus for HEs via either internal ice sheet oscillations or external ocean-climate system forcing. We present a terrestrial record of HEs from the northeastern LIS that strongly supports ocean-climate forcing. Subglacial carbonate precipitates from Baffin Island record episodes of subglacial melting coincident with the three most recent HEs, resulting from acceleration of nearby marine-terminating ice streams. Synchronized ice stream acceleration over Baffin Island and Hudson Strait is inconsistent with internal ice sheet oscillations alone and indicates a shared ocean-climate stimulus to coordinate these different glaciological systems. Isotopic compositions of these precipitates record widespread subglacial groundwater connectivity beneath the LIS. Extensive basal melting and flushing of these aquifers during the last HE may have been a harbinger for terminal deglaciation.

Precision medicine can significantly improve outcomes for patients with cancer, but implementation requires comprehensive characterization of tumor cells to identify therapeutically exploitable vulnerabilities. Here, we describe somatic biallelic TET2 mutations in an elderly patient with acute myeloid leukemia (AML) that was chemoresistant to anthracycline and cytarabine but acutely sensitive to 5'-azacitidine (5'-Aza) hypomethylating monotherapy, resulting in long-term morphological remission. Given the role of TET2 as a regulator of genomic methylation, we hypothesized that mutant TET2 allele dosage affects response to 5'-Aza. Using an isogenic cell model system and an orthotopic mouse xenograft, we demonstrate that biallelic TET2 mutations confer sensitivity to 5'-Aza compared with cells with monoallelic mutations. Our data argue in favor of using hypomethylating agents for chemoresistant disease or as first-line therapy in patients with biallelic TET2-mutated AML and demonstrate the importance of considering mutant allele dosage in the implementation of precision medicine for patients with cancer.

Rueppel's conjecture on the linear complexity of the first $n$ terms of the sequence $(1,1,0,1,0^3,1,0^7,1,0^{15},\ldots)$ was first proved by Dai using the Euclidean algorithm. We have previously shown that we can attach a homogeneous (annihilator) ideal of $F[x,z]$ to the first $n$ terms of a sequence over a field $F$ and construct a pair of generating forms for it. This approach gives another proof of Rueppel's conjecture. We also prove additional properties of these forms and deduce the outputs of the LFSR synthesis algorithm applied to the first $n$ terms. Further, dehomogenising the leading generators yields the minimal polynomials of Dai.

BackgroundContaining coronavirus disease 2019 (COVID-19) has been difficult, due to both the large number of asymptomatic infected individuals and the long duration of infection. Managing these challenges requires understanding of the differences between asymptomatic vs symptomatic patients and those with a longer duration of infectivity.MethodsIndividuals from Los Angeles were tested for COVID-19, and a group positive for COVID-19 chose to have follow-up testing. Associations between symptoms and demographic factors, viral burden measured by cycle threshold (CT) value, and duration of polymerase chain reaction (PCR) positivity were analyzed.ResultsEighteen point eight percent of patients were positive for COVID-19. Asymptomatic COVID-19-positive patients were significantly younger than symptomatic patients (2.6 years; P < .001). There were no differences in average CT between asymptomatic and symptomatic patients. The estimated median duration of COVID-19 PCR positivity was 23 days. Being asymptomatic throughout the course of infection was the only factor associated with a shorter course of COVID-19 PCR positivity (21 vs 28 days; P = .002).ConclusionsWe found important differences and similarities between asymptomatic and symptomatic COVID-19-positive patients, the most meaningful being a similar level of virus as measured by PCR, but a shorter duration of PCR positivity for asymptomatic patients. These findings suggest that asymptomatic patients may have more efficient clearance of virus, which may be relevant for management and screening.

Background: Tuberculosis (TB) can present as acute, severe pneumonia in children, but features which distinguish TB from other causes of pneumonia are not well understood. We conducted a systematic review to determine the prevalence and to explore clinical and demographic predictors of TB in children presenting with pneumonia over three decades. Method(s): We searched for peer-reviewed, English language studies published between 1990 and 2020 that included children aged between 1 month and 17 years with pneumonia and prospectively evaluated for TB. There were 895 abstracts and titles screened, and 72 full text articles assessed for eligibility. Result(s): Thirteen clinical studies, two autopsy studies and one systematic review were included in analyses. Majority of studies were from Africa (12/15) and included children less than five years age. Prevalence of bacteriologically confirmed TB in children with pneumonia ranged from 0.2% to 14.8% (median=3.7%, interquartile range (IQR)=5.95) and remained stable over the three decades. TB may be more likely in children with pneumonia if they have a history of close TB contact, HIV infection, malnutrition, age less than one year or failure to respond to empirical antibiotics. However, these features have limited discriminatory value as TB commonly presents as acute severe pneumonia - with a short duration of cough, and clinical and radiographic features indistinguishable from other causes of pneumonia. Approximately half of patients with TB respond to initial empirical antibiotics, presumably due to bacterial co-infection, and follow-up may be critical to detect and treat TB. Conclusion(s): TB should be considered as a potential cause or comorbidity in all children presenting with pneumonia in high burden settings. Clinicians should be alert to the presence of known risk factors for TB and bacteriological confirmation sought whenever possible. Quality data regarding clinical predictors of TB in childhood pneumonia are lacki

BACKGROUND: Childhood pneumonia presents a large global burden, though most data and guidelines focus on children less than 5 years old. Less information is available about the clinical presentation of pneumonia in children 5-9 years of age. Appropriate diagnostic and treatment algorithms may differ from those applied to younger children. This systematic literature review aimed to identify clinical features of pneumonia in children aged 5-9 years, with a focus on delineation from other age groups and comparison with existing WHO guidance for pneumonia in children less than 5 years old. METHODS: We searched MEDLINE, EMBASE and PubMed databases for publications that described clinical features of pneumonia in children 5-9 years old, from any country with no date restriction in English. The quality of included studies was evaluated using a modified Effective Public Health Project Practice (EPHPP) tool. Data relating to research context, study type, clinical features of pneumonia and comparisons with children less than 5 years old were extracted. For each clinical feature of pneumonia, we described mean percentage (95% confidence interval) of participants with this finding in terms of aetiology (all cause vs Mycoplasma pneumoniae), and method of diagnosis (radiological vs clinical). RESULTS: We included 15 publications, eight addressing all-cause pneumonia and seven addressing Mycoplasma pneumoniae. Cough and fever were common in children aged 5-9 years with pneumonia. Tachypnoea was documented in around half of patients. Dyspnoea/difficulty breathing and chest indrawing were present in approximately half of all-cause pneumonia cases, with no data on indrawing in the outpatient setting. Chest and abdominal pain were documented in around one third of cases of all-cause pneumonia, based on limited numbers. In addition to markers of pneumonia severity used in children <5 years, pallor has been identified as being associated with poorer outcomes alongside comorbidities and

BACKGROUND: Severe childhood pneumonia requires treatment in hospital by trained health care workers. It is therefore important to determine if health facilities provide quality health services for children with acute respiratory infections (ARI), including pneumonia. Using established indicators from WHO to measure quality of care (QoC) as a reference standard, this review aims to evaluate how well existing tools assess QoC for children presenting to health facilities with ARI. METHODS: Existing assessment tools identified from a published systematic literature review that evaluated QoC assessment tools for children (<15 years) in health facilities for all health conditions were included in this ARI-specific review. 27 ARI-specific indicators or "quality measures" from the WHO "Standards for improving quality of care for children and young adolescents in health facilities" were selected for use as a reference standard to assess QoC for children presenting to health facilities with ARI symptoms. Each included assessment tool was evaluated independently by two paediatricians to determine how many of the WHO ARI quality measures were assessable by the tool. The assessment tools were then ranked in order of percentage of ARI quality measures assessable. RESULTS: Nine assessment tools that assessed QoC for children attending health facilities were included. Two hospital care tools developed by WHO had the most consistency with ARI-specific indicators, assessing 22/27 (81.5%) and 20/27 (74.1%) of the quality measures. The remaining tools were less consistent with the ARI-specific indicators, including between zero to 16 of the 27 quality measures. The most common indicators absent from the tools were assessment of appropriate use of pulse oximetry and administration of oxygen, how often oxygen supply was unavailable, and mortality rates. CONCLUSIONS: The existing WHO hospital-based QoC assessment tools are comprehensive but could be enhanced by improved data quality arou

INTRODUCTION: Oxygen is an essential medicine for children and adults. The current systems for its delivery can be expensive and unreliable in settings where oxygen is most needed. FREO2 Foundation Australia has developed an integrated oxygen system, driven by a mains-powered oxygen concentrator, with the ability to switch automatically between low-pressure oxygen storage device and cylinder oxygen in power interruptions. The aim of this study is to assess the clinical impact and cost-effectiveness of expanding this system to 20 community and district hospitals and level IV facilities in Western Uganda. METHODS AND ANALYSIS: This will be a phased implementation with preintervention and postintervention comparison of outcomes. Standardised baseline data collection and needs assessment will be conducted, followed by implementation of the FREO2 Oxygen System in combination with pulse oximetry in 1-2 facilities per month over a 16-month period, with a total 23-month data collection period. The primary outcome will be the proportion of hypoxaemic children receiving oxygen pre and post oxygen system. Secondary outcomes will assess clinical, economic and technical aspects. Pre and post oxygen system primary and secondary outcomes will be compared using regression models and standard tests of significance. Useability will be quantitatively and qualitatively evaluated in terms of acceptability, feasibility and appropriateness, using standardised implementation outcome measure tools. ETHICS AND DISSEMINATION: Ethics approval was obtained from Mbarara University of Science and Technology (MUREC 1/7) and the University of Melbourne (2021-14489-13654-2). Outcomes will be presented to the involved facilities, and to representatives of the Ministry of Health, Uganda. Broader dissemination will include publication in peer-reviewed journals and academic conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12621000241831.

BACKGROUND: Tuberculosis (TB) can present as acute, severe pneumonia in children, but features which distinguish TB from other causes of pneumonia are not well understood. We conducted a systematic review to determine the prevalence and to explore clinical and demographic predictors of TB in children presenting with pneumonia over three decades. METHODS: We searched for peer-reviewed, English language studies published between 1990 and 2020 that included children aged between 1 month and 17 years with pneumonia and prospectively evaluated for TB. There were 895 abstracts and titles screened, and 72 full text articles assessed for eligibility. RESULTS: Thirteen clinical studies, two autopsy studies and one systematic review were included in analyses. Majority of studies were from Africa (12/15) and included children less than five years age. Prevalence of bacteriologically confirmed TB in children with pneumonia ranged from 0.2% to 14.8% (median = 3.7%, interquartile range (IQR) = 5.95) and remained stable over the three decades. TB may be more likely in children with pneumonia if they have a history of close TB contact, HIV infection, malnutrition, age less than one year or failure to respond to empirical antibiotics. However, these features have limited discriminatory value as TB commonly presents as acute severe pneumonia - with a short duration of cough, and clinical and radiographic features indistinguishable from other causes of pneumonia. Approximately half of patients with TB respond to initial empirical antibiotics, presumably due to bacterial co-infection, and follow-up may be critical to detect and treat TB. CONCLUSION: TB should be considered as a potential cause or comorbidity in all children presenting with pneumonia in high burden settings. Clinicians should be alert to the presence of known risk factors for TB and bacteriological confirmation sought whenever possible. Quality data regarding clinical predictors of TB in childhood pneumonia are lacking.

BACKGROUND: Pneumonia is a major cause of death in children aged under five years. As children with severe pneumonia have the highest risk of morbidity and mortality, previous studies have evaluated the additional benefit of adjunctive treatments such as oseltamivir, oral steroids, macrolides, and vitamin supplementation that can be added to standard antibiotic management to improve clinical outcomes. The study reviewed the evidence for the role of these additional treatments for children with severe pneumonia in low- and middle-income countries (LMICs). METHODS: Four electronic databases were searched for English-language articles between 2000 to 2020. Systematic reviews (SRs) with meta-analyses, comparative cohort studies, and randomised controlled trials (RCTs) from LMICs that reported clinical outcomes for children with severe pneumonia aged between one month to 9 years who received adjunct treatment in addition to standard care were included. Risk of bias of included SRs was assessed using AMSTAR 2, and of individual studies using the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies. RESULTS: Overall, the search identified 2147 articles, 32 of which were eligible, including 7 SRs and 25 RCTs. These studies evaluated zinc (4 SRs, 17 RCTs), Vitamin D (1 SR, 4 RCTs), Vitamin A (3 SRs, 1 RCT), Vitamin C (1 SR, 2 RCTs) and micronutrients (1 RCT). Most studies reported clinical outcomes of time to improvement, length of stay, and treatment failure (including mortality). No studies of oseltamivir, steroids, or macrolides fulfilling the inclusion criteria were identified. For zinc, pooled analyses from SRs showed no evidence of benefit. Similarly, a Cochrane review and one RCT found that Vitamin A did not improve clinical outcomes. For Vitamin D, an RCT evaluating a single high dose of 100 000 international units (IU) of vitamin D found a reduction in time to improvement, with 38%-40% documented vitamin D deficiency at b

BACKGROUND: WHO pneumonia guidelines recommend that children (aged 2-59 months) with chest indrawing pneumonia and without any "general danger sign" can be treated with oral amoxicillin without hospital admission. This recommendation was based on trial data from limited contexts whose generalisability is unclear. This review aimed to identify which children with chest-indrawing pneumonia in low- and middle-income countries can be safely treated at home, and under what conditions is it safe to do so. METHODS: We searched MEDLINE, EMBASE, and PubMed for observational and interventional studies of home-based management of children (aged 28 days to four years) with chest-indrawing pneumonia in low- or middle-income countries. RESULTS: We included 14 studies, including seven randomised trials, from a variety of urban and rural contexts in 11 countries. Two community-based and two hospital-based trials in Pakistan and India found that home treatment of chest-indrawing pneumonia was associated with similar or superior treatment outcomes to hospital admission. Evidence from trials (n = 3) and observational (n = 6) studies in these and other countries confirms the acceptability and feasibility of home management of chest-indrawing pneumonia in low-risk cases, so long as safeguards are in place. Risk assessment includes clinical danger signs, oxygen saturation, and the presence of comorbidities such as undernutrition, anaemia, or HIV. Pulse oximetry is a critical risk-assessment tool that is currently not widely available and can identify severely ill patients with hypoxaemia otherwise possibly missed by clinical assessment alone. Additional safeguards include caregiver understanding and ability to return for review. CONCLUSIONS: Home treatment of chest-indrawing pneumonia can be safe but should only be recommended for children confirmed to be low-risk and in contexts where appropriate care and safety measures are in place.

BACKGROUND: Streptococcus pneumoniae is one of the most common bacteria causing pneumonia and the World Health Organization (WHO) recommends first-line treatment of pneumonia with penicillins. Due to increases in the frequency of penicillin resistance, this systematic review aimed to determine the clinical outcomes of children with pneumonia in low- and middle-income countries (LMICs), with penicillin-group resistant pneumococci in respiratory and/or blood cultures specimens. METHODS: English-language articles from January 2000 to November 2020 were identified by searching four databases. Systematic reviews and epidemiological studies from LMICs that included children aged one month to 9 years and reported outcomes of pneumonia with a penicillin-resistant pneumococcus in respiratory and blood culture specimens with or without comparison groups were included. Risk of bias was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. A narrative synthesis of findings based on the results of included studies was performed. RESULTS: We included 7 articles involving 2864 children. One strong- and four medium-quality studies showed no difference in clinical outcomes (duration of symptoms, length of hospital stay and mortality) between those children with penicillin non-susceptible compared to susceptible pneumococci. Two weak quality studies suggested better outcomes in the penicillin-susceptible group. CONCLUSIONS: Current evidence suggests no difference in clinical outcomes of child pneumonia due to a penicillin-resistant S. pneumoniae and as such, there is no evidence to support a change in current WHO antibiotic guidelines.

BACKGROUND: Chest x-ray (CXR) is commonly used (when available) to support clinical management decisions for child pneumonia and provide a reference standard for diagnosis in research studies. However, its diagnostic and technical limitations for both purposes are well recognised. Recent evidence suggests that lung ultrasound (LUS) may have diagnostic utility in pneumonia. This systematic scoping review of research on the utility of CXR and LUS in the management of severe childhood pneumonia aims to inform pragmatic guidelines for low- and middle-income countries (LMICs) and identify gaps in knowledge. METHODS: We included peer-reviewed studies published between 2000 and 2020 in infants and children aged from one month to nine years, presenting with severe pneumonia. CXR studies were limited to those from LMICs, while LUS studies included any geographic region. LUS and CXR articles were mapped into the following themes: indications, role in diagnosis, role in management, impact on outcomes, and practical considerations for LMIC settings. RESULTS: 85 articles met all eligibility criteria, including 27 CXR studies and 58 LUS studies. CXR studies were primarily observational and examined associations between radiographic abnormalities and pneumonia aetiology or outcomes. The most consistent finding was an association between CXR consolidation and risk of mortality. Difficulty obtaining quality CXR images and inter-reader variability in interpretation were commonly reported challenges. Research evaluating indications for CXR, role in management, and impact on patient outcomes was very limited. LUS studies primarily focused on diagnostic accuracy. LUS had higher sensitivity for identification of consolidation than CXR. There are gaps in knowledge regarding diagnostic criteria, as well as the practical utility of LUS in the diagnosis and management of pneumonia. Most LUS studies were conducted in HIC settings with experienced operators; however, small feasibility studies

PurposeThe purpose of this study was to develop consensus for the surgical indications of anterior distal femur hemiepiphysiodesis in children with cerebral palsy using expert surgeon opinion through a modified Delphi technique.MethodsThe panel used a 5-level Likert-type scale to record agreement or disagreement with 27 statements regarding anterior distal femur hemiepiphysiodesis. Consensus was defined as at least 80% of responses being in the highest or lowest 2 of the Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest 2 ratings.ResultsFor anterior distal femur hemiepiphysiodesis, 27 statements were surveyed: consensus or general agreement among the panelists was achieved for 22 of 27 statements (22/27, 82%) and 5 statements had no agreement (5/27, 18%). There was general consensus that anterior distal femur hemiepiphysiodesis is indicated for ambulatory children with cerebral palsy, with at least 2 years growth remaining, and smaller (<30 degrees) knee flexion contractures and for minimally ambulatory children to aid in standing/transfers. Consensus was achieved regarding the importance of close radiographic follow-up after screw insertion to identify or prevent secondary deformity. There was general agreement that percutaneous screws are preferred over anterior plates due to the pain and irritation associated with plates. Finally, it was agreed that anterior distal femur hemiepiphysiodesis was not indicated in the absence of a knee flexion contracture.ConclusionAnterior distal femur hemiepiphysiodesis can be used to treat fixed knee flexion contractures in the setting of crouch gait, but other associated lever arm dysfunctions must be addressed by single-event multilevel surgery.Level of evidenceV.

Op 7 december van het afgelopen jaar organiseerde het Nationale Referentielaboratorium voor bijenziekten (NRL) een online minisymposium over de mijt Tropilaelaps.

The Games-Chan algorithm finds the minimal period of a periodic binary sequence of period $2^n$, in $n$ iterations. We generalise this to periodic $q$-ary sequences (where $q$ is a prime power) using generating functions and polynomials and apply this to find the multiplicity of $x-1$ in a $q$-ary polynomial $f$ in $\log_{\,q}\deg(f)$ iterations., Comment: Exposition and main theorem improved, typos corrected. Application to finding multiplicity of x-1 in any $q$-ary polynomial added

For many students, introductory college science courses are often the only opportunity in their formal higher education to be exposed to science, shaping their view of the subject, their scientific literacy, and their attitudes towards their own ability in STEM. While science writing instruction has been demonstrated to impact attitudes and outlooks of STEM majors in their coursework, this instructional strategy has yet to be explored for non-majors. In this work, we investigate student attitudes towards STEM before and after taking a writing-intensive introductory astronomy course. We find that students cite writing about science as beneficial to their learning, deepening their understanding of science topics and their perspective on science as a field and finding writing to be a "bridge" between STEM content and their focus on humanities in their majors. Students also report increased perceptions of their own ability and confidence in engaging with STEM across multiple metrics, leaving the course more prepared to be informed, engaged, and science literate citizens., Comment: 22 pages; submitted to Astronomy Education Journal (AEJ)

Introduction: A datathon is an event designed to bring researchers, clinicians, and data scientist together. Machine learning enables exploratory data analysis and hypothesis generation for clinically relevant questions in a collaborative environment. At present, it is unclear which patients are at greatest risk of dysphagia post invasive mechanical ventilation in an Australian population. A recent international meta-analysis demonstrated that 49% of all intubated patients present with dysphagia. Objectives/Aims: To utilise a datathon as a platform for trend analysis with access to large health databases to determine the incidence, and possible risk factors for dysphagia post invasive mechanical ventilation across the state of Victoria. Method(s): This pilot study occurred at a regional critical care datathon. The data have been extracted from the Victorian Admitted Episodes Database, using minimal data entry fields and ICD 10-AM codes. All results presented are preliminary findings based on trend analysis. Result(s): In 2017 across Victoria, 15,033 patients underwent invasive mechanical ventilation. Of these 1,221 (8%) were identified as dysphagic. Incidence of dysphagia was noted to increase with length of ventilation, however plateaued at 24% after 4 days. 18% of patients with dysphagia were ventilated for less than 48 hours. Patients with delirium were more likely to present with dysphagia (23.5% vs. 5.5%). Based on data visualisation age did not appear to increase the risk of dysphagia until 70+ years. Conclusion(s): Prolonged ventilation is a frequently reported risk for dysphagia. Despite this, 1 in 5 patients with dysphagia in this study were for ventilated for 48 hours or less. It is unclear whether the lower incidence (8%) compared to previous reports reflects underdiagnosis and recognition of dysphagia post mechanical ventilation, or differences in international practice.

The aim of the present study was to investigate the variability in nutrient digestibility associated with corn genetic background and its influence on the feeding value for broiler chickens. A total of 960 1-day-old male broiler chicks (Ross 308) were distributed in eight treatments, with 12 pens per treatment and 10 birds per pen in a 42-day study. Eight corn samples (Variety 1 to Variety 8) were selected based on their nutrient composition. A fixed amount of each corn (577 g/kg in the starter diets and 662 g/kg in the finisher diets) was used to formulate feeds. Diets were offered ad libitum in pellet form. Performance parameters were determined at d 21 and d 42, and excreta samples collected at d 21 to determine energy, organic matter and dry matter (DM) whole-tract digestibility. The results revealed a decrease (P < 0.05) in body weight (BW) and feed intake in birds fed variety 8 compared to other varieties at d 21. The lowest whole tract DM and energy apparent digestibility were also observed for the variety 8 diet (P < 0.05), together with varieties 3 and 5. Energy digestibility was higher in varieties 2, 4 and 7 (P < 0.05). Multivariate analysis revealed that corn protein concentration was positively correlated with vitreousness (r = 0.60, P = 0.054) and the arabinose:xylose ratio (r = 0.67, P < 0.05) and negatively correlated with starch (r = -0.62, P < 0.05). Soluble non-starch polysaccharide content was negatively correlated with the protein solubility index (r = -0.88, P < 0.05). In addition, corn protein concentration was negatively correlated (P < 0.05) with 21-d BW (r = -0.71) and weight gain (r = -0.62). In conclusion, the corn genetic background influenced the nutrient digestibility and growth performance of broiler chickens. The content and nature of the non-starch polysaccharides were found to be two of the main factors affecting the solubility and availability of nutrients in corn, and could be the reason for the negative effects on the performanc

BACKGROUND: Pneumonia is the largest cause of child deaths in low-income countries. Lack of availability of oxygen in small rural hospitals results in avoidable deaths and unnecessary and unsafe referrals. METHOD: We evaluated a programme for improving reliable oxygen therapy using oxygen concentrators, pulse oximeters and sustainable solar power in 38 remote health facilities in nine provinces in Papua New Guinea. The programme included a quality improvement approach with training, identification of gaps, problem solving and corrective measures. Admissions and deaths from pneumonia and overall paediatric admissions, deaths and referrals were recorded using routine health information data for 2-4 years prior to the intervention and 2-4 years after. Using Poisson regression we calculated incidence rates (IRs) preintervention and postintervention, and incidence rate ratios (IRR). RESULTS: There were 18 933 pneumonia admissions and 530 pneumonia deaths. Pneumonia admission numbers were significantly lower in the postintervention era than in the preintervention era. The IRs for pneumonia deaths preintervention and postintervention were 2.83 (1.98-4.06) and 1.17 (0.48-1.86) per 100 pneumonia admissions: the IRR for pneumonia deaths was 0.41 (0.24-0.71, p<0.005). There were 58 324 paediatric admissions and 2259 paediatric deaths. The IR for child deaths preintervention and postintervention were 3.22 (2.42-4.28) and 1.94 (1.23-2.65) per 100 paediatric admissions: IRR 0.60 (0.45-0.81, p<0.005). In the years postintervention period, an estimated 348 lives were saved, at a cost of US$6435 per life saved and over 1500 referrals were avoided. CONCLUSIONS: Solar-powered oxygen systems supported by continuous quality improvement can be achieved at large scale in rural and remote hospitals and health care facilities, and was associated with reduced child deaths and reduced referrals. Variability of effectiveness in different contexts calls for strengthening of quality improvement

BACKGROUND: This research prioritization aimed to identify major research gaps in maternal, newborn, child and adolescent health (MNCAH) to help mitigate the direct and indirect effects of the COVID-19 pandemic. METHODS: We adapted the Child Health and Nutrition Research Initiative methodology. We defined scope, domains, themes and scoring criteria. We approached diverse global experts via email to submit their research ideas in MNCAH and MNCAH-related cross-cutting/health systems area. We curated the research ideas as research questions (RQs) and sent them to the consenting experts for scoring via the online link. For each RQ, the research priority score (RPS) was calculated as an average of individual criterion scores and ranked based on RPS in each area. RESULTS: We identified top-ranked 10 RQs in each maternal, newborn, and child and adolescent health and 5 in the cross-cutting/health systems area. In maternal health, indirect effects on care, measures to improve care, health risks and outcomes, and preventing and managing SARS-CoV-2 infection/COVID-19 disease were priority RQs. In newborn health, clinical characterization and managing SARS-CoV-2 infection/COVID-19 disease, mode of transmission and interventions to prevent transmission were the focus. For child and adolescent health, top-ranked RQs were indirect effects on care, clinical status and outcomes, interventions to protect against SARS-CoV-2 infection/COVID-19 disease, and educational institute-related RQs. The cross-cutting RQs were the effects of the pandemic on availability, access, care-seeking and utilization of MNCAH services and potential solutions. CONCLUSIONS: We call on partners, including governments, non-governmental organizations, research institutes, and donors, to address this urgent research agenda.

For the Chinese, French, German, and Spanish translations of the abstract see Supplementary Materials section.

PurposeThe purpose of this study was for an international panel of experts to establish consensus indications for distal rectus femoris surgery in children with cerebral palsy (CP) using a modified Delphi method.MethodsThe panel used a five-level Likert scale to record agreement or disagreement with 33 statements regarding distal rectus femoris surgery. The panel responded to statements regarding general characteristics, clinical indications, computerized gait data, intraoperative techniques and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert ratings, and general agreement as 60% to 79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached.ResultsConsensus or general agreement was reached for 17 of 33 statements (52%). There was general consensus that distal rectus femoris surgery is better for stiff knee gait than is proximal rectus femoris release. There was no consensus about whether the results of distal rectus femoris release were comparable to those following distal rectus femoris transfer. Gross Motor Function Classification System (GMFCS) level was an important factor for the panel, with the best outcomes expected in children functioning at GMFCS levels I and II. The panel also reached consensus that they do distal rectus femoris surgery less frequently than earlier in their careers, in large part reflecting the narrowing of indications for this surgery over the last decade.ConclusionThis study can help paediatric orthopaedic surgeons optimize decision-making for, and outcomes of, distal rectus femoris surgery in children with CP.Level of evidenceV.

Het Nationaal Referentie Laboratorium (NRL) bijenziekten is een samenwerking tussen Wageningen Plant Research (WPR) in Wageningen en Wageningen Bioveterinary Research (WBVR) in Lelystad. WBVR richt zich met name op de meldingsplichtige dierziekten, oftewel de dierziekten waarvan het wettelijk verplicht is een verdenking te melden aan de Nederlandse Voedsel- en Warenautoriteit (NVWA). In het kader van deze meldingsplichtige ziekten, maar ook voor andere dierziekten, voert WBVR diagnostiek en onderzoek uit voor de overheid en het bedrijfsleven. Daarnaast heeft WBVR een adviserende rol ter preventie en bestrijding van besmettelijke dierziekten.

This article presents a classification of lower limb musculoskeletal pathology (MSP) for ambulant children with cerebral palsy (CP) to identify key features from infancy to adulthood. The classification aims to improve communication, and to guide referral for interventions, which if timed appropriately, may optimise long-term musculoskeletal health and function. Consensus was achieved by discussion between staff in a Motion Analysis Laboratory (MAL). A four-stage classification system was developed: Stage 1: Hypertonia: Abnormal postures are dynamic. Stage 2: Contracture: Fixed shortening of one or more muscle-tendon units. Stage 3: Bone and joint deformity: Torsional deformities and/or joint instability (e.g., hip displacement or pes valgus), usually accompanied by contractures. Stage 4: Decompensation: Severe pathology where restoration of optimal joint and muscle-tendon function is not possible. Reliability of the classification was tested using the presentation of 16 clinical cases to a group of experienced observers, on two occasions, two weeks apart. Reliability was found to be very good to excellent, with mean Fleiss’ kappa ranging from 0.72 to 0.84. Four-stages are proposed to classify lower limb MSP in children with CP. The classification was reliable in a group of clinicians who work together. We emphasise the features of decompensated MSP in the lower limb, which may not always benefit from reconstructive surgery and which can be avoided by timely intervention.

The Lancet Countdown is an international collaboration established to provide an independent, global monitoring system dedicated to tracking the emerging health profile of the changing climate. The 2020 report presents 43 indicators across five sections: climate change impacts, exposures, and vulnerabilities; adaptation, planning, and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement. This report represents the findings and consensus of the 35 leading academic institutions and UN agencies that make up The Lancet Countdown, and draws on the expertise of climate scientists, geographers, engineers, experts in energy, food, and transport, economists, social, and political scientists, data scientists, public health professionals, and doctors.

Providing safe and reliable sanitation services to the billions of people currently lacking them will require a multiplicity of approaches. Improving onsite wastewater treatment to standards enabling water reuse would reduce the need to transport waste and fresh water over long distances. Here, we describe a compact, automated system designed to treat the liquid fraction of blackwater for onsite water reuse that combines cross-flow ultrafiltration, activated carbon, and electrochemical oxidation. In laboratory testing, the system consistently produces effluent with 6 ≤ pH ≤ 9, total suspended solids (TSS) < 30 mg L-1, and chemical oxygen demand (COD) < 150 mg L-1. These effluent parameters were achieved across a wide range of values for influent TSS (61-820 mg L-1) and COD (384-1505 mg L-1), demonstrating a robust system for treating wastewater of varying strengths. A preliminary techno-economic analysis (TEA) was conducted to elucidate primary cost drivers and prioritize research and development pathways toward commercial feasibility. The ultrafiltration system is the primary cost driver, contributing to >50% of both the energy and maintenance costs. Several scenario parameters showed an outsized impact on costs relative to technology parameters. Specific technological improvements for future prototype development are discussed.

Objective To evaluate the effectiveness of intermittent pulse oximetry in guiding oxygen therapy in neonates in a low-resource setting. Design and setting Prospective validation study at three hospitals in southwest Nigeria. We performed concealed continuous pulse oximetry on participants to evaluate intermittent SpO 2 monitoring. Patients We recruited all preterm or low birthweight neonates, and all term neonates who required oxygen therapy, who were admitted to the neonatal ward(s) of the study hospitals during the study period. Main outcome measures Proportion of time preterm/low birthweight neonates on oxygen spent within, above and below the target SpO 2 range of 90%-95%; and the proportion of time term neonates and neonates not on oxygen spent within and below the target range of 90%-100%. Results Preterm/low birthweight neonates receiving oxygen therapy (group A) spent 15.7% (95% CI 13.3 to 18.9) of time in the target SpO 2 range of 90%-95%. They spent 75.0% (63.6-81.1) of time above 95%, and 2.7% (1.7-5.6) of time below 85%. Term neonates and all neonates not receiving oxygen (group B) spent 97.3% (95% CI 96.4 to 98.6) of time within the target range of 90%-100%, and 0.9% (0.3-1.4) of time below 85%. Guidelines recommended SpO 2 monitoring 3 times per day for all patients, however neonates in groups A and B were monitored an average of 4.7 and 5.3 times per day, respectively. Conclusions To better maintain SpO 2 within the target range, preterm/low birthweight neonates on oxygen should have their SpO 2 monitored more frequently than the current 4.7 times per day. In all other neonates, however, monitoring SpO 2 5.3 times per day appears suitable.Copyright © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.

BACKGROUND: Interventions to reduce pneumonia mortality exist; however, stakeholder engagement is needed to prioritize these. We explored diverse stakeholder opinions on current policy challenges and priorities for pediatric pneumonia in Nigeria. METHODS: We conducted a mixed-methods study, with a web-survey and semi-structured interviews, to explore stakeholder roles, policy barriers, opportunities, and priorities. Web-survey participants were identified through stakeholder mapping, including researchers' networks, academic and grey literature, and "Every Breath Counts" coalition membership. Stakeholders included actors involved in pediatric pneumonia in Nigeria from non-governmental, government, academic, civil society, private, and professional organizations. Stakeholder interviews were conducted with local government, healthcare managers, professional associations, and local leaders in Lagos and Jigawa states. Quantitative data were analyzed descriptively; qualitative data were analyzed using a thematic framework. RESULTS: Of 111 stakeholders, 38 (34%) participated in the web-survey and 18 stakeholder interviews were conducted. Four thematic areas emerged: current policy, systems barriers, intervention priorities, and champions. Interviewees reported a lack of pneumonia-specific policies, despite acknowledging guidelines had been adopted in their settings. Barriers to effective pneumonia management were seen at all levels of the system, from the community to healthcare to policy, with key issues of resourcing and infrastructure. Intervention priorities were the strengthening of community knowledge and improving case management, focused on primary care. While stakeholders identified several key actors for pediatric pneumonia, they also highlighted a lack of champions. CONCLUSION: Consistent messages emerged to prioritize community and primary care initiatives, alongside improved access to oxygen, and pulse oximetry. There is a need for clear pneumonia policies, a

OBJECTIVE: To evaluate the effectiveness of intermittent pulse oximetry in guiding oxygen therapy in neonates in a low-resource setting. DESIGN AND SETTING: Prospective validation study at three hospitals in southwest Nigeria. We performed concealed continuous pulse oximetry on participants to evaluate intermittent SpO2 monitoring. PATIENTS: We recruited all preterm or low birthweight neonates, and all term neonates who required oxygen therapy, who were admitted to the neonatal ward(s) of the study hospitals during the study period. MAIN OUTCOME MEASURES: Proportion of time preterm/low birthweight neonates on oxygen spent within, above and below the target SpO2 range of 90%-95%; and the proportion of time term neonates and neonates not on oxygen spent within and below the target range of 90%-100%. RESULTS: Preterm/low birthweight neonates receiving oxygen therapy (group A) spent 15.7% (95% CI 13.3 to 18.9) of time in the target SpO2 range of 90%-95%. They spent 75.0% (63.6-81.1) of time above 95%, and 2.7% (1.7-5.6) of time below 85%. Term neonates and all neonates not receiving oxygen (group B) spent 97.3% (95% CI 96.4 to 98.6) of time within the target range of 90%-100%, and 0.9% (0.3-1.4) of time below 85%. Guidelines recommended SpO2 monitoring 3 times per day for all patients, however neonates in groups A and B were monitored an average of 4.7 and 5.3 times per day, respectively. CONCLUSIONS: To better maintain SpO2 within the target range, preterm/low birthweight neonates on oxygen should have their SpO2 monitored more frequently than the current 4.7 times per day. In all other neonates, however, monitoring SpO2 5.3 times per day appears suitable.

BACKGROUND: Appropriate and timely care seeking can reduce pneumonia deaths, but are influenced by caregivers and community norms of health and illness. We explore caregiver and community perceptions, and care-seeking experience, of childhood pneumonia, to understand contexts that drive pediatric service uptake in Nigeria. METHODS: Community group discussions and qualitative interviews with caregivers in Lagos and Jigawa states were completed between 1 November 2018 and 31 May 2019. Participants were recruited from purposively sampled health facility catchment areas with assistance from facility staff. We used episodic interviews, asking caregivers (Jigawa = 20; Lagos = 15) to recount specific events linked to quests for therapy. Community group discussions (n = 3) used four vignettes from real pneumonia cases to frame a discussion around community priorities for healthcare and community-led activities to improve child survival. Data were analyzed using the framework method. RESULTS: We found poor knowledge of pneumonia-specific symptoms and risk factors among caregivers and community members, with many attributing pneumonia to cold air exposure. Interviews highlighted that care-seeking decision making involved both husbands and wives, but men often made final decisions. In Lagos, older female relatives also shaped quests for therapy. Cost was a major consideration. In both states, there were accounts of dissatisfaction with health workers' attitudes and a general acceptance of vaccination services. CONCLUSION: There is a need for community-based approaches to improve caregiver knowledge and care seeking for under-five children with pneumonia. Messaging should attend to knowledge of symptoms, risk factors, family dynamics, and community responsibilities in healthcare service delivery and utilization.

BACKGROUND: Hypoxemia is a severe condition associated with high rates of mortality, particularly in low- and middle-income countries (LMICs) with poor access to oxygen therapy. Despite its clinical significance, there have been few studies to describe the burden of hypoxemia. Thus, the primary objective of this study is to systematically describe the prevalence of hypoxemia among pediatric and adult patients in low- and middle-income countries. METHODS/DESIGN: Standard systematic review methods will be used. Bibliographic databases (MEDLINE, EMBASE, CINAHL) will be searched from 1998 onwards. The search strategy aims to identify studies that have measured peripheral blood oxygen saturation (SpO2) in children and adults presenting to health facilities in LMICs. Studies will be included if oxygen saturation measurements by pulse oximetry were measured. No studies will be excluded based on study design though patients recruited from intensive care units and post-operative care will be excluded. The primary outcome is the prevalence of hypoxemia on presentation to the healthcare facility. We define hypoxemia on the basis of SpO2 measurements, and use a threshold of SpO2 less than 90% at sea level though allow for a lower threshold for studies conducted at higher altitude and where justified. Standardized tools will be used to extract data on number of patients with SpO2 measurements, number of patients with hypoxemia, patient population characteristics, and study characteristics. Quality of the included studies will be assessed using the "Checklist for Prevalence Studies" developed by the Joanna Briggs Institute. If there are enough studies to do so, we will conduct meta-analysis using a random effects model to estimate prevalence of hypoxemia and conduct subgroup analyses by age and disease groups. DISCUSSION: Hypoxemia is a critical condition and understanding the burden of hypoxemia may support decision-making in LMICs to deploy pulse oximeters and oxygen treatments

BACKGROUND: Oxygen is an essential medical therapy that is poorly available globally. We evaluated the quality of oxygen therapy in 12 secondary-level Nigerian hospitals, including access to oxygen equipment, equipment functionality, healthcare worker knowledge and appropriateness of use. METHODS: We conducted a three-part evaluation of oxygen access and use involving: (1) facility assessment (including technical evaluation of oxygen equipment), (2) clinical audit (children and neonates admitted January 2014-December 2015) and (3) survey of healthcare worker training and experience on the clinical use of oxygen (November 2015). RESULTS: Oxygen access for children and newborns is compromised by faulty equipment, lack of pulse oximetry and inadequate care practices. One hospital used pulse oximetry for paediatric care. Eleven hospitals had some access to oxygen supplies. Testing of 57 oxygen concentrators revealed two (3.5%) that were 'fit for use'. Overall, 14.4% (3708/25 677) of children and neonates received oxygen some time during their admission; 19.4% (1944/10 000) of hypoxaemic children received oxygen; 38.5% (1217/3161) of children who received oxygen therapy were not hypoxaemic. CONCLUSIONS: Oxygen access for children in Nigerian hospitals is poor, and likely results in substantial excess mortality. To improve oxygen access for children globally we must focus on actual provision of oxygen to patients-not simply the presence of oxygen equipment at the facility level. This requires a systematic approach to improve both oxygen (access [including equipment, maintenance and affordability]) and oxygen use (including pulse oximetry, guidelines and continuing education).

BACKGROUND: Pneumonia and malaria are the leading causes of global childhood mortality. We describe the clinical presentation of children diagnosed with pneumonia and/or malaria, and identify possible missed cases and diagnostic predictors. METHODS: Prospective cohort study involving children (aged 28 days to 15 years) admitted to 12 secondary-level hospitals in south-west Nigeria, from November 2015 to October 2017. We described children diagnosed with malaria and/or pneumonia on admission and identified potential missed cases using WHO criteria. We used logistic regression models to identify associations between clinical features and severe pneumonia and malaria diagnoses. RESULTS: Of 16 432 admitted children, 16 184 (98.5%) had adequate data for analysis. Two-thirds (10 561, 65.4%) of children were diagnosed with malaria and/or pneumonia by the admitting doctor; 31.5% (567/1799) of those with pneumonia were also diagnosed with malaria. Of 1345 (8.3%) children who met WHO severe pneumonia criteria, 557 (41.4%) lacked a pneumonia diagnosis. Compared with "potential missed" diagnoses of severe pneumonia, children with "detected" severe pneumonia were more likely to receive antibiotics (odds ratio [OR], 4.03; 2.63-6.16, P < .001), and less likely to die (OR, 0.72; 0.51-1.02, P = .067). Of 2299 (14.2%) children who met WHO severe malaria criteria, 365 (15.9%) lacked a malaria diagnosis. Compared with "potential missed" diagnoses of severe malaria, children with "detected" severe malaria were less likely to die (OR, 0.59; 0.38-0.91, P = 0.017), with no observed difference in antimalarial administration (OR, 0.29; 0.87-1.93, P = .374). We identified predictors of severe pneumonia and malaria diagnosis. CONCLUSION: Pneumonia should be considered in all severely unwell children with respiratory signs, regardless of treatment for malaria or other conditions.

BACKGROUND: Case fatality rates for childhood pneumonia in Nigeria remain high. There is a clear need for improved case management of pneumonia, through the sustainable implementation of the Integrated Management of Childhood Illnesses (IMCI) diagnostic and treatment algorithms. We explored barriers and opportunities for improved case management of childhood pneumonia in Lagos and Jigawa states, Nigeria. METHODS: A mixed-method analysis was conducted to assess the current health system capacity to deliver quality care. This was done through audits of 16 facilities in Jigawa and 14 facilities in Lagos, questionnaires (n = 164) and 13 focus group discussions with providers. Field observations provided context for data analysis and triangulation. RESULTS: There were more private providers in Lagos (4/8 secondary facilities) and more government providers in Jigawa (4/8 primary, 3/3 secondary, and 1/1 tertiary facilities). Oxygen and pulse oximeters were available in two of three in Jigawa and six of eight in Lagos of the sampled secondary care facilities. None of the eight primary facilities surveyed in Jigawa had oxygen or pulse oximetry available while in Lagos two of three primary facilities had oxygen and one of three had pulse oximeters. Other IMCI and emergency equipment were also lacking including respiratory rate timers, particularly in Jigawa state. Health care providers scored poorly on knowledge of IMCI, though previous IMCI training was associated with better knowledge. Key enabling factors in delivering pediatric care highlighted by health care providers included accountability procedures and feedback loops, the provision of free medication for children, and philanthropic acts. Common barriers to provide care included the burden of out-of-pocket payments, challenges in effective communication with caregivers, delayed presentation, and lack of clear diagnosis, and case management guidelines. CONCLUSION: There is an urgent need to improve how the prevention a