Search

Objective: To evaluate whether induction of labor (IOL) is associated with cesarean birth (CB) and perinatal mortality in uncomplicated first births at term compared with expectant management outside the confines of a randomized controlled trial. Methods: Population‐based retrospective cohort study of all births in Victoria, Australia, from 2010 to 2018 (n = 640,191). Preliminary analysis compared IOL at 37 weeks with expectant management at that gestational age and beyond for uncomplicated pregnancies. Similar comparisons were made for IOL at 38, 39, 40, and 41 weeks of gestation and expectant management. The primary analysis repeated these comparisons, limiting the population to nulliparous women with uncomplicated pregnancies and excluding those with a medical indication for IOL. We compared perinatal mortality between groups using Chi‐square tests and multivariable logistic regression for all other comparisons. Adjusted odds ratios and 99% confidence intervals were reported. p < 0.01 denoted statistical significance. Results: Among nulliparous, uncomplicated pregnancies at ≥37 weeks of gestation in Victoria, IOL increased from 24.6% in 2010 to 30.0% in 2018 (p < 0.001). In contrast to the preliminary analysis, the primary analysis showed that IOL in lower‐risk nulliparous women was associated with increased odds of CB when performed at 38 (aOR 1.23(1.13–1.32)), 39 (aOR 1.31(1.23–1.40)), 40 (aOR 1.42(1.35–1.50)), and 41 weeks of gestation (aOR 1.43(1.35–1.51)). Perinatal mortality was rare in both groups and non‐significantly lower in the induced group at most gestations. Discussion: For lower‐risk nulliparous women, the odds of CB increased with IOL from 38 weeks of gestation, along with decreased odds of perinatal mortality at 41 weeks only. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to characterize the circumstances of drug overdose deaths and determine whether naloxone administration differed by overdose decedent race and ethnicity. Design and setting: Analysis of data on unintentional and undetermined intent drug overdose deaths in Pennsylvania (2019–21) was collected from death certificates and the State Unintentional Drug Overdose Reporting System. Multivariable logistic regression models were adjusted for overdose death circumstances and the odds of naloxone administration were estimated by race/ethnicity and year. Cases: The analytical sample included 3386 fatal overdose decedents in 2019, 3864 in 2020 and 3816 in 2021. Measurements Evidence of naloxone administration (yes/no) was defined using scene evidence and toxicology reports from coroner and medical examiner records, while race/ethnicity (Hispanic, non‐Hispanic Black, non‐Hispanic White) was based on the death certificate. Findings In the analytic sample, overdose death rates were the highest among Black people and increased over time (rate per 10 000 population, 2019: 4.3; 2020: 6.1; 2021: 6.5); rates were lowest among White people and remained constant over time (rate per 10 000 population, 2019: 2.6; 2020: 2.7; 2021: 2.6). Throughout all years, Black decedents had approximately 40–50% lower odds of naloxone administration compared with White decedents as referent [2019: odds ratio (OR) = 0.7, 95% confidence interval (CI) = 0.5–0.9; 2020: OR = 0.5, 95% CI = 0.4–0.7; 2021: OR = 0.6, 95% CI = 0.5–0.8], while Hispanic decedents had similar odds of naloxone administration to that of White decedents. Conclusion: After controlling for overdose circumstances in drug overdose deaths in Pennsylvania, USA, from 2019 to 2021, Black people had lower odds of naloxone administration compared with White people, while there were no differences between Hispanic and White people. [ABSTRACT FROM AUTHOR]

Background: In recent decades, progress has been made in the care of people with polyhandicap/profound intellectual and multiple disabilities (PIMD) through a better understanding of the pathophysiology and the development of new care management and rehabilitation strategies adapted to these extreme pathologies. Although there is a lack of knowledge about the health status and care management of the oldest people, a better understanding of the natural course of life of people with polyhandicap/PIMD would consequently allow the optimisation of preventive and curative care management strategies. Few robust data on mortality and life expectancy have been documented for this population in France. Our aims are to estimate the median survival time and assess the factors associated with mortality in people with polyhandicap/PIMD receiving care in France. Methods: This study included people with polyhandicap/PIMD, followed by the French national cohort 'Eval‐PLH' since 2015. These individuals were included in specialised rehabilitation centres and residential institutions. The people included in the first wave of the cohort (2015–2016) were eligible for the present study. Vital status on 1 January 2022 (censoring date) was collected in two ways: (1) spontaneous reporting by the participating centre to the coordinating team and (2) systematic checking on the French national death platform. According to the vital status, survival was calculated in years from the date of birth to the date of death or from the date of birth to the censoring date. The factors associated with mortality were evaluated using the Cox proportional regression hazards model. Results: Data from 780 individuals aged between 3 and 67 years were analysed. At the censoring date, 176 (22.6%) had died, and the mean survival was 52.8 years (95% confidence interval: 51.1–54.5). Mortality was significantly associated with a progressive aetiology, recurrent pulmonary infections, drug‐resistant epilepsy and a higher number of medical devices. Conclusions: This study shows for the first time the survival and impact of factors associated with mortality in people with polyhandicap/PIMD in France. Highlights: This study is the first to examine and estimate the median survival of people with polyhandicap/profound intellectual and multiple disabilities in France.Data from a national cohort include a large number of people with polyhandicap/profound intellectual and multiple disabilities.The first results from robust mortality data on people with polyhandicap/profound intellectual and multiple disabilities cared for in France.The instability of this disorder and the high number of medical devices are the main factors associated with earlier mortality in people with polyhandicap/profound intellectual and multiple disabilities. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to examine determinants of undernutrition among children under 2 years of age. Design and Methods: A matched case‐control study design was conducted to recruit 300 mothers comprising 100 mothers with an undernourished child (case group) and 200 mothers with a healthy child (control group). Measurements consisted of demographic characteristics of children data, mother's data, household data, mother's knowledge of child undernutrition, mother's knowledge of nutrition, complementary feeding practices, and undernutrition parameters of the children. A conditional logistic regression was used to identify determinants of undernutrition. The risk of undernutrition was estimated by odds ratios (ORs) and 95% confidence intervals (CIs). Statistical significance was defined as any p value of <.05. Results: Findings showed that mother's knowledge of undernutrition (AOR: 0.95; 95% CI: 0.91−0.98), mother's knowledge of nutrition (AOR: 0.90; 95% CI: 0.85−0.96), and mother's knowledge (AOR: 0.78; 95% CI: 0.67−0.91) and behavior of complementary feeding practices (AOR: 0.97; 95% CI: 0.94−0.99) were significant determinants of undernutrition (p <.05). Practice Implications: Mothers with high scores on knowledge of undernutrition, knowledge of nutrition, and knowledge and behaviors of complementary feeding practices would benefit the children under 2 years to reduce the risk of undernutrition. Healthcare professionals (i.e., pediatric nurses and community health nurses) should provide early assessment of knowledge related to undernutrition, nutrition, and complementary feeding practices for mothers with children under 2 years. [ABSTRACT FROM AUTHOR]

Introduction: Dolutegravir + rilpivirine (DTG + RPV) is an effective antiretroviral therapy regimen approved in clinical guidelines as a switch therapy for virologically suppressed people with HIV. Our study aimed to compare the effectiveness and tolerability of DTG + RPV in women and men in real‐world clinical practice. Methods: This was a retrospective analysis of treatment‐experienced people with HIV from a large HIV unit who switched to DTG + RPV. We analysed treatment effectiveness, rates of adverse events and discontinuation, and metabolic changes after 48 weeks of treatment. HIV‐RNA levels <50 copies/mL were analysed at 48 weeks using both intention‐to treat analysis (where missing data were interpreted as failures) and per‐protocol analysis (excluding those with missing data or changes due to reasons other than virological failure). Outcomes were compared between women and men based on sex at birth. Results: A total of 307 patients were selected (71 women and 236 men). No transgender people were included. At baseline, women had lived with HIV infection and received antiretroviral therapy for longer than men (23.2 vs 17.4 years and 18.9 vs 14.2 years, respectively). In the intention‐to‐treat analysis, 74.6% (95% confidence interval [CI] 63.4–83.3%) of women and 83.5% (95% CI 78.2–87.7) of men had HIV‐RNA <50 copies/mL. In the per‐protocol analysis, 96.4% (95% CI 87.7–99) of women and 99% (95% CI 98.9–99.7) of men had HIV‐RNA levels <50 copies/mL. Two women and two men had HIV‐RNA >50 copies/mL at 48 weeks. Discontinuation due to adverse events was more frequent in women than in men: 12.7% vs 7.2% (p < 0.02). Neuropsychiatric and gastrointestinal events were the most frequently reported. A median (interquartile range) weight gain of 1.9 kg (0–4.2) in women and 1.2 kg (−1–3.1) in men was reported (median of differences between baseline visit and week 48); the remaining changes in metabolic parameters were neutral. Conclusions: DTG + RPV exhibited good and similar virological effectiveness in women and men in real‐world settings. However, poorer tolerability and more treatment interruptions were observed in women. [ABSTRACT FROM AUTHOR]

Background: Immunotherapy has revolutionized cancer treatment. Recent studies have suggested that the efficacy of immunotherapy can be further enhanced by the influence of gut microbiota. In this study, we aimed to investigate the impact of bacteria on the effectiveness of cancer immunotherapy by combining analysis of clinical samples with validation in animal models. Methods: In order to characterize the diversity and composition of microbiota and its relationship with response to immune checkpoint inhibitors (ICIs), 16S ribosomal RNA (rRNA) and GC–MS sequencing was performed on 71 stool samples from patients with advanced non‐small cell lung cancer (NSCLC) prior to treatment with immune checkpoint blockade (ICB). Furthermore, fecal microbiota transplantation (FMT) was performed from different patients into mice and a subcutaneous tumor model established using the Lewis lung cancer cell line to evaluate the therapeutic effect of PD‐1 on mice with varying gut microbiota. Results: The results demonstrated a significant association between elevated gut microbiota diversity and response to treatment with ICIs, p < 0.05. Faecalibacterium was markedly increased in the gut microbiota of responders (R), accompanied by increased short‐chain fatty acid (SCFA) levels, especially butanoic acid, acetic acid and hexanoic acid, p < 0.05. Additionally, FMT from R and nonresponders (NR) could promote an anticancer effect and reduce the expression of Ki‐67 cells in tumors in mice, p < 0.05. Moreover, R and NR FMT did not alter PD‐L1 expression in the tumor tissues of mice, p > 0.05. The diversity of gut microbiota consistently correlated with an optimistic prognosis in NSCLC patients with immunotherapy, which could be functionally mediated by SCFAs. Conclusion: The findings of the present study indicated that the diversity of gut microbiota and SCFAs is related to the efficacy of immunotherapy. FMT can effectively delay tumor progression, and enhance the effect of immunotherapy, thus providing evidence for improving the efficacy of immunotherapy in NSCLC patients. [ABSTRACT FROM AUTHOR]

Introduction: Patients in emergency departments (EDs) constitute a diverse population with multiple health‐related risk factors, many of which are associated with intimate partner violence (IPV). This paper examines the interaction effect of depression, posttraumatic stress disorder (PTSD), impulsivity, drug use, adverse childhood experiences (ACEs), at‐risk drinking, and having a hazardous drinker partner with gender on mutual physical IPV in an urban ED sample. Methods: Research assistants surveyed 1037 married, cohabiting, or partnered patients in face‐to‐face interviews (87% response rate) regarding IPV exposure, alcohol and drug use, psychological distress, ACEs, and other sociodemographic features. IPV was measured with the Revised Conflict Tactics Scale. Interaction effects were examined in multinomial and logistic models. Results: Results showed a significant interaction of gender and PTSD (odds ratio [OR] 3.06, 95% CI 1.21–7.23, p < 0.05) for mutual IPV. Regarding main effects, there were also statistically significant positive associations between mutual physical IPV and at‐risk drinking (OR 1.73, 95% CI 1.07–2.77, p < 0.05), having a hazardous drinker partner (OR 2.19, 95% CI 1.35–3.55, p < 0.01), illicit drug use (OR 2.09, 95% CI 1.18–3.71, p < 0.01), ACEs (OR 1.23, 95% CI 1.06–1.42, p < 0.01), days of cannabis use past in the 12 months (OR 1.003, 95% CI 1.002–1.005, p < 0.001), and impulsivity (OR 2.04, 95% CI 1.29–3.22, p < 0.01). Conclusions: IPV risk assessment in EDs will be more effective if implemented with attention to patients' gender and the presence of various and diverse other risk factors, especially PTSD. [ABSTRACT FROM AUTHOR]

Background: The majority of the US population have poor knowledge of cancers related to human papillomavirus (HPV). Identifying best sources for communicating this information can guide strategies to promote HPV vaccination. Objectives: To assess the relationship between sources of health information and individuals' knowledge of HPV‐related cervical and oropharyngeal cancer. Methods: This study conducts logistic regression on the most recent wave (2019) of the Health Information National Trends Survey. Dependent variables are indicators for self‐reported awareness that HPV causes (a) cervical cancer and (b) oropharyngeal cancer. The primary indicator is a variable for different sources of health information: The Internet, professional sources, print materials, friends/family and never looked for health information. Results: Being female, young, non‐Hispanic White and having college education is associated with higher odds of knowing about HPV‐related cervical cancer. Controlling for demographic factors, individuals using professionals and the Internet are more likely to know that HPV causes cervical cancer (aOR: 2.65, 95% CI: 1.66, 4.25; aOR: 2.47, 95% CI: 1.75, 3.50, respectively) compared to those who have never looked for health information. Similar results were found for HPV‐related oropharyngeal cancer. Conclusion: Findings provide implications for targeted messaging through effective channels to improve HPV vaccination uptake. [ABSTRACT FROM AUTHOR]

The abdominal skin is not a common area for keloid formation. The knowledge of laparoscopically induced keloids (LIK) remains little. This article aimed to review the case series of LIK and analyse the characteristics. A retrospective and descriptive study was conducted. Patients' clinical records in the database were collected, including the demographics, medical history, laparoscopic surgery information, keloid information, and the severity of LIKs recorded using the Patient and Observer Scar Assessment Scale. Twenty‐four LIK patients were enrolled. 18 patients were female and 10 had chronic diseases. 11 patients had non‐LIKs. 91.6% patients received laparoscopic cholecystectomy. LIKs were mainly located under the xiphoid process (N = 20), followed by the umbilicus (N = 16). 41.7% patients developed keloids at all trocha sites. The severity of the LIK was significantly negatively associated with the presence of the non‐LIK. Laparoscopic procedures could lead to the formation of keloids. Two types of LIKs were noticed: extended incisions induced long "spreading" type and trocha induced round bulging type. The presence of non‐LIKs could significantly reduce the severity of LIKs. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to identify prognostic autophagy‐related genes and lncRNAs to predict clinical outcomes in head and neck squamous cell carcinoma (HNSCC). Subjects and methods: Differentially expressed autophagy‐related genes and autophagy‐related lncRNAs were identified by comparing pare‐carcinoma and carcinoma samples of HNSCC. And then, we constructed an ARG and an AR‐lncRNA signature risk score. Receiver operating characteristic (ROC) curve analyses were performed to assess the prognostic prediction capacity. Gene Set Enrichment Analysis (GSEA) and Gene Ontology (GO) functional annotation were used to analysis the functions of ARGs and AR‐lncRNAs. Results: Six ARGs and thirteen AR‐lncRNAs were identified in the ARG and AR‐lncRNA signatures, and overall survival (OS) in the high‐risk group was significantly shorter than the low‐risk group. ROC analysis showed the ARG and AR‐lncRNA signatures have excellent ability of predicting the total OS of patients with HNSCC. What's more, GSEA and GO functional annotation proved that autophagy‐related pathways are mainly enriched in the high‐risk group. Conclusions: These findings indicated that our ARG signature and AR‐lncRNA signature could be considered to predict the prognosis of patients with HNSCC and provide a deep understanding of the biological mechanisms of autophagy in HNSCC. [ABSTRACT FROM AUTHOR]

Background: The safety of waterbirth is contested because of the lack of evidence from randomized trials and conflicting results. This research assessed the feasibility of a prospective study of waterbirth (trial or cohort). Methods: We conducted a prospective cohort study at an Australian maternity hospital. Eligible women with uncomplicated pregnancies at 36 weeks of gestation were recruited and surveyed about their willingness for randomization. The primary midwife assessed waterbirth eligibility and intention on admission in labor, and onset of second stage. Primary outcomes measured feasibility. Intention‐to‐treat analysis, and per‐protocol analysis, compared clinical outcomes of women and their babies who intended waterbirth and nonwaterbirth at onset of second stage. Results: 1260 participants were recruited; 15% (n = 188) agreed to randomization in a future trial. 550 women were analyzed by intention‐to‐treat analysis: 351 (waterbirth) and 199 (nonwaterbirth). In per‐protocol analysis, 14% (n = 48) were excluded. Women in the waterbirth group were less likely to have amniotomy and more likely to have water immersion and physiological third stage. There were no differences in other measures of maternal morbidity. There were no significant differences between groups for serious neonatal morbidity; four cord avulsions occurred in the waterbirth group with none in the landbirth group. An RCT would need approximately 6000 women to be approached at onset of second stage. Conclusions: A randomized trial of waterbirth compared with nonwaterbirth, powered to detect a difference in serious neonatal morbidity, is unlikely to be feasible. A powered prospective study with intention‐to‐treat analysis at onset of second stage is feasible. [ABSTRACT FROM AUTHOR]

Background: The longitudinal associations of sleep timing and time in bed (TIB) with dementia and cognitive decline in older adults are unclear. Methods: This population‐based cohort study used data from 1982 participants who were aged ≥60 years, free of dementia, and living in rural communities in western Shandong, China. At the baseline (2014) and follow‐up (2018) examinations, sleep parameters were assessed using standard questionnaires. Cognitive function was measured using the Mini‐Mental State Examination (MMSE). Dementia was diagnosed following the DSM‐IV criteria, and the NIA‐AA criteria for Alzheimer disease (AD). Data were analyzed using restricted cubic splines, Cox proportional‐hazards models, and general linear models. Results: During the mean follow‐up of 3.7 years, dementia was diagnosed in 97 participants (68 with AD). Restricted cubic spline curves showed J‐shaped associations of sleep duration, TIB, and rise time with dementia risk, and a reverse J‐shaped association with mid‐sleep time. When sleep parameters were categorized into tertiles, the multivariable‐adjusted hazard ratio (HR) of incident dementia was 1.69 (95%CI 1.01–2.83) for baseline sleep duration >8 hours (vs. 7–8 h), 2.17 (1.22–3.87) for bedtime before 9 p.m. (vs. 10 p.m. or later), and 2.00 (1.23–3.24) for mid‐sleep time before 1 a.m. (vs. 1–1.5 a.m.). Early bedtime and mid‐sleep time were significantly associated with incident AD (HR range: 2.25–2.51; p < 0.05). Among individuals who were free of dementia at follow‐up, baseline long TIB, early bedtime and mid‐sleep time, early and late rise time, and prolonged TIB and advanced bedtime and mid‐sleep time from baseline to follow‐up were associated with a greater decline in MMSE score (p < 0.05). These associations with cognitive decline were statistically evident mainly among men or participants who were aged 60–74 years. Conclusions: Long TIB and early sleep timing are associated with an increased risk of dementia, and the associations with greater cognitive decline are evident only among older people aged 60–74 years and men. [ABSTRACT FROM AUTHOR]

Background: Although T factor is defined as the size of invasive area rather than total tumor size in the eighth edition of the TNM classification, whether the pathological invasive area to tumor ratio (ITR) is a prognostic factor has not yet been evaluated. Methods: In total, 432 lung adenocarcinoma patients were analyzed, among which 266 patients with pathological stage IA were used to perform a subanalysis. Results: Smoking status (odds ratio [OR]: 0.43, p = 0.01), neutrophil‐to‐lymphocyte ratio (NLR) (OR: 1.97, p = 0.03), maximum standardized uptake value (SUVmax) (OR: 3.62, p < 0.01), and ITR (OR: 6.76, p < 0.01) were significantly different in univariate analysis. Smoking status (OR: 0.34, p < 0.01), SUVmax (OR: 3.05, p < 0.01), and ITR (OR: 5.44, p < 0.01) were risk factors for recurrence in multivariate analysis. In patients with pathological stage IA disease, smoking status (OR: 0.34, p = 0.03), NLR (OR: 2.30, p = 0.04), SUVmax (OR: 3.63, p < 0.01), pathological invasive area (OR: 4.00, p < 0.01), and ITR (OR: 6.03, p < 0.01) were significantly different in univariate analysis. Smoking status (OR: 0.27, p = 0.02), SUVmax (OR: 3.93, p < 0.01), and ITR (OR: 4.38, p < 0.01) were significant risk factors for recurrence in multivariate analysis. Conclusions: SUVmax and ITR are risk factors for recurrence. These results suggest that SUVmax is important for deciding the indication for limited resection or adjuvant chemotherapy, and ITR is an adaptation criterion for adjuvant chemotherapy for early‐stage lung adenocarcinoma patients. [ABSTRACT FROM AUTHOR]

Aims and objectives: Pressure ulcers (PUs) are a serious health problem. They can be considered as an indicator of the quality of health care and are associated with considerable cost increases for the health care system. The prevention of PUs is a major concern in hospital care. The aim of the study was to reveal the current PU prevention‐related processes and structures with a specific focus on the Accident and Emergency (A&E) Department. Method: In late 2018/early 2019, all German hospitals were invited to participate in a nationwide cross‐sectional survey. One standardized questionnaire was assigned to a representative of each hospital. The representative was asked to state what PU‐related structures and processes are implemented in their hospital, in general and specific to the A&E department. Besides mostly descriptive analysis, PU‐related processes were analysed on PU incidence in a multivariate linear regression model. Results: Two hundred seventy‐six hospitals participated in the survey. 63.4% (n = 175) of the participating hospitals had at least one PU manager. Skin inspection was the most frequently performed procedure. Although not recommended, 1.3% (2.1%) of the facilities still use sheepskins quite often (very often). In the regression model on PU incidence, only the process 'mobilization in bed' was statistically significantly associated. Although the risk of developing a PU in the emergency department is high, more than half of the facilities had no PU guidelines. Conclusion: Even if recommended procedures (skin inspection, 30° positioning) have been used frequently, regular training could help to bring new scientific findings such as the use of local skin protection dressings into clinical practice. Prevention guidelines should be established in all areas of care even for A&E as well as when patients are transferred inside or out of the hospital, where the risk of PU development was considered low. [ABSTRACT FROM AUTHOR]

Background/Aim: This study aims to understand early (<24 h post ictus) and late (up to 12 months) survival post aneurysmal subarachnoid haemorrhage (aSAH), with a focus on rurality and socioeconomic status. Methods: A statewide population‐based cohort of aSAH cases in Tasmania, Australia, was established from 2010 to 2014 using multiple overlapping sources. Clinical data were collected from medical records and the Tasmanian Death Registry, with area‐level rurality and socioeconomic status geocoded to participants' residential address. Results: From a cohort of 237 (70% women, 36% disadvantaged, 38% rural) individuals over a 5‐year period, 12‐month mortality was 52.3% with 54.0% of these deaths occurring within 24 h post ictus. In univariable analysis of 12‐month survival, outcome was not influenced by socioeconomic status, but rural geographical location was associated with a non‐significant increase in death (hazard ratio (HR) 1.22; 95% confidence interval (CI) 0.85–1.75) along with hypertension (HR 1.78; 95% CI 1.07–2.98) and hypercholesterolaemia (HR 1.70; 95% CI 0.99–2.91). Multivariable analysis demonstrated a statistically significant increase in death to 12 months after aSAH for both hypertension (HR 1.81; 95% CI 1.08–3.03) and hypercholesterolaemia (HR 1.71; 95% CI 1.00–2.94) but not socioeconomic status or geographic location. Conclusion: We found high early death in this population‐based aSAH Australian population. Survival to 12 months after aSAH was not related to either geographical location or socioeconomic status but modifiable risk factors increased the risk of death. [ABSTRACT FROM AUTHOR]

Objective: To investigate the factors that are associated with medical student interest in remote and very remote practice in Australia. Design: Aggregated data of an annual cross‐sectional survey from 2013 to 2017. Setting: Australia. Participants: Medical students from 17 medical schools, at the point of finishing one year of clinical training in a rural or remote location in Australia. Main outcome measures: Intention for working in a remote or very remote location as a doctor. Results: Responses were analysed from 3328 medical students. From this cohort, 37.6%, 54.0% and 7.0% of students reported future career intent in capital or major cities; regional Australia; and remote or very remote Australia respectively. Multivariable analysis indicated students interested in remote and very remote practice compared to those interested in regional practice were more likely to be from a rural background, have prior generalist intentions, felt as though their rural clinical school (RCS) experience increased interest in remote and very remote practice, and had higher rural practice self‐efficacy. Odds ratios were larger for these factors when students interested in remote or very remote practice were compared with students interested in practicing in capital or major cities. Conclusions: Rural background, prior generalist intentions, rural practice self‐efficacy and the overall influence of the RCS experience are associated with interest in remote and very remote practice. [ABSTRACT FROM AUTHOR]

Aim: Skeletal muscle loss is often observed in advanced cancer patients. This study investigates whether skeletal muscle loss is associated with survival outcomes of advanced epithelial ovarian cancer (EOC) patients after induction chemotherapy (IC) in a Japanese cohort. Whether serum inflammatory markers are associated with skeletal muscle changes is also addressed. Methods: We retrospectively reviewed 60 patients with stage III/IV EOC who underwent IC between 2010 and 2017. Skeletal muscle area (SMA) was measured at the third lumbar vertebrae level on a single axial computed tomography‐scan image. Receiver operating curve analysis was used to determine cut‐off values of pre‐ and post‐IC SMA and SMA ratio (SMAR). Univariate and multivariate analyses of overall survival (OS) were conducted using the log–rank test and Cox proportional hazards regression model, respectively. Results: The SMA decreased significantly after IC (P = 0.019). The cut‐off value between low and high SMAR was 0.96. High or low SMAR was observed in 34 (57%) and 26 (43%) patients, respectively. Univariate analysis revealed that low SMAR was associated with poor OS (P = 0.025). Multivariate analysis showed that incomplete resection during interval debulking surgery (hazard ratio, 0.30; 95% CI, 0.11–0.80; P = 0.016) and a low SMAR (hazard ratio, 3.17; 95% CI, 1.18–9.06; P = 0.022) were independent predictors of poor OS. Of the serum inflammatory markers investigated, only post‐IC absolute neutrophil count correlated significantly with SMAR (P = 0.012). Conclusion: Low SMAR can be used to predict poor prognosis in advanced EOC patients who have undergone IC. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to evaluate the effectiveness of a peer coaching smoking cessation program in a high‐risk Medicaid population. Design and Sample: In this manuscript, we present an evaluation of a pilot program. Participants (N = 138) were recruited out of a larger smoking cessation program administered statewide and funded by the Center for Medicare and Medicaid Services. The participant sample was diverse, with 52% self‐identifying as White, 39% as Black, and 56% Latino ethnicity (any race). Methods: Motivational interviewing techniques were utilized by peer coaches in clinical and community settings to achieve smoking cessation using face‐to‐face, telephone, and text/email encounters over a period of 6 months. Results: There was a statistically significant increase in the number of participants who had quit smoking from program enrollment to discharge (5.1%–18.5%, p = 0.02). Number of peer coaching encounters predicted quitting in program participants. Conclusions: This study adds to the literature that community‐based smoking cessation services led by peer coaches can be effective in a diverse, high‐risk population. [ABSTRACT FROM AUTHOR]

Objectives: Previous studies have suggested that hypertension in HIV‐positive individuals is associated primarily with traditional risk factors such as older age, diabetes and dyslipidaemia. However, controversy remains as to whether exposure to antiretroviral (ARV) drugs poses additional risk, and we investigated this question in the Data Collection on Adverse Events of Anti‐HIV Drugs (D:A:D) cohort. Methods: The incidence of hypertension [systolic blood pressure (BP) > 140 and/or diastolic BP > 90 mmHg and/or initiation of antihypertensive treatment] was determined overall and in strata defined by demographic, metabolic and HIV‐related factors, including cumulative exposure to each individual ARV drug. Predictors of hypertension were identified using uni‐ and multivariable Poisson regression models. Results: Of 33 278 included persons, 7636 (22.9%) developed hypertension over 223 149 person‐years (PY) [incidence rate: 3.42 (95% confidence interval (CI) 3.35–3.50) per 100 PY]. In univariable analyses, cumulative exposure to most ARV drugs was associated with an increased risk of hypertension. After adjustment for demographic, metabolic and HIV‐related factors, only associations for nevirapine [rate ratio 1.07 (95% CI: 1.04–1.13) per 5 years] and indinavir/ritonavir [rate ratio 1.12 (95% CI: 1.04–1.20) per 5 years] remained statistically significant, although effects were small. The strongest independent predictors of hypertension were male gender, older age, black African ethnicity, diabetes, dyslipidaemia, use of lipid‐lowering drugs, high body mass index (BMI), renal impairment and a low CD4 count. Conclusions: We did not find evidence for any strong independent association between exposure to any of the individual ARV drugs and the risk of hypertension. Findings provide reassurance that screening policies and preventative measures for hypertension in HIV‐positive persons should follow algorithms used for the general population. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the incidence and risk factors of deep surgical site infection (DSSI) during hospitalisation after closed tibial plateau fractures treated with open reduction and internal fixation (ORIF). We performed this retrospective study at a university‐affiliated hospital with an advanced trauma centre. The data of adult patients with closed tibial plateau fractures treated with ORIF from January 2012 to February 2017 were extracted from the electronic medical records. Demographics, injury‐related and surgery‐related variables of DSSI and non‐DSSI groups were compared by univariate test. Multivariate logistic analysis models were used to investigate the independent risk factors. In total, 676 patients with complete data met the inclusion criteria and were included, and of them, 17 developed DSSI (2.51%) during hospitalisation. Approximately 60% (9/17) of DSSI was caused by Staphylococcus aureus. Compared to the non‐DSSI group, DSSI patients had a significantly longer stay in hospital (25.8 vs 15.2 days). Independent risk factors of DSSI identified by multivariate analysis were higher BMI (>26.0) (OR, 1.58; 95% CI, 1.09 to 3.27; P = 0.032), prolonged surgical duration (>138 min) (OR, 4.26; 95% CI, 1.54 to 11.19; P = 0.005) and current smoking (OR, 3.42; 95% CI, 1.47 to 8.62; P = 0.01). A relatively low incidence rate of DSSI (2.51%) was found in this study, and several significant risk factors were identified. Smoking cessation programmes should be implemented immediately after hospitalisation, especially for obesity and morbid obesity patients. Detailed and comprehensive preoperative assessment and a considerate operative plan should be guaranteed to reduce surgical duration. [ABSTRACT FROM AUTHOR]

Preventing intraoperatively acquired pressure ulcers (IAPUs) in patients undergoing spinal surgery in the prone position using a Relton‐Hall frame is challenging. We investigated the efficacy of soft silicone foam dressings in preventing IAPUs. A prospective dual‐center sham study was conducted among patients undergoing elective spinal surgery in a general hospital and a university hospital in Japan. The incidence of IAPUs that developed when soft silicone foam dressings and polyurethane film dressings were used was compared on two sides in the same patient. IAPUs developed on the chest in 11 of 100 patients (11%). Polyurethane film dressings were associated with a significantly higher rate of IAPUs than soft silicone foam dressings (11 versus 3, P = 0·027). A multivariate logistic regression analysis revealed that a diastolic blood pressure of <50 mmHg (P = 0·025, OR 3·74, 95% confidence interval [CI] 1·18–13·08) and the length of surgery (by 1 hour: P = 0·038, OR 1·61, 95% CI 1·03–2·64) were independently associated with the development of IAPUs. The use of soft silicone foam dressings reduced the risk of IAPUs (P = 0·019, OR 0·23, 95% CI 0·05–0·79) and was more effective than film dressings for preventing IAPUs in spinal surgery patients. [ABSTRACT FROM AUTHOR]

Maternal capabilities-qualities of mothers that enable them to leverage skills and resources into child health-hold potential influence over mother's adoption of child caring practices, including infant and young child feeding. We developed a survey ( n = 195) that assessed the associations of 4 dimensions of maternal capabilities (social support, psychological health, decision making, and empowerment) with mothers' infant and young child feeding practices and children's nutritional status in Uganda. Maternal responses were converted to categorical subscales and an overall index. Scale reliability coefficients were moderate to strong (α range = 0.49 to 0.80). Mothers with higher social support scores were more likely to feed children according to the minimum meal frequency (odds ratio [OR] [95% confidence interval (CI)] = 1.38 [1.10, 1.73]), dietary diversity (OR [95% CI] = 1.56 [1.15, 2.11]), iron rich foods, (OR [95% CI] = 1.47 [1.14, 1.89]), and minimally acceptable diet (OR [95% CI] = 1.55 [1.10, 2.21]) indicators. Empowerment was associated with a greater likelihood of feeding a minimally diverse and acceptable diet. The maternal capabilities index was significantly associated with feeding the minimum number of times per day (OR [95% CI] = 1.29 [1.03, 1.63]), dietary diversity (OR [95% CI] = 1.44 [1.06, 1.94]), and minimally acceptable diet (OR [95% CI] = 1.43 [1.01, 2.01]). Mothers with higher psychological satisfaction were more likely to have a stunted child (OR [95% CI] = 1.31 [1.06, 1.63]). No other associations between the capabilities scales and child growth were significant. Strengthening social support for mothers and expanding overall maternal capabilities hold potential for addressing important underlying determinants of child feeding in the Ugandan context. [ABSTRACT FROM AUTHOR]

In formula-fed infants, rapid weight gain during the first week of life is associated with later obesity. To examine the association between weight gain during the first week and overweight at age 2 among infants with various feeding practices and the relationship between exclusive breastfeeding in early infancy and overweight, we enrolled a prospective cohort of healthy mother-infant dyads and followed them for 2 years. We enrolled 450 mother/infant pairs and obtained information on 306 infants at year 2. Weight change during the first week of life and detailed feeding information were collected during the first month of life. Anthropometric measures were collected at 2 years. Overweight was defined as body mass index (BMI) ≥85th percentile for age. At 2 years, 81% had normal weights and 19% were overweight. Maternal pre-pregnancy BMI; infant birth weight; maternal education; and Women, Infants, and Children status were associated with the risk of overweight at age 2. Children who gained more than 100 g during the first week were 2.3 times as likely after adjustment ( p = .02) to be overweight at age 2 compared to infants who lost weight. There was no association between feeding type and BMI, but feeding type was significantly associated with change in weight at week 1 and anthropometric measurements at age 2. Infant weight gain in the first week of life is related to overweight at age 2, and exclusively breastfed infants are least likely to gain ≥100 g. [ABSTRACT FROM AUTHOR]

Early childhood development plays a key role in a child's future health, educational success, and economic status. However, suboptimal early development remains a global challenge. This study examines the influences of quality of the home learning environment (HOME) and child stunting in the first year of life on child development. We used data collected from a randomized controlled trial of preconceptional micronutrient supplementation in Vietnam ( n = 1,458). The Bayley Scales of Infant Development-III were used to assess cognition, language, and motor development domains at 2 years. At 1 year, 14% of children were stunted, and 15%, 58%, and 28% of children lived in poor, medium, and high HOME environments, respectively. In multivariate generalized linear regression models, living in a high HOME environment was significantly associated with higher scores (0.10 to 0.13 SD) in each of the developmental domains. Stunted children scored significantly lower for cognitive, language, and motor development (−0.11 to −0.18), compared to nonstunted children. The negative associations between stunting on development were modified by HOME; the associations were strong among children living in homes with a poor learning environment whereas they were nonsignificant for those living in high-quality learning environments. In conclusion, child stunting the first year of life was negatively associated with child development at 2 years among children in Vietnam, but a high-quality HOME appeared to attenuate these associations. Early interventions aimed at improving early child growth as well as providing a stimulating home environment are critical to ensure optimal child development. [ABSTRACT FROM AUTHOR]

Although iron deficiency (ID) is considered the most frequent micronutrient deficiency in industrialized countries and is associated with impaired neurodevelopment when occurring in early years, accurate recent estimations of its prevalence are lacking. Our objective was to estimate ID prevalence and associated sociodemographic markers in young children in France. The Saturn-Inf national cross-sectional hospital-based survey recruited 3,831 French children <6 years old between 2008 and 2009 to assess lead poisoning prevalence and to establish a biobank. This secondary analysis measured serum ferritinemia (SF) in sera kept frozen at −80 °C for children with sufficient serum aliquots and C-reactive protein <10 mg/L. For the 657 participating children (17% of the Saturn-Inf study), the median age was 3.9 years (interquartile range: 2.2-5.1); 52% were boys. The median SF was 44 μg/L (interquartile range: 28-71). ID prevalence was 2.8% (95% confidence interval [1.7, 4.7]) and 3.2% (95% confidence interval [2.0, 5.1]) with an SF threshold of 10 and 12 μg/L, respectively. Low SF was significantly associated ( p < .05) with mother being a migrant (32 vs. 45 μg/L for a mother born in France) or unemployed (37 vs. 50 μg/L for a mother employed). In this first national cross-sectional hospital-based study in France, ID prevalence was much lower than that in other French and European studies performed in underprivileged populations but close to the lowest values observed in other population-based studies in Europe. [ABSTRACT FROM AUTHOR]

Background The decision to lose weight among adolescents is complex and is guided by a number of body-related factors. This study examined the extent of agreement between actual weight, measured as body mass index, and self-perceived weight and assessed their relative importance in weight loss behaviour among Lebanese adolescents. Methods Data on 278 adolescents aged 13-17 years were drawn from the nationwide Nutrition and Non-Communicable Disease Risk Factor Survey (Lebanon, 2009). Binary multivariable logistic regressions were conducted to test associations with 'effort to lose weight' as the outcome variable, controlling for a number of potential confounders. Results Close to 36% reported trying to lose weight. Around 21% and 13% were overweight and obese, respectively, and 40% and 10% perceived their weight as slightly high and very high, respectively. Inaccurate perceivers, those underestimating or overestimating their weight, constituted 39%, with overall percent agreement between actual and self-perceived weight being 60.8% (kappa statistic = 0.319, 95% CI [0.242, 0.396]). About a third of the overweight adolescents (30.5%) and more than half of the obese (56.8%) underestimated their weight. In the multivariable analysis, self-perceived weight was statistically significant and a stronger predictor of weight loss effort than body mass index (adjusted odds ratios = 14.42 and 6.42 for slightly high and very high perceived weight, respectively, compared to odds ratios = 1.47 and 2.31 for overweight and obese adolescents, respectively). Conclusion Health professionals need to consider self-perceived weight in conjunction with actual weight in their pursuit of weight management goals and in planning prevention programmes that guide weight loss behaviours for adolescents. [ABSTRACT FROM AUTHOR]

Objective Rural exposure during medical school is associated with increased rural work after graduation. How much of the increase in rural workforce by these graduates is due to pre-existing interest and plans to work rurally and how much is related to the extended clinical placement is not known. Design This cohort study compared the employment location of medical graduates who professed no rural interest as undergraduates (negative control), with those who applied but did not participate in Rural Clinical School of Western Australia ( RCSWA) (positive control), and those who applied and participated in RCSWA (participants). Participants All 1026 University of Western Australia students who had an opportunity to apply for a year-long rotation in RCSWA from 2004 to 2010, and who had subsequently graduated by the end of 2011, were included. Main Outcome Measure Graduates' principal workplace location ( AHPRA, Feb 2014). Result The three groups differed significantly in their graduate work locations (χ2 = 39.2, P < 0.001). In multivariate analysis, only being of older age at graduation ( OR 2.28 (95% CI 1.40, 3.72), P = 0.001), being from a rural background ( OR 2.99 (95% CI 1.85, 4.85), P < 0.001), being a recipient of a Medical Rural Bonded Scholarship ( OR 3.36 (95% CI 1.68, 6.73, P = 0.001) and actually participating in the RCSWA remained significantly related to rural work ( OR 3.10 (95% CI 1.95, 4.93), P < 0.001). Conclusion After accounting for other factors relating to rural work, RCSWA graduates were three times more likely to work rurally than either control group. These data suggest that RCSWA has a significant independent effect on rural workforce. [ABSTRACT FROM AUTHOR]

Objective To investigate the feasibility of using a General Practice registrar ( GPR) to coordinate rural palliative care services. Design A quasi-experimental design was used. Intervention group participants received the GPR service, which involved liaison among the patient, family, General Practitioner, specialist palliative care team and community nurses. Specified risk assessment, care planning and continuity of care were provided. Patients in the comparison group received the standard service. Setting Rural community palliative care. Participants: One hundred and ninety-one rural community palliative care patients (99 intervention and 92 control patients). Main outcome measures: Hospital admissions per 100 patient-days, bed-days per 100 patient-days and proportion of deaths at home. Results Patients receiving standard care were twice as likely to spend ≥8 bed-days in hospital ( OR 2.09 (95% CI 1.10-3.97); P = 0.02) and were more likely to have ≥ 2 admissions to hospital ( OR 3.37 (95% CI 1.83-6.21); P < 0.001), per 100 patient-days than the intervention group after adjusting for diagnosis group (cancer or not) and residence in residential aged care. Controls were significantly less likely to die at home than the intervention group ( OR 0.41 (95% CI 0.20-0.86); P = 0.02). Conclusion This is a small proof of concept pilot study limited by lack of randomisation. The results demonstrate the feasibility of using a GPR to manage continuity of care for rural community palliative care patients. Given the potential confounding factors, further investigation via a larger randomised trial is required. [ABSTRACT FROM AUTHOR]

Aim: The impact of sarcopenia on hospitalisation has been under intense investigation; however, little is known about the association between sarcopenia and their costs among hospitalised patients. The aim of the present study was to quantify the association between sarcopenia and hospitalisation costs among older adults. Methods: A cross ‐ sectional study was conducted in 201 hospitalised older adults in a general hospital. Sarcopenia was identified according to the European Working Group on Sarcopenia in Older People (EWGSOP) criteria. Muscle mass was assessed by anthropometric measurements, muscle strength through handgrip strength evaluation and physical performance by Timed Up and Go Test. Nutritional status was evaluated using the Mini Nutritional Assessment—Short Form (MNA ‐ SF), and hospital costs were assessed with the Diagnosis Related Groups (DRGs) system. Multivariable logistic regression models were fitted to quantify the association between sarcopenia and hospital costs. Increased hospital costs were considered when a patients′ cost was higher than the mean cost of an average patient (€2396.24). Results: Within this sample, 10.4% sarcopenic, 43.8% at nutritional risk and 14.9% undernourished older adults were identified. After adjustment, sarcopenia (OR = 5.70, 95% CI 1.57 – 20.71) and low muscle strength (OR = 2.40, 95% CI 1.12 – 5.15) were associated with increased hospital costs. Conclusions: Sarcopenia and low muscle strength at hospital admission were independently associated with increased hospital costs. [ABSTRACT FROM AUTHOR]

Aim In the treatment of cervical cancer, the extent of lymphadenectomy is a matter of debate. The goal of the current study was to examine the question of whether the number of retrieved lymph nodes (RLN) can influence survival of patients with early stage cervical cancer. Methods The medical records of 180 FIGO stage IB-IIA cervical cancer patients treated with primary radical surgery were reviewed. Patients were divided into two groups: those with ≤ 40 RLN and those with > 40 RLN. Patients were also assigned to either the bulky (tumor size > 4 cm) cervical cancer group or the non-bulky (tumor size ≤ 4 cm) cervical cancer group. Results The number of RLN had a statistically significant effect on both disease-free survival ( P = 0.04) and overall survival ( P = 0.02) of all patients. Patients with > 40 RLN had better prognoses than those with ≤ 40 RLN. In the bulky cervical cancer group, the number of RLN was an independent prognostic factor. In multivariate analysis for the bulky cervical cancer group, > 40 RLN had a significant positive effect on disease-free survival (adjusted hazard ratio, 0.36; 95% confidence interval, 0.13-0.97) and overall survival (adjusted hazard ratio, 0.23; 95% confidence interval, 0.06-0.90). However, number of RLN was not an independent prognostic factor in the non-bulky cervical cancer group. Conclusions A more extensive lymphadenectomy increased the survival of bulky cervical cancer patients. This finding may be helpful in determining surgical extent before surgery for cervical cancer. [ABSTRACT FROM AUTHOR]

There is scant research on the clinical utility of differentiating International Classification of Diseases (ICD) 10 diagnoses F50.0 anorexia nervosa (typical AN) and F50.1 atypical anorexia. We reviewed systematically records of 47 adolescents who fulfilled criteria for ICD-10 F50.0 ( n = 34) or F50.1 ( n = 13), assessing the impact of diagnostic subtype, comorbidity, background factors and treatment choices on recovery. Atypical AN patients were significantly older ( p = 0.03), heavier (minimum body mass index 16.7 vs 15.1 kg/m2, p = 0.003) and less prone to comorbidities (38% vs 71%, p = 0.04) and had shorter, less intensive and less costly treatments than typical AN patients. The diagnosis of typical versus atypical AN was the sole significant predictor of treatment success: recovery from atypical AN was 4.3 times (95% confidence interval [1.1, 17.5]) as likely as recovery from typical AN. Overall, our findings indicate that a broader definition of AN may dilute the prognostic value of the diagnosis, and therefore, ICD-11 should retain its distinction between typical and atypical AN. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association. [ABSTRACT FROM AUTHOR]

Background The present study aimed to determine whether total fibre or specific fibre food sources are associated with the incidence of the metabolic syndrome (MetS) after 3 years of follow-up in the Tehran Lipid and Glucose Study. Methods This population-based prospective study, conducted within the framework of the Tehran Lipid and Glucose Study, included 1582 adults, who were aged 19-84 years and free of MetS at baseline. Usual dietary fibre intake was assessed at baseline using a 168-item food frequency questionnaire. Anthropometrics, blood pressure, and fasting blood glucose and lipid profiles were measured at baseline and 3 years later. The MetS was defined according to the definition of the revised Adult treatment Panel III. Results During the 3-year follow-up, there was 15.2% incidence of MetS. Among sources of dietary fibre, fruit fibre was significantly and inversely associated with the occurrence of MetS, after adjustment for confounding factors, with a 21% lower risk [odds ratio ( OR) = 0.79, 95% confidence interval ( CI) = 0.60-0.97] in the highest tertile of intake compared to the lowest tertile. Subjects in the highest tertile of cereal fibre intake had lower odds of MetS compared to those in the lowest tertile ( OR = 0.73, 95% CI = 0.52- 0.97) and this association disappeared after adjustment for confounders. No significant association was found between intakes of vegetables, legumes and nut fibre with the incidence of MetS. Conclusions Among specific fibre food sources, fruit fibre had a protective effect against the risk of MetS. [ABSTRACT FROM AUTHOR]

Objective To examine the association between children's clinical oral health status and their residential location using the latest available data (2009) and to ascertain whether poor oral health among rural children is related to being Indigenous, having less access to fluoridated water or being of lower socioeconomic status ( SES), than children from urban areas. Design Cross-sectional survey. Setting and participant Data were collected on 74 467 children aged 5-12 years attending school dental services in Australia (data were not available for Victoria or New South Wales). Main outcome measures Clinical oral health was determined by the mean number of permanent teeth with untreated caries, missing and filled permanent teeth, and the mean decayed, missing and filled permanent teeth index ( DMFT) of 8 to 12-year-old-children and the mean number deciduous teeth with untreated caries, missing and filled deciduous teeth, and the mean decayed, missing and filled deciduous teeth index (dmft) of 5-10-year-olds. Results The multivariable models that included coefficients on whether the child was Indigenous, from an area with fluoridated water and SES, were controlled for age and sex. The mean DMFT of 8-12-year-old children and the mean dmft of 5-10-year-old-children were significantly higher in rural areas compared with urban centres after accounting for Indigenous status, fluoridated water and SES. Conclusion Children's oral health was poorer in rural areas than in major city areas. [ABSTRACT FROM AUTHOR]

While literature describing immigrant's breastfeeding practices exists, especially among those living within developed countries, there is a significant gap in knowledge on how the host culture may influence the EBF behaviors of refugees, especially those living in protracted situations within sub-Saharan Africa. A cross-sectional study was conducted in the Buduburam Refugee Settlement in Ghana from July-August 2008 to explore the association between the amount of time living in Ghana and exclusive breastfeeding practices among Liberian refugees and Ghanaians in surround villages. The study included 480 women: 239 Liberians living in 12 settlement zones (in two of which Liberians and Ghanaians co-exist), 121 Ghanaians living in two settlement zones, and 120 Ghanaians living in nearby urban village of Awutu. Liberian mothers who lived in Ghana at least eight years were significantly more likely to exclusively breastfeed (OR: 1.78, 95% CI: 1.02, 3.09) compared to Ghanaian mothers living in Awutu. These findings suggest that increased time living in Buduburam improved the chances of EBF success among Liberians, perhaps as a result of unique EBF education/support opportunities offered in the settlement to Liberian refugees that were not readily available to Ghanaians. Further research to understand the 'mechanisms' explaining exclusive breastfeeding differences as a function of time spent in host country is needed for improving breastfeeding support in refugee settlements and host communities. [ABSTRACT FROM AUTHOR]